We report a case of localized abdominal aortic dissecting aneurysm, diagnosed in association with an intractable ulcer on the right leg. The patient, a 62-year-old man, with a history of hypertension and hyperlipidemia, was admitted to another hospital for hematemesis and phlegmon of the left lower leg. He subsequently needed intensive care, including mechanical ventilation, because of loss of consciousness and extreme leucocytosis caused by meningitis. The skin ulcer that developed on his right leg leaked gabexate mesilate, which had been administered to treat disseminated intravascular coagulation. The ulcer was resistant to several surgical treatments, including skin graft implantation. As he complained of intermittent claudication, ischemia of the right lower limb was suspected. Angiography and computed tomography revealed infrarenal abdominal aortic dissecting aneurysm and occlusion of the right common iliac artery. He was referred to us for surgery. After performing a median laparotomy, we resected the aneurysm and implanted a Y-shaped prosthetic graft. The postoperative course was uneventful, and the patient was discharged 4 weeks after operation. The surgical indications of infrarenal abdominal aortic dissecting aneurysm are the same as those for abdominal aortic aneurysm.

A 72-year-old man presented with acute abdominal pain from the left lateral to the left lower quadrant. His medical history included hypertension and hyperthyroidism. Four days after the onset, abdominal computed tomography revealed left hydronephrosis and a solitary left common iliac aneurysm obstructing the left ureter. The irregularity of the pelvic border made us suspect injuries to the left pelvis. We diagnosed acute left hydronephrosis, caused by the ureteral obstruction due to the left common iliac aneurysm. The aneurysm was replaced with a prosthetic graft to remove the pressure on the urinary tract. We did not try to dissect the left ureter from the aneurysmal wall. The postoperative course was uneventful, and the ureter recovered from the obstruction.

We report a case of superior mesenteric arterial revascularization by bypass grafting between the right external iliac artery and the superior mesentery artery for intestinal ischemia by the superior mesenteric arterial dissection associated with Stanford type B, DeBakey type III b acute aortic dissection. The patient was 48-year-old man with Marfan's syndrome. He had received aortic root replacement with a composite graft 10 years ago. He suffered from sudden back pain and severe abdominal pain. Contrast enhanced computed tomography revealed the superior mesenteric arterial dissection accompanied by Stanford type B acute aortic dissection. We performed bypass grafting using the greater saphenous vein between the right external iliac artery and the superior mesentery artery. A year later, we performed replacement of the descending thoracic aorta. The vein graft is patent, and he has been doing well since the operation.

In patients with type I CD 36 deficiency, immunization with CD 36 antigen (Nak^a) through pregnancy or transfusion, could produce anti-CD 36 antibody (anti-Nak^a), and potentially lead to platelet transfusion refractoriness or posttransfusion purpura. We report a 72-year-old woman who had no history of pregnancy or previous blood transfusions. She had been treated medically for hypertension and heart failure since the age of 65 years. Type I CD 36 deficiency was also diagnosed based on the findings of ¹²³I-β-methyl-iodophenyl pentadecanoic acid cardiac scintigraphy. At 72 years of age, she suffered acute thromboembolism in the left external iliac artery. The thrombus was removed and a left external iliac artery to left superficial femoral artery bypass was performed without any blood transfusion. Echocardiography, left ventriculography and coronary angiography showed left ventricular aneurysm and coronary artery disease. Resection of the left ventricular aneurysm and coronary artery bypass grafting were performed without donor blood transfusion. Autotransfusion by autologous blood donation and intraoperative autologous blood transfusion was used to avoid sensitization by the CD 36 antigen through donor blood transfusion. Autotransfusion should be performed to avoid complications associated with donor blood transfusion particularly in patients with type I CD 36 deficiency.

The patient was a 75-year-old woman, who had been treated for tuberculosis by artificial right pneumothorax at the age of 25. Although a cardiac murmur had been pointed out in her infancy, no treatment had been recommended because she had no symptoms. Effort dyspnea augmented along with her aging by degrees. She began to need oxygen therapy at the age of 75. She had her calcified ductus arteriosus. The systemic to pulmonary blood flow ratio (Qp/Qs) was 1.89. We diagnosed that pulmonary dysfunction after artificial right pneumothorax and pulmonary hypertension caused by persistent ductus arteriosus were the cause of her symptoms. After median sternotomy we closed the persistent ductus arteriosus using a patch through the pulmonary artery under cardiopulmonary bypass. Although she needed respiratory management with a ventilator for 2 days and oxygen therapy for 4 weeks, she has been doing well afterwards. We think that we should close persistent ductus arteriosus even in the elderly.

The patient was an 86-year-old man, whose medical history included pulmonary tuberculosis, pulmonary emphysema, hypothyroidism, subtotal gastrectomy for gastric cancer and proctectomy for rectal cancer. Since he suffered sick sinus syndrome (bradycardia-tachycardia syndrome), a DDD pacemaker was implanted using the right subclavian vein approach. Three months later, he suffered from a pacemaker infection of Methicillin-resistant Staphylococcus aureus. We performed extraction of the infected pacemaker system and implanted a new pacemaker. Because he had thoracic deformity, colostomy, and was in poor condition in general, we implanted the myocardial electrode through a small thoracotomy at the 6th costal bed under local anesthesia. The postoperative course was uneventful and there was no relapse of infection. Although this method is conventionally performed under general anesthesia, it is also possible to perform it under local anesthesia in selected patients. This method could be an alternative when endocardial electrode insertion is very difficult.

To evaluate whether general medicine training in our general ward has beneficial effects on postgraduate surgical training, questionnaires on general medicine training was sent to 30 doctors who had undergone initial training as residents in our hospital and were involved in surgical practice at the time of the survey. Twenty-two responses were obtained. Fifteen respondents had motivation for general practice at the beginning of their residency, and 20 attained their objectives during the 2-year training. Nineteen respondents appreciated their experiences in managing a variety of diseases encompassing the disciplines of internal medicine and surgery, although 12 complained of a shortage of teaching staff. From the viewpoint of its contribution to their present practice, their training in the general ward was evaluated by all respondents as having been beneficial. We conclude that general medicine training has beneficial effects on postgraduate surgical training that emphasizes comprehensive patient care.