An 81-year-old man complaining of back pain was admitted. Computed tomographic scan revealed an aortic arch aneurysm and an abnormal retroesophageal artery. It was believed to be an aberrant right subclavian artery. The diagnosis was confirmed by angiogram. Although there was no evidence of rupture, his back pain prompted us to perform emergency surgery. Through median sternotomy using a cardiopulmonary bypass, systemic hypothermia and selective cerebral perfusion, total arch replacement was done. There was evidence of impending rupture, which was probably the cause of his back pain. The proximal portion of the aberrant right subclavian artery was severely calcified, so the right subclavian artery was reconstructed. It was anastomosed with one branch of the arch graft which passed the anterior of the trachea. The postoperative course was uneventful. We believe median sternotomy was a proper approach for such a situation.

A 74-year-old woman presented with a pulsatile mass and pain in the right mid-thigh. Angiography demonstrated a ruptured solitary aneurysm at the superficial femoral artery (SFA), 45mm in diameter. The operation consisted of replacement of the aneurysm with a saphenous vein bypass grafting to the SFA. The pathological examination of the resected arterial wall revealed degenerative changes due to cystic medial necrosis. In the literature, there has been no report, as far as we know, on true aneurysm of the superficial femoral artery caused by cystic medial necrosis. Therefore, it is considered that our case is a very rare presentation of aneurysm with this particular etiology which occurred in the peripheral artery of a lower extremity.

Dacron grafts have made great progress and the material has become almost perfect recently. However, we encountered a rare case of a late-graft complication. A 34-year-old man was operated on for coarctation of the aorta in July 1982. Left subclavian artery-descending aortic bypass was performed using a Cooley double velour knitted graft. Eighteen years later, the patient was admitted to our hospital with an abnormal shadow in his chest X-ray. Angiography and computed tomography demonstrated a non-anastomotic aneurysm of the graft. Under cardiopulmonary bypass and deep hypothermic circulatory arrest, reoperation with a woven Dacron graft was successfully performed. This case suggests that it is important to follow up patients with implanted Dacron arterial prostheses because of the potential for rupture.

Gelatin-resorcin-formalin (GRF) glue has been widely used in repair of dissected aortic wall tissue, and the use of GRF glue has been reported to significantly reduce mortality from this surgical emergency. On the other hand, various late complications possibly due to GRF glue have also been reported. We performed reoperations after total arch replacement for acute type A aortic dissection using GRF glue in 2 cases. In case 1, total arch replacement was performed 3 years ago. Pseudoaneurysms of the aortic root and brachiocephalic artery and redissection of the descending aorta were revealed by subsequent computed tomography (CT). Partial graft replacement for these 3 sites were performed with open distal anastomosis and right common carotid artery perfusion. In case 2, total arch replacement was performed 5 years previously. Redissection of the aortic root was revealed by CT, and ultrasound cardiography revealed severe aortic regurgitation and severe mitral valve insufficiency. A modified Bentall procedure and mitral valve replacement were performed. In these 2 cases, the sites of redissection and pseudoaneurysm were identified as the sites of use of GRF glue at the first operation. We suspected that the use of GRF glue is associated with a certain amount of risk of redissection and pseudoaneurysm. Such patients should be carefully followed for years after surgery. It is necessary to use appropriate surgical and glue application techniques to obtain the desired effect of the glue.

We describe a case of cardiac surgery for a patient with CD36 deficiency. A 56-year old man had progressive dyspnea on effort for 1 year. On admission, echocardiography revealed severe aortic valve regurgitation. He required medical treatment for heart failure, and subsequently elective aortic valve replacement was planned. Pre-operative cardiac scintigraphy (¹²³I-BMIPP) showed total defect of myocardial uptake. CD 36 deficiency was diagnosed based on the characteristic findings. CD 36 deficiency could cause transfusion related complication by donor blood transfusion. We prepared 1,200 ml autologous blood preoperatively in a two week period. The operation was performed successfully without donor blood transfusion. He was discharged uneventfully.

A 75-year-old man, who had undergone aortic valve and ascending aorta replacement at the age of 73 years, was admitted to our hospital with one week of fever. Blood culture showed growth of Streptococcus bovis and echocardiography showed vegetation on the prosthetic valve. Although antibiotic treatment was commenced, he complained of abdominal pain, and computed tomography showed a superior mesenteric artery embolism. The abdominal pain improved with fasting, but echocardiography showed another vegetation, and re-aortic valve replacement was performed to prevent embolism recurrence. When he resumed eating postoperatively, he again complained of abdominal pain and computed tomography showed mesenteric ischemia. The necrotic intestine was extensively resected and he recovered successfully. A superior mesenteric artery should be revascularized to 2/11 prevent perioperative mesenteric ischemia when cardiac surgery complicated by acute superior mesenteric artery embolism is performed.

A semicomatose 53-year-old woman who had been injured in an automobile accident was admitted. Injury to the thoracic descending aorta was suspected because of widening of the upper mediastinum on a chest X-ray film and confirmed by chest contrast-enhanced computed tomography (CT). We postponed surgical treatment because brain CT showed traumatic intracerebral hemorrhage. She was maintained in an intensive care unit and had pharmacological treatment and medical support. Two days later, brain CT showed that the intracerebral hematoma was a stable and inactive lesion, so she underwent aortic repair 3 days after the accident. Left thoracotomy was performed and an artificial vascular prosthesis was interposed under hypothermic circulatory arrest (open proximal method). The postoperative course was uneventful and the patient was discharged 44 days after the operation. Hypothermic circulatory arrest may be a valuable adjunct for traumatic injury of the thoracic aorta at risk for impending rupture.

A 16-year-old schoolgirl had aortic valve insufficiency, detected incidentally on electrocardiogram taken for a physical checkup. She was noted to have hyperextensibility of joints, hyperelasticity of the skin and an atrophic scar over the knees on physical examination and type II Ehlers-Danlos syndrome (EDS) was diagnosed by skin biopsy after admission. A Carpentier-Edwards pericardial bioprosthesis was chosen for aortic valve replacement because she was of childbearing age and had EDS. Seven years after the replacement she became pregnant, resulting in spontaneous vaginal delivery of a healthy male infant at 39 weeks. However, a second aortic valve replacement was staged for structural failure of the bioprosthesis which was accelerated during the gestation. Aortic valve re-replacement was carried out using a 21-mm Sorin Bicarbon mechanical prosthesis 4 months after the delivery. She was discharged on the 10th postoperative day without any complications.

A 77-year-old man with diabetes mellitus and hypertension presented with acute onset of pain and swelling of the right thigh. Physical examination showed a pulsatile mass in the mid-portion of the right thigh. Computed tomography revealed the presence of a 7-cm diameter aneurysm at superficial femoral artery with gas shadow around the aneurysmal wall. A diagnosis of infected superficial femoral aneurysm was made and emergency surgery was undertaken. The total resection of the aneurysmal wall, debridement of necrotic tissues including part of sartorius and quadriceps muscles were done. Femoro-popliteal bypass through subcutaneous route using a 6-mm diameter Dacron prosthesis was used as the mean of vascular reconstruction procedure. Citrobacter koseri was cultured from the infected aneurysmal wall. The antibiotic treatment was continued for total of 2 weeks. Although additional debridement was required, the patient was amkulabony when discharged on the 37th postoperative day.

A 74-year-old woman had undergone right axillo-bifemoral bypass for infrarenal aortic stenosis due to aortitis syndrome in another hospital. She was admitted as an emergency case to our hospital with a ruptured thoracoabdominal aortic aneurysm, and an emergency operation was performed. We used arterial cannulation to the artificial vascular graft implanted for axillo-bifemoral bypass and first cooled the body temperature to below 25°C, then dissected the aorta. In the case of ruptured descending and thoracoabdominal aortic aneurysm, profound hypothermia is a valuable adjunct for unexpected blowout rupture during the preparation of the aneurysm and spinal cord and visceral protection.