Six surgical cases of localized abdominal aortic dissections experienced from 1977 to August, 1992 comprised 1.1% of all true aneurysms of the abdominal aorta (563 cases) and 2.5% of all aortic dissections (242 cases) for the same period. The mean age of the 6 patients at operation was 70 years (range from 62 to 74 years, 2 males, 4 females). All dissections were localized at the infrarenal abdominal aorta and one case showed three-channeled dissection. All cases were diagnosed preoperatively and prosthetic graft replacement was performed. Localized abdominal aortic dissection was reported in only 30 cases, including our cases, in the Japanese literature. Compared to thoracic aortic dissection, the development of symptoms is slow, age is high and the condition is often accompanied by hypertension and atherosclerosis.

A 75-year-old man with severe mitral valve regurgitation and 80% stenosis of the right internal carotid artery was referred to us for surgical treatment. He had a history of ipsilateral cerebral artery thrombosis 28 months previously. Although preoperative percutaneous transluminal carotid angioplasty with stenting (PTCAS) was performed, 60% stenosis of the artery still remained. He underwent mitral valve repair 2 months after PTCAS due to cardiac symptom progression. Intraaortic balloon pumping was used to maintain higher pressure during the extracorporeal circulation of the heart surgery. He recovered uneventfully and without any cerebral complications.

Between 1988 and 1991, 231 patients underwent surgical repair for abdominal aortic aneurysm. Among them 132 patients underwent isolated Y graft replacement electively. They were divided into two groups, according to the operative procedure; transperitoneal approach (n=51) and retroperitoneal approach (n=81), and the surgical results were compared retrospectively. There was no significant difference in operative time, amount of operative bleeding, operative transfusion, total transfusion, autotransfusion, duration of intubation, total use of analgesia or length of postoperative stay in the two groups. The amount of fluid drained from the nasogastric tube was significantly greater in the transperitoneal group. The initiation of drinking and eating were both significantly prolonged in the transperitoneal group. The transperitoneal approach is indicated for cases with thoracic or thoracoabdominal aneurysm which may be operated on in the future, cases of bilateral common iliac aneurysms and cases with heart disease. Otherwise it is preferable to select the retroperitoneal approach as the first choice for elective surgical treatment of abdominal aortic aneurysm, because the retroperitoneal approach is superior in terms of the recovery of gastro-intestinal movement.

A 41-year-old woman was given a diagnosis of Behçet's disease at age 25. When she was 31, a large aortic pseudoaneurysm developed near the left renal artery. Isolation of the aneurysm and anatomical grafting and ancillary bypass were performed. Ten years later, a graft duodenal fistula developed. Extra-anatomical reconstruction was done after complete resection of the original graft and the infectious lesion. It was found that the intra-abdominal organs were receiving blood supply only from the inferiol mesenteric artery. Moreover, severe ischemia of the intra-abdominal organs was a concern during surgery. Therefore, hepatic vein oxygen saturation was monitored continuously with a Swan-Ganz catheter for ischemia of the intra-abdominal organs. It proved to be a very effective indicator and we could perform this operation safely. Reoperation of grafting is often inevitable in patients with Behçet's disease. Also, two stumps of abdominal aorta were left in this patient because of the extra-anatomical reconstruction. Pseudoaneurysm may later occur at the site of the stumps, thus necessitating careful follow-up observations.

A 52-year-old man was referred to our institution because of a solitary aneurysm of the left common iliac artery. The presence of the aneurysm was demonstrated by CT and angiography. The aneurysm had a diameter of about 30mm. The walls of the bilateral external iliac arteries were irregular, like a string of beads. The aneurysm was resected and replaced with a vascular prosthesis. Histological examination of the aneurysm and a part of the left external iliac artery indicated a diagnosis compatible with fibromuscular dysplasia (FMD: medial fibroplasia). A solitary iliac aneurysm is rare, and is usually due to atherosclerosis. However, the aneurysm in this case was related to FMD. To the best of our knowledge, only one other case of a solitary common iliac aneurysm caused by FMD has so far been described.

Intravenous leiomyomatosis (IVL) is defined as the extension into the venous channels of histologically benign smooth muscle tumors originating either from a uterine myoma or from the walls of a uterine vessel. We report a case of IVL extending to the right atrium and right ventricle through the right internal iliac vein and the inferior vena cava. The patient was a 43-year-old woman. The tumor was extirpated by simultaneous median sternotomy and laparotomy with the use of cardiopulmonary bypass. It was necessary to use cardiopulmonary bypass in order to open the right atrium. However, it proved difficult to insert the venous cannulae into the inferior vena cava due to the presence of the tumors. In order to perform the cannulation, a trans-right atrial excision of this tumor was necessary. Nevertheless, hemodynamic deterioration tended to occur during the procedure because of unexpected bleeding. We believe that to safely carry out this operation, it would be better to ensure circulatory arrest before trans-right atrial excision of the tumor. We have been continuing preventive antiestrogen therapy because recurrence would be very likely if any tumorous tissue remained after surgery. Fortunately, no intravenous infiltration of the tumor has been detected by either pelvic computed tomography or ultrasonography during the 26-month follow-up period. Surgical excision of the tumors and postoperative medication are now believed to have been effective.