The results of endovascular abdominal aortic aneurysm repair (EVAR) for severe neck angulation with an Excluder were evaluated. We performed EVAR in 51 patients, using an Excluder, from September 2007 to September 2011. The angle between proximal neck and the aneurysm (Angle) was less than 61° in 31 patients (Group I), 61-90° in 13 patients (Group II) and more than 90° in 7 patients (Group III). In Groups I and II, the angled proximal neck was straightened with a stiff guide wire and a Trunkipsilateral device was deployed slowly (aortic modification technique). In Group III, the device modification technique was applied. In this technique, the stiff guide wire was inserted in the aortic root. The Trunkipsilateral device was bent to the contra lateral limb side and was inserted into the aorta. The stiff guide wire was pushed in with a fulcrum at the aortic valve. This procedure resulted in bending of the wire and the trunk-ipsilteral device became parallel to the proximal neck. The renal artery position was confirmed on angiographys and the main body was deployed slowly. We performed angiography after planned device deployment to evaluated Type Ia endoleak, and if it was observed, an additional procedure such as Aortic Extender or Palmaz XL stent deployment was performed and the Type Ia endoleak was evaluated during the procedure by completion angiography. The Angle change was measured by enhanced CT at 7 days and 6 month after EVAR. The Angle were 97-137° in Group III. The frequency of Type Ia endoleak after planned device deployment (35% in Group I, 55% in Group II and 17% in Group III), additional procedure for Type Ia endoleak (29% in Group I, 23% in Group II and 14% in Group III) and Type Ia endoleak by completion angiography (0% in Group I, 8% in Group II and 14% in Group III) did not differ significantly between the 3 groups. When Group I was sub divided into those with Angle less than 41° (Group Ia, 15 patients) and those with an Angle from 41 to 60° (Group Ib, 16 patients), Type Ia endoleak after planned device deployment (18% in Group Ia, 63% in Group Ib) was significantly more frequent in Group Ib and the additional procedure for Type Ia endoleak (7% in Group Ia, 50% in Group Ib) was more frequent in Group Ib. The Angle significantly decreased 7 days after EVAR and did not change thereafter in all 3 groups. EVAR with an Excluder for severe neck angulation was feasible by device modification with the bending technique. This technique might be useful for patients with an Angle of more than 41°.

Endovascular repair for abdominal aortic aneurysm (EVAR) has become widespread in Japan because of its low invasiveness. However adequate proximal neck length is required for EVAR. Unfortunately the surgical mortality of para-renal aortic aneurysm cases has been higher than that of infrarenal aortic aneurysm cases, especially in high-risk patients. A manufacture-modified fenestrated Zenith stent graft system has already been developed, however this new device is not yet available in Japan. Furthermore this device could not be used in an emergency situation because it takes 2-3 weeks for preparation. Therefore we introduced a surgeon-modified fenestrated Zenith stent graft (fenestrated Zenith) system in December 2010 for patients with a proximal neck length of 5-10 mm. The fenestrated Zenith was not indicated if the supra-renal angle and proximal neck angle exceeded 35°. From May 2007 to February 2012, abdominal aortic aneurysms (AAA) with a short neck were repaired with fenestrated Zenith in 11 high-risk patients (group Fene), and AAAs with a proximal neck length of more than 15 mm were repaired with a standard Zenith in 43 patients (group IFU). There were two ruptured AAA in the Fene group. Proximal neck length was significantly shorter in the Fene group (5.5±1.4 mm in the Fene group, 26.4±9.5 mm in the IFU group, p<0.0001) and proximal neck angle was significantly less in the Fene group (20±13° in the Fene group, 36±18° in the IFU group, p=0.008). The Zenith stentgraft system was deployed successfully in all patients. The frequency of type Ia endoleak detected by angiography after stent graft deployment and balloon attachment did not differ significantly (36% in the Fene group 26% in the IFU group, p=0.475) and the frequency of Palmaz stent requirement for type Ia endoleak which persisted after 10 min of additional balloon attachment also did not differ significantly (27% in Fene group, 9% in IFU group). All fenestrated renal arteries were shown to be patent by angiography. There was no hospital death despite 2 cases of ruptured AAA, nor were these major complications in either group. Serum creatinine levels at 1, 3, 6 and 30 days after EVAR did not differ significantly between the 2 groups. In 9 out of 11 patients, only type II endoleaks were detected and aneurysm shrinkage tended to be more in Fene group (9.9±5.7 mm in Fene group, 5.4±6.1 mm in IFU group, p=0.062) on enhanced CT 6 months after EVAR. Also all fenestrated renal arteries were patent in these 9 patients. The surgeon-modified fenestrated Zenith system seemed to be effective for AAA patients with short proximal necks, but long term follow up is mandatory.

Endovascular aortic aneurysm repair using stent graft (SG) for both thoracic and abdominal aortic aneurysms (SG therapy) rapidly became widespread in Japan because of its relatively low invasiveness. Pre- and postoperative contrast enhanced CT are mandatory in SG therapy and angiography is required during SG therapy. Therefore contrast induced nephropathy (CIN) might occur after SG therapy. In our hospital, a renal protection protocol (oral N-acetylcysteine, perioperative normal saline infusion and bicarbonate infusion during SG therapy) was introduced in June 2010. In this report, the effect of the renal protection protocol on renal function after SG therapy was evaluated. During May 2008 and March 2012, 229 patients underwent SG therapy in our hospital. Serum creatinine (CRTN) was higher than 1.5 mg/dl and estimated glomerular filtration rate (eGFR) was less than 50 ml/min/1.73 m² in 26 patients. In these 26 patients, the renal protection protocol was applied in 15 patients (group P) and group P was compared with the 11 patients without renal protection protocol (group N). Also the relationship between CIN occurrence and preoperative renal function was evaluated in 192 patients who did not receive the renal protection protocol. CIN was defined as more than 25% or 0.5 mg/dl increase of CRTN based on the European Guidelines. As renal protection protocol, N-acetylcysteine (600 mg) was given 4 times every 12 h. Normal saline infusion was started on the evening of the day before surgery at the rate of 50 ml/h and was continued until 1h before surgery. Sodium bicarbonate solution (151 mEq/l) was started 1 h before surgery at the rate of 180 ml/h and the infusion rate was decreased to 60 ml/h during surgery. After surgery, 1,000 ml of normal saline was given at a rate of 60 ml/h. In group N, CRTN increased 1 and 3 days after SG therapy and returned to baseline level 6 days after SG therapy. On the other hand, CRTN was lower than baseline after SG therapy in group P. At 3 days after SG therapy, the percent change of CRTN component with baseline level was significantly lower in group P (14.5±19.1% in group N, -3.7±15.8% in group P, p=0.014). CIN occurrence tended to be more in group N (45% in group N, 7% in group P, p=0.054). Among the 192 patients without the renal protection protocol, CIN occurred in 16 patients (29.1%) out of 55 patients with preoperative CRTN≥1.0 mg/dl and eGFR≤50 ml/min/1.73 m², however CIN occurred in only 1 patient (0.7%) among 137 patients with preoperative renal function out of this range (p<0.001). Renal protection protocol seemed to be effective to prevent CIN after SG therapy. Renal protection might be useful for patients with a CRTN≧1.0 mg/dl and eGFR≦50 ml/min/1.73 m².

In off-pump coronary artery bypass grafting (OPCAB), adequate exposure under stable hemodynamic condition is mandatory. We introduced left side pericardiotomy to expose the left anterior descending artery without lifting up the ventricle in 2008. With this pericardiotomy approach, the exposure of the circumflex and right coronary artery territory became easier and OPCAB with left side pericardiotomy was compared with OPCAB with midline pericardiotomy. From 2004 to 2011, 194 elective first time coronary artery bypass grafting (CABG) were performed in our hospital. Before 2008, 62 patients underwent OPCAB with midline pericardiotomy which constituted 61% of the CABG in that period. After 2008, the pericardium was dissected on the left side and a small pericadiotomy was made on the left side of the main pulmonary artery. This incision was then extended to the apex. With this pericardiotomy, only two patients underwent CABG with cardiopulmonary bypass (one patient with 15% left ventricle ejection fraction and one more patient who developed acute coronary syndrome during anesthesia induction). Thus 91 out of 93 patients underwent OPCAB (98%) (Group L). In Group L, old myocardial infarction and unstable angina patients were frequent. The frequency of the patients with left ventricular ejection fraction less than 40% tended to be more in Group L. The operation time was significantly shorter in Group L (Group M 305±71 min, Group L 223±54, p<0.0001) and the number of distal anastomoses number was significantly more in Group L (Group M 2.3±0.7, Group L 2.8±1.0, p<0.0001). Blood pressure during left circumflex coronary artery and right coronary artery anastomosis was significantly higher in Group L, and even continuous dopamine infusion requirement was significantly less in Group L (92% in Group M, 13% in Group L, p<0.001) among the patients with left ventricle ejection fraction less than 60%. There was only 1 hospital death in Group M. Postoperative maximum CK-MB was significantly lower in Group L (Group M 48±107 IU/l, Group L 13±16 IU/l, p=0.005) and the patients with CK-MB more than 12 IU/l was significantly frequent in Group M (Group M 73%, Group L 33%, p<0.0001). Postoperative ICU and hospital stay period was significantly shorter in Group L (ICU stay : Group M 3.4±2.3 days, Group L 2.0±1.4 days, p<0.0001, hospital stay : Group M 27±21 days, Group L 16±7 days, p<0.0001). The patency of the graft to the left anterior descending artery did not differ significantly (Group M 94%, Group L 99%), however the patencies of the grafts to left circumflex artery and right coronary artery were significantly better in Group L (left circumflex artery : Group M 75%, Group L 98%, p=0.001, right coronary artery : Group M 81%, Group L 98%, p=0.014). Left side pericardiotomy seemed to be useful because OPCAB with left side pericardiotomy yielded shorter operation time, less myocardial enzyme release, improved postoperative recovery and better patency of graft to the left circumflex and right coronary artery.

This study was designed to evaluate the optimal surgical treatment strategy for abdominal aortic aneurysm (AAA) coexisting with coronary artery disease (CAD). Twenty-six patients (21 men and 5 women with a mean age of 72.6±3.7 years old) who required surgical treatment of both conditions were examined. Eleven patients underwent a one-stage operation. Four of them had on-pump CABG and 7, including 3 high-risk-patients, underwent off-pump CABG. There were no operative mortalities, but 3 patients had severe morbidity (respiratory failure, acute renal failure, pneumonia). Fifteen patients underwent a two-stage operation. None of them had rupture of the AAA during the interval between the two operations, but 2 patients with large AAA (more than 6cm in diameter) required emergency operation due to impending rupture of the AAA. There was no operative mortality, but one patient suffered acute renal failure. One-stage operation for low-risk patients seems to be a safe and reasonable strategy. One-stage operation for high-risk patients should be performed cautiously, and off-pump CABG is especially useful in such patients.

A 72-year-old woman underwent a double aortic valve replacement with the Freestyle aortic bioprosthesis and subcoronary implantation with the Mosaic mitral bioprosthesis because of rheumatic multivalvular heart disease in 2000. During her annual follow-up, her Sinotubular junction was observed to have gradually increased in diameter on echocardiography and computed tomography. Therefore, 9 years after surgery we performed a reoperation for severe aortic regurgitation. Intraoperatively, the stentless bioprosthesis was found to be structurally intact. We believe that the dilation of the Sinotubular junction associated with a stentless bioprosthesis in the subcoronary position have caused her severe aortic regurgitation.

A 78-year-old woman underwent mitral valve replacement (MVR) with bioprosthesis in 1984. By 1997 the valve had become dysfunctional and was replaced with a Mosaic valve. Dyspnea on exertion occurred in 2005 and a systolic murmur was detected at that time. Echocardiography revealed severe mitral regurgitation (MR). The mitral valve was replaced for the third time. The explanted valve showed commissural dehiscence at the stent position and calcified leaflets. The mitral valve of a 70-year-old man was replaced with a bioprosthesis in 1986, and again with a Mosaic valve in 1997 because the original bioprosthesis had become dysfunctional. Seven years later, a systolic murmur appeared and echocardiography revealed severe MR. The valve was replaced for the third time. A leaflet tear was found in the removed valve. The Mosaic valve is a third generation porcine bioprosthesis that reportedly has excellent long-term durability. However, in these cases, the Mosaic valves deteriorated prematurely, and no obvious causes of this early structural deterioration could be identified. Continued long-term follow up is necessary, and the possibility of premature deterioration should be considered when selecting bioprostheses.

Vasculo-Behçet disease (VBD) is a special type of Behçet disease (BD) involving some vascular disorders like aneurysmal formation, arterial occlusion, and venous thrombosis in various vessels. VBD has a poor prognosis due to aneurysmal rupture or recurrence of vascular disorders despite optimal treatment. However, definite diagnosis in BD is made on the basis of clinical features, and early diagnosis is difficult. We report 2 patients whose first clinical symptoms were femoral-pseudoaneurysms. They received a diagnosis of VBD after surgery. The first patient was a 69-year-old man, who underwent autologous-vein patch closure of a perforated region in the left femoral artery. One year later, he had a pseudoaneurysm of the right profunda femoris artery, which was ligated. The second patient was a 51-year-old man, who underwent the interposition of the saphenous vein for defective artery due to left superficial femoral-pseudoaneurysm.

We encountered a rare case of a 75-year-old woman who fell into right ventricular failure and shock with a comparatively rapid course due to a huge primary right atrial angiosarcoma occupying the right atrium. An emergency surgical excision of the tumor was performed and the right atrium was reconstructed with an EPTFE patch under cardiopulmonary bypass. On account of the positive margin, postoperative radiotherapy was added. There was no local recurrence, but adjuvant chemotherapy was performed for multiple lung and liver metastases 14 months after surgery. Primary cardiac angiosarcomas are extremely rare and have dismal prognoses. Although a complete surgical resection is the cornerstone of treatment, multidisciplinary therapy may improve patient outcomes.

We report a case of thoracic endovascular aortic repair (TEVAR) with a fenestrated stent graft for ulcer-like projection (ULP) of the proximal anastomosis after total arch replacement (TAR) for acute type A aortic dissection (DAA). A 73-year-old woman with a history of surgical resection of a left atrial myxoma in January 2009 underwent TAR for DAA in November 2011. The contrast enhanced CT (CE-CT) 72 days after TAR revealed two ULPs anterior and posterior to the proximal anastomosis. Surgical repair would be difficult because of the history of cardiac and aortic surgery, therefore TEVAR with a fenestrated stent graft was performed. The postoperative course was uneventful and she was discharged on the 8th postoperative day. The CE-CT 3 months after TEVAR showed almost completely thrombosed ULPs. Endovascular repair with fenestrated stent graft for the proximal anastomotic ULP can be a useful and effective treatment.