A 68-year-old woman on chronic hemodialysis was admitted to our hospital for further evaluation because of recurrent angina 14 months after coronary bypass surgery (left internal thoracic artery-left anterior descending artery (LITA-LAD), gastro-epiploic artery-4 posterior descending artery (GEA-4PD), saphenous vein graft-#9-#14 sequential (SVG-#9-#14 sequential)). On coronary angiography, a localized 90% stenosis of the vein graft was present at the anastomosis with the diagonal branch of the native coronary artery. Although the lesion was relieved with a 5mm balloon catheter inflated to 14 atmospheres, contrast injection demonstrated extravasation of dye into the pericardial space, indicating vein graft rupture. Repositioning the inflated balloon across the rupture site for hemostasis was unsuccessful, and the patient was transferred to the operating room. Emergency reoperation was accomplished through a left lateral thoracotomy without cardiopulmonary bypass. Although hemorrhage was not noted at the rupture site, the vein graft was ligated at the proximal and distal portions of the rupture, followed by a new vein graft bypass. Postoperative cardiac catheterization clearly demonstrated the patent graft. Although localized hypokinesis was observed in the lateral wall on postoperative echocardiography, the left ventricular ejection fraction was 67%, her activity level was good, and she had no angina.

Redo of off-pump coronary artery bypass grafting (CABG) through a left thoracotomy with a patent left internal thoracic artery graft was very effective. A 62-year-old man was admitted because of unstable angina for whom CABG had been performed 6 years earlier (LITA-LAD, Ao-SVG-OM1), the saphenous vein graft soon become occluded. Coronary angiography revealed total occlusion of the right coronary artery (RCA)#1. For vasoconstruction of the left circumflex artery (LCx) and RCA, off-pump coronary artery bypass (OPCAB) was performed through a left thoracotomy. During normal cardiac contraction, a radial artery graft (RAG) was anastomosed sequentially from the descending aorta to the obtuse margin (OM) 1, OM2, RCA#4PL (postero-lateral branch). The postoperative course was uneventful and he was discharged on the 26th post-operative day. In patients with patent grafts, re-median sternotomy has a high risk of injury to already patent grafts and adhesions make the dissection difficult. Alternatively, as in this case, off-pump coronary artery bypass through a left thoracotomy can be very effective. Total arterial vasoconstruction was performed and postoperatively there was no early graft occlusion.

A case of multiple coronary artery aneurysms associated with bilateral coronary-pulmonary artery fistulae is described. A 60-year-old man was found to have a continuous heart murmur. Plain chest X-ray showed mild cardiomegaly and an abnormal shadow at the left periphery of the heart. Enhanced chest CT revealed multiple round masses around the main pulmonary artery. Cardiac catheterization studies confirmed the presence of a left-to-right shunt of 26% at the site of the main pulmonary artery, with a pulmonary-to-systemic flow ratio of 1.35:1. Coronary angiography revealed multiple coronary artery aneurysms associated with bilateral coronary-pulmonary artery fistulae and an abnormal coronary artery adjacent to the right coronary artery. Mild aortic regurgitation was also noted on ascending aortography. On February 10, 2006, surgical intervention was undergone. The maximum diameter of the coronary artery aneurysms was 4cm and the aneurysmal wall was very thin. Dilated abnormal vessels connected with the aneurysms were also noted. Under complete cardiopulmonary bypass, extirpation of the aneurysms and ligation of the abnormal vessels were performed. Although the main pulmonary artery was opened to inspect the draining portion from the fistula, the orifice could not be confirmed. The aortic valve was replaced with a mechanical prosthesis. Histopathological findings of the excised specimen included fibrosis, myxoid change, and calcification. The postoperative clinical course was uneventful, and no residual mass was noted on chest CT. The patient was discharged on the 14th postoperative day.

A 47-year-old man with active aortic valve endocarditis underwent direct closure of a paraannular abscess and valve replacement. Methicillin-resistant Staphylococcus aureus was isolated from his blood culture preoperatively. Because of a postoperative paravalvular leak (PVL) and an echo-free space suggesting a residual cavity, he was reoperated for patch closure of the aneurysm and prosthetic valve replacement. However, the PVL and paraannular cavity were still observed after the 2nd surgery. At the 3rd operation, prosthetic valve detachment along one fourth of its circumference was confirmed, and the cavity was fully opened. A patch was used to cover the pseudoaneurysm and was placed under the orifice of the left coronary artery. This patch repair of the cavity was accomplished, followed by prosthetic valve replacement in situ. Trivial PVL was identified after the operation, and a diagnosis of intravascular mechanical hemolysis was made. Clinical examination revealed partial detachment of the prosthetic valve resulting in a significant PVL and paraannular pseudoaneurysm. Because of unremitting hemolysis and the increased PVL, the patient underwent a 4th repair. Inspection showed that the prosthetic valve was partially detached and the defect was opened at the upper edge. The orifice of the aneurysmal was covered, and valve replacement was performed in the supraannular position using 3 U-stays, which were passed through both the aortic wall and the patch, followed by ascending aortic graft replacement. In the case of aortic valve endocarditis with paraannular involvement, radical debridement and complete reconstruction of the left ventriculoaortic discontinuity without tension are required.

A 6-year-old girl who had undergone repair of an endocardial cushion defect 4.5 years previously, developed discrete subaortic stenosis requiring surgical intervention. On two-dimensional echocardiography a membrane was visualized below the aortic valve. A pressure gradient of 97mmHg was recorded across the left ventricular outflow tract by cardiac catheterization. Operative findings showed a fibrous ring tissue just below the aortic valve, which was peeled away by sharp dissection. Postoperative cardiac catheterization revealed a 25mmHg pressure gradient across the left ventricular outflow tract. Two years later, she continues to do well and the pressure gradient remains unchanged on Doppler echocardiography.

We present a case of solitary arteriosclerotic aneurysm of the profunda femoris artery (PFA), which is very rare among peripheral aneurysms and a reviewed the 19 cases reported in the Japanese literature. A 78-year-old man had a chief complaint of a painful pulsatile mass in the left thigh. Enhanced CT showed the ruptured solitary aneurysm of the PFA. The aneurysm was 6.8cm in diameter. It was removed after ligation of the the PFA. In the Japanese literature, the mean age of patients with solitary arteriosclerotic aneurysm of the PFA was 73 (64-84), all patients were males, the rate of rupture of PFA aneurysm was 47%, and the mean diameter was 8.9cm. In our case, we simply ligated the aneurysm because the patient did not have any evidence of peripheral artery occlusive disease and the distal artery of the aneurysm was very small. However, there is a need to reconstruct the PFA whenever possible because the surgical importance of PFA in occlusive arterial disease has been recognized.