A 63-year-old man had undergone patch repair of a chronic dissecting thoracoabdominal aortic aneurysm 8 years previously. Postoperative course was uneventful during 8 years after the first operation. However follow-up CT scan 8 years after demonstrated pseudoaneurysm of thoracoabdominal aorta at the anastomotic side. Reoperation for pseudoaneurysm was performed through left thoracotomy under partial cardiopulmonary bypass. Pseudoaneurysm was revealed at the proximal anastomotic side. Graft replacement for thoracoabdominal aorta and reconstruction of two pairs of intercostal arteries and the celiac artery was performed under SEP and MEP monitoring. His postoperative course was uneventful. He was discharged from our hospital 12 days after surgery. Follow-up CT scan demonstrates no recurrence of pseudoaneurysm for 1 year after surgery.

Risk factors for stroke after coronary artery bypass grafting (CABG) were assessed. We retrospectively investigated 681 consecutive patients who underwent isolated, first-time CABG at our institute between 1987 and 1998. Ninety-eight patients (14%) had a history of preoperative stroke. They tended to be older and with a higher incidence of peripheral vascular disease (PVD) than those without preoperative stroke. In spite of several techniques for prevention of postoperative stroke, such as the aortic non-touch technique, 14 patients (2.0%) suffered postoperative stroke. Postoperative stroke was diagnosed soon after surgery in 7 patients (50%), and the causes of stroke in these patients seemed to be intraoperative manipulation of the ascending aorta in 5, and hypoperfusion during cardiopulmonary bypass in two. Stroke in the remaining 7 patients occurred after normal awakening from anesthesia, and the cause was unknown. We then compared the patients with postoperative stroke (n=14) to those without postoperative stroke (n=667). Statistical analysis demonstrated no significant difference between the two groups in variables such as history of preoperative stroke, duration of cardiopulmonary bypass, and prevalence of PVD. Four (29%) of the patients with postoperative stroke died, due mainly to aspiration pneumonia. The morbidity and mortality of the patients who suffered postoperative stroke were very high.

A 11-year-old boy was admitted to our hospital with a diagnosis of the progressive residual coarctation of the aorta, severe left ventricular hypertrophy and dilatation of the ascending aorta. He had previously undergone 3 operations for coarctation of the aorta. We performed ascending-to-descending aortic bypass through a median sternotomy for residual coarctation of the aorta. Partial cardiopulmonary bypass (CPB) was established via the right femoral artery and right atrium. A cephalad retraction of the heart with a heart positioner and a longitudinal pericardial incision over the descending aorta allowed excellent exposure of the aorta through the posterior pericardium. The graft was anastomosed to the ascending aorta and descending aorta. The graft was brought around the right lateral aspect of the right atrium and through to the anterior aspect of right pulmonary veins and inferior vena cava. The bypass graft size was 14 mm in diameter. The CPB time was 134 min, and operation time was 232 min. The postoperative course was uneventful, and he did not suffer from paraplegia. His blood pressure postoperatively normalized without medication. He was discharged 20 days after surgery. The ascending-descending aortic bypass through a posterior pericardium approach is a safe and effective option for relieving residual coarctation and improving hypertension, for patients who have complex coarctation requiring surgical correction. However, because of his young age (II) it is necessary to follow him up carefully.

The patient was an 81-year-old male. During treatment of a refractory subcutaneous abscess, he was diagnosed with an infection of an infrarenal aortic aneurysm caused by unknown bacteria. Antibiotic administration was initiated, but the infection persisted and there was no improvement of the aortic infection focus or aneurysm morphology. In order to control the infection and avoid rupture of the aortic aneurysm, excision of the infectious abdominal aortic aneurysm, omental plombage, and debridement of the surrounding infected tissue were performed. According to histopathological examination of the extracted sample, findings were consistent with an infection of the aortic aneurysm. Although administration of antibiotics continued, the infection continued to worsen during the postoperative course and an enlarged subcutaneous abscess and miliary tuberculosis were indicated by computed tomography. Therefore, an acid-fast bacteria culture test of the subcutaneous abscess, sputum, and urine and Tuberculous (Tb)-real time polymerase chain reaction (PCR) tests were carried out. According to Tb-PCR test of the subcutaneous abscess, mycobacterium tuberculosis was detected. In the re-evaluation of the extracted sample, granulomatous inflammation with spindle-shaped cell fenestration around the necrotic tissue and the appearance of epithelial cells and multinucleated giant cells were observed. Findings were consistent with a tubercular infection of the aortic aneurysm. Anti-tuberculosis treatment was initiated, and significant improvement of the inflammation and subcutaneous pus in the right chest were observed. On Day 39 after surgery, the patient was discharged from the hospital and walked home with no help. We experienced a successful case of tubercular infection of an infrarenal aortic aneurysm requiring surgery. Infection was controlled and rupture of the aortic aneurysm was avoided with surgical treatment and antituberculosis therapy. (Surgical treatment by excision of infectious abdominal aortic aneurysm, omental plombage, and debridement of the surrounding infected tissue, and antituberculosis therapy were carried out.)

A 48-year-old woman was admitted to our hospital with exertional dyspnea and lower leg edema since 2 months previously. Echocardiogram presented dilation of Valsalva sinus, severe AR (aortic regurgitation) and a supra-annular flap. Enhanced cardiac cycle-gated computed tomography revealed Stanford type A aortic dissection. Primary entry was found just above the aortic valve, the right coronary artery branched from the false lumen, and the commissure between the right and non-coronary cusps was detached. The left coronary artery branched from the true lumen. The false lumen was all patent to the bilateral bifurcations of the common iliac artery. We performed valve sparing partial root remodeling, right coronary artery bypass and total arch replacement after the heart failure management. The operation, cardiopulmonary bypass, aortic cross clamp and selective cerebral perfusion times were 402, 234, 167 and 109 min, respectively. The postoperative course was uneventful, and the patient was discharged 12 days after the operation without any complication. Postoperative CT revealed a well-shaped Valsalva and complete thrombosis of the false lumen on the thoracic aorta. Aortic regurgitation completely disappeared according to a postoperative echocardiogram.

Alkaptonuria is a rare genetic disease, in which amino acids and tyrosine cannot be processed. A 72-year-old man with a history of aortic valve stenosis presented with coronary 3-vessel disease. Intraoperative findings included ochronosis, which is pigmentation caused by the accumulation of homogentistic acids in connective tissues, or on the severely calcified aortic valve, the intima of the aorta, and the coronary arteries. The pigmented region of the coronary arteries had significant stenosis. Aortic valve replacement and coronary artery bypass were performed. From these findings and his past history of arthritis, we diagnosed alkaptonuria. The patient had an uneventful recovery.