A 25-year-old woman, at 38 weeks of gestation, suddenly developed a left lumbar pain. Emergency cesarean section was performed to rescue the fetus since there was fetal bradycardia. At operation, a slight amount of retroperitoneal hematoma was observed, but was left without further examination. After the surgery, the patient complained of severe lumbar pain and fell into shock. A ruptured aneurysm of the left renal artery was suspected by computed abdominal tomography. At the second operation, a massive hematoma was observed in the retroperitoneal space, and a ruptured aneurysm of the left renal artery was confirmed after mobilization of the left kidney with the aid of manual hemostasis. Aneurysmectomy with arterial reconstruction was not considered feasible, and complete left nephrectomy was done because the patient was severely ill, in addition to the fact that the aneurysm was located at the trifurcation of the left main renal artery. The postoperative course was uneventful. On the surgical specimen the aneurysm measured 27mm in circular length, the lower half of which was ruptured. Histologically, the internal elastic lamina was torn, and the medial smooth muscle fibers were sporadically replaced with fibroblastic cells. The prognosis of ruptured aneurysm of a renal artery is often lethal. Therefore it is very important to suspect this lesion when we have to manage physical problems with patients in pregnancy so that we can make an early diagnosis with better results.

Case 1 presented congestive heart failure with atrial fibrillation. Echocardiography and cardiac catheterization demonstrated mitral regurgitation and communications between the right and left coronary arteries and pulmonary artery (PA). The fistula orifice was directly closed and mitral annuloplasty was done at the same time. Case 2 had a history of open mitral commissurotomy for mitral atenosis (MS), and was diagnosed as to be re-MS. Selective coronary angiography (CAG) newly documented an aberrant artery originating from the left coronary artery and draining into the distal right PA. At operation, the origin of the aberrant artery was successfully ligated, and mitral valve was replaced with a prosthetic one. This paper presented relatively rare types of coronary artery fistulae, focusing on the importance of routine CAG before open heart surgery and of consideration on the association of this anomaly in respect to perioperative myocardial protection.

A 53-year-old man underwent aortic and mitral valve replacement, but postoperative cardioangiograms unexpectedly demonstrated aneurysms that had developed right-anteriorly and exactly anteriorly to the ascending aorta. They were initially thought to be pseudoaneurysms formed at the sites of aortotomy for valve replacement and of the aortic hole made by the needle puncture for air-venting. Operative findings, however, strongly suggested that it was a DeBakey type II dissecting aneurysm with two entries at the same sites as described. It was found that almost all distal parts of the aneurysmal cavity, probably a pseudolumen, had been occluded with clots, leaving two round cavities at the entries, which were preoperatively observed as pseudoaneurysms. The entries were successfully closed with approximation of the aortic walls using cardiopulmonary bypass, and the patient survived the operation.

We performed the thromboexclusion procedure with reconstruction by an axillo-bifemoral bypass for unresectable abdominal aortic aneurysm combined with chronic renal faliure, and obtained satisfactory postoperative result. The patient was a 68-year-old male who suffered from a huge abdominal aortic aneurysm (AAA) and had a history of hypertension and chronic renal failure. The AAA was accompanied with a saccular portion 10cm in diameter which compressed and eroded the vertebral body. Aortic cross-clamping above the bilateral renal arteries was inevitable for resection in spite of the renal dysfunction. We decided that direct manipulation of the aneurysm was impossible despite it being on the verge of rupture, considering the high operative mortality. We employed the exclusion-bypass method to stabilize the aneurysm, that is, we constructed axillo-bifemoral bypass using a knitted Dacron T-graft 8mm in diameter and then intercepted the bilateral common iliac arteries by suture closure. Postoperative intraaneurysmal thrombosis progressed rapidly from the distal side, then it halted just below the bilateral renal arteries on the 12th postoperative day. Renal arterial flow was maintained and renal function improved. Bleeding from the operative wound occurred suddenly on the 5th postoperative day. Although this appeared to be disseminated intravascular coagulation initially, it had resulted from augmentation of fibrinolysis due do acceleration of coagulation. The markers of fibrinolysis for example α₂ plasmin inhibitor (α₂PI) and plasmin-α₂ plasmin inhibitor complex (PIC) were useful for diagnosis, and tranexam acid and aprotinin were effective for therapy. Although the exclusion-bypass method is technically less invasive and useful for high-risk AAA, the postoperative management is not easy because of the acceleration of the coagulation-fibrinolysis system.