A 67-year-old man was considered a candidtate for CABG because coronary angiogram showed obstruction segment 6 and stenoses of segments 9 and 12. He underwent emergency CABG due to acute myocardial infarction (AMI) with cardiogenic shock caused by hemorrhage from a gastric ulcer. Because of hypoxia due to pulmonary edema and acute renal failure an intraaortic baloon was inserted. He had a history of cerebrovascular stroke. Although coronary angiogram revealed multiple vessel disease, we performed off-pump coronary artery bypass (saphenous vein graft-left anterior descending artery) for salvage, because cardiopulmonary bypass was considered very risky and further systemic heparinization might be fatal. He has returned to his job, and is now free from angina. As AMI with cardiogenic shock is often caused by a lesion in the LAD, CABG without cardiopulmonary bypass may be an effective technique in certain selected patients.

NIPPV provides positive pressure ventilation through a face mask without intubation. We performed NIPPV for 2 patients with acute respiratory failure following cardiovascular surgery. (Case 1) A 63-year-old man, who had had COPD (Hugh-Jones class III), underwent replacement of the aortic arch. He was extubated after 5 days. However, he was re-intubated under controlled ventilation because of deterioration of his respiratory condition. The patient had NIPPV after extubation on postoperative day 14 because he was alert and had no cardiovascular compromise. On the 18th postoperative day he was weaned from NIPPV. (Case 2) A 67-year-old man underwent coronary artery bypass surgery. On the next day he was extubated, but he suffered from hypoxemia due to impaired respiratory condition on postoperative day 3. The patient underwent NIPPV instead of conventional mechanical ventilation because his condition was stable except for respiration. Respiratory condition improved quickly and he was weaned from NIPPV on the 7th postoperative day. NIPPV is an effective method for managing patients with acute respiratory failure after cardiovascular surgery.

We report a case with successful surgical resection for a leiomyoma with an extension into the right atrium from the pelvic vein. The patient was a 54-year-old woman who presented with syncope in 1989. She had had a history of resection of a uterine leiomyoma 10 years previously. Preoperative angiograms showed a long tumor with an extension into the right atrium through the inferior vena cava originating from the right internal iliac vein. The diagnosis of intravenous leiomyomatosis was made. The operation was performed through a median sterno-laparotomy using cardiopulmonary bypass with successful results. Histologic sections showed a benign leiomyoma. To our knowledge, 20 cases of resection of intravenous leiomyomatosis with the use of extracorporeal circulation have been reported in the literature. This rare condition was discussed with the review of the literature.

We studied the incidence of associated ischemic heart disease (IHD) among 143 consecutive patients (male 118, female 25, mean age 68.5±6.9 years) operated upon for abdominal aortic aneurysm (AAA), excluding ruptured aneurysms. The screening of IHD was routinely performed by using dipyridamole thallium scintigraphy, and when it was positive, the lesion was further confirmed by selective coronary angiography. More than 50% luminal stenosis of the major coronary arteries was judged positive for IHD. Sixty-two patients (43%) with AAA were simultaneously afflicated with IHD. We also compared the 62 AAA patients with IHD with the remaining 81 AAA patients in this series. The patients with IHD had higher incidences of risk factors such as diabetes mellitus (p=0.0031) and hyperlipidemia (p=0.0029) than those without IHD. Five patients were operated on for AAA after coronary artery bypass grafting (CABG), 11 were operated on for AAA and IHD (CABG) simultaneously, 10 were operated on after PTCA, thirty-two patients underwent elective surgery for AAA and four had emergency procedures due to impending rupture of AAA with continuous infusion of nitroglycerin with or without diltiazem. There was no significant difference in surgical mortality between AAA patients with IHD and those without IHD (3%vs2%), and no cardiac death in this series. When both AAA and IHD are severe enough to warrant surgical treatments at the earliest opportunity, we recommend concomitant operations for AAA and IHD (CABG) since these have been performed quite successfully in our series.

A 76-year-old man with multivessel disease in the coronary artery and abdominal aortic aneurysm, including the bilateral common iliac artery aneurysms, underwent off-pump coronary artery bypass (OPCAB) combined with repair of the aneurysms. We were able to perform three coronary artery bypass graftings (left internal thoracic artery-left anterior descending artery, saphenous vein graft-diagonal branch, and saphenous vein graft-atrio-ventricular branch) using an Octopus 2 and a“Lima”suture technique without cardiopulmonary bypass. The postoperative course was uneventful. All grafts were patent on postoperative angiograms. OPCAB combined with repair of abdominal aortic aneurysm was useful for the high-risk patient.

A 77-year-old man had undergone CABG (coronary artery bypass grafting) (SVGs (saphenous vein grafts) to LAD (left anterior descending coronary artery), OM (obtuse marginal) and RCA (right coronary artery)) 15 years previously. Three years previously, he underwent CABG again (LITA (left internal thoracic artery)-OM, RGEA (right gastroepiploic artery)-RCA) due to recurrence of angina pectoris, but there was no evidence of graft disease in the SVG to the LAD. Six months before the present procedure, graft disease developed in the SVG to the LAD and caused unstable angina pectoris. Therefore, the left axillary artery was bypass grafted to the coronary artery (LAD) using SVG without cardiopulmonary bypass by means of the MIDCAB (minimally invasive direct coronary artery bypass) technique. The patient has had no angina pectoris subsequently. Postoperative angiography revealed that the graft was patent. The axillo-coronary (LAD) bypass appears to be a useful procedure for re-revascularization to the LAD in patients with no available arterial graft, such as ITA (internal thoracic artery) or RGEA.

Retroperitoneal lymphocele is a very rare complication of abdominal aortic aneurysm repair. An abdominal aortic aneurysm 5cm in diameter was repaired with the retroperitoneal approach in a 70-year-old man. On the 17th postoperative day, mild abdominal distention was reported and a fever of 38°C had developed. A computed tomography scan demonstrated massive fluid collection in the retroperitoneal cavity. Total parenteral nutrition with complete fasting was initiated. A pigtail catheter was inserted into the cavity, and 1, 000ml of milky, odorless, alkaline and sterile fluid was drained. Subsequently, a retroperitoneal lymphocele following abdominal aortic surgery was diagnosed. The leaking lymph tract was ligated because the lymphocele did not improve with long term drainage. Administration of ice cream through the nasogastric tube was used to detect the leaking lymph tract, and we ligated the leaking lymph tract completely. We believe that surgical repair is an alternative strategy when conservative treatments, i. e., fasting, intravenous hyperallimentation and drainage are not effective.

We performed redo coronary artery bypass grafting (CABG) using lateral MIDCAB for 3 patients with severe symptomatic ischemia in the left circumflex system alone. When the descending thoracic aorta had no atherosclerotic lesions on chest CT, it was selected as the inflow of the bypass. According to the location of the target artery, we undertook sequential or T-composite off-pump bypass using the radial artery through a left lateral thoracotomy. On the other hand, when the descending aorta was diseased, the left axillary artery was chosen as the inflow of the bypass. We selected the saphenous vein as a conduit to obtain sufficient graft length. A proximal anastomosis was made through a left infraclavicular incision, and then a distal anastomosis was done through a left lateral thoracotomy without cardiopulmonary bypass. Moreover, care was taken not to kink the grafts. The postoperative course was uneventful in all patients. Lateral MIDCAB technique was useful for redo revascularization to the circumflex system. We believe that selection of bypass conduits, routes, and bypass inflow according to the individual patient is essential for the procedure.

Multivessel coronary artery bypass grafting (CABG) utilizing ITA grafts was performed in 110 consecutive patients, ranging in age from 24 to 76 years with a mean of 54±9 years. A mean of 3.2±0.8 grafts per patient was placed with a hospital mortality of 0.9%. Bilateral ITAs (BITA) were used in 87 patients and sequential ITA grafting (SQ-ITA) was carried out in 31, and both BITA and SQ-ITA were used in 8 patients. Noncardiac late death occurred in 1 patient and a 5-year survival rate was 98%. During this follow-up term, 11 (10%) patients underwent low-risk PTCA for ITA anastomotic stenosis (4 lesions), SVG stenosis (5 lesions) and native coronary stenosis (4 lesions) with a success in all. No reoperation has been required so far in this series. Graft patency rates were 97% for BITA with no differences for the left and right ITAs, and 100% for SQ-ITA (both proximal and distal). No sternal infection was encountered in this series, on which we believe mediastinal, sternal and subcutaneous irrigation appeared most effective. In BITA grafting, right ITA was frequently anastomosed to the LAD, passing on the aorta, which will make reoperation through a median sternotomy dangerous to this graft. To improve safety for reoperation, we have covered the ITA graft with an 8mm EPTFE graft or membrane with no side effects on ITA grafts. However, true efficacy of this protective method remains unproved because no reoperations have been required in this series of patients.

The sudden onset of anuria in a 71-year-old man was found to be caused by the non-inflammatory (atherosclerotic) large abdominal aortic aneurysm compressing the bilateral ureters. A computed tomography scan demonstrated the bilateral extrinsic ureteral obstructions due to the large aneurysm of 13cm in diameter, left hydronephrosis and no thick layer of perianeurysmal fibrotic tissue. On the 9th day from the onset of anuria, an emergency operation was performed. There was no fibrotic adhesions around the aneurysm and mobilization of the aorta was easy. A straight Dacron prosthesis was inserted between the infrarenal aorta and the bifurcation of the abdominal aorta following resection of the aneurysm of the atherosclerotic origin. Soon after the operation, the patient had very good urinary output with adequate recovery of renal function. This case seems to be very uncommon, but very important in the surgical management of abdominal aortic aneurysm complicated by oliguria or anuria.