We encountered three cases of infra-renal infected abdominal aortic aneurysm in 2007 and 2008. Preoperative blood culture was positive in two of the three patients. All of the patients presented with fever of unknown origin. We replaced the affected segment of the abdominal aorta with a synthetic graft in 1 patient, and with a cryopreserved arterial homograft in the remaining 2 patients. An infected abdominal aortic aneurysm is a life-threatening condition. Diagnosis is often difficult, and emergency surgery may be necessitated by rupture of the aneurysm. Our experience suggests that computed tomography is effective for the diagnosis of infected aneurysms. The most effective surgical technique consists of complete resection of the aneurysm, in-situ replacement of the affected aortic segment with a synthetic graft or homograft, and omental coverage.

Thoracic graft infection is a serious complication and has high mortality. We report a case of successful treatment of graft infection after ascending thoracic aortic reconstruction. A 66-year-old woman underwent surgery for DeBakey type I aortic dissection in June 2007. The ascending aorta was replaced with a prosthetic graft. Although her postoperative course was complicated with Methicillin-resistant Staphylococcus aureus (MRSA) mediastinitis, the infection was conservatively controlled by mediastinal lavage and antibiotics. However, she was readmitted in April 2008 due to lumbar pain and high fever, and was diagnosed with infectious spondylitis. Lumbar plastic surgery was performed. During hospitalization, she underwent total systemic examination. The results indicated aneurysm of the ascending aorta. MRSA was detected from culture fluid of her blood. Taken together, the presence of an infected aortic aneurysm was considered possible. Consequently, reconstruction of the ascending aorta using two allografts was performed after removing the prosthetic graft. The postoperative course was uneventful, and she was discharged on the 71st postoperative day. The patient continues to thrive 9 months after the operation. This case of an infected aortic aneurysm repaired with the use of allografts will be reported together with references to the literature.

Fifty-three patients who had received aortic valve replacement (AVR) using tilting disc valve prostheses (Lillehei-Kaster valve, Omniscience valve, Omnicarbon valve), underwent replacement of their aortic valve prostheses over the past 13 years. The indications for reoperation were non-structural opening failure in 35 patients, thrombosed valves, including 2 stuck valves in 8, prosthetic valve endocarditis (PVE) in 7 and perivalvular leakage (PVL) in 3. The interval periods until reoperation for opening failure and thrombosed valve were 112 and 118 months respectively, and for PVE and PVL were 21 and 25 months. There were 7 hospital deaths (13.2%). Surgical results in cases of active PVE with root abscess and stuck valve required emergency operation were significantly worse than these for nonstructural opening failure. Opening failures, which accounted for two-thirds of the indications for reoperation was found to be due to subvalvular pannus formation on minor orifices which hindered the disc from opening properly. It was suggested that reoperation for these types of prosthetic valve should be done before they develop into emergency cases, taking account of these valve-related complications.

Ninety patients with abdominal aortic aneurysm underwent endovascular stent grafting in our hospital between 2001 and 2006 and two patients required graft replacement of abdominal aortic aneurysms during the late postoperative phase. Case 1 was a 77-year-old man for whom endovascular stent grafting for an abdominal aortic aneurysm and thoracic aortic aneurysm had been performed concomitantly. Six months later, because the abdominal aortic aneurysm had expanded from 68mm to 75mm in diameter, due to a type I endoleak which was detected postoperatively, he underwent open surgery. An occlusion balloon was inflated at the proximal site of the celiac artery until the stent graft was extracted. After positioning the aortic clamp below the origin of the renal arteries, a bifurcated graft was implanted. The postoperative course was uneventful. Case 2 was an 86-year-old woman who had undergone endovascular stent grafting for an abdominal aortic aneurysm. The endovascular procedure was successful and no endoleak was detected postoperatively. However, 13 months later, a community hospital admitted her in a state of shock due to ruptured abdominal aortic aneurysm. She was transferred to our hospital and underwent an emergency operation. Because insertion of an occlusion balloon into the brachial artery failed, we primarily performed supravisceral aortic cross clamping. After opening the aneurysm sac, the stent graft was removed and a bifurcated graft was implanted. After declamping, we found that the right common iliac artery was occluded, and therefore aorto-right external iliac bypass grafting was then also performed. The postoperative course was uneventful.

A 58-year-old man was admitted because of enlargement in diameter of the descending thoracic aorta. Six years previously, he had undergone graft replacement of the proximal descending aorta due to a chronic dissecting aneurysm. During that surgery, distal fenestration involving resection of the intimal flap of the distal anastomotic site and graft replacement with distal anastomosis of the true and false lumen were performed. Our preoperative enhanced computed tomography (eCT) revealed a thoracic aortic aneurysm 58mm in diameter at the site of distal fenestration. Graft replacement through left lateral thoracotomy was considered difficult because of previous occurrence of methicillin-resistant Staphylococcus aureus (MRSA) empyema after the previous operation: hence, endovascular repair was done using a handmade stent graft to interrupt blood flow into the false lumen. The postoperative course was uneventful. Postoperative eCT showed the thrombosed false lumen and the shrinkage of the aneurysm from 58 to 38mm in diameter over a period of 18 months.

Mucolipidosis is an autosomal recessive lysosomal storage disorder that demonstrates a clinical resemblance to mucopolysaccharidosis. Accumulation of glycoproteins throughout the body causes dysfunction of several organs, in particular, valvular heart diseases are an important cause of mortality, however, there is no consensus guideline regarding the indications and optimal timing of the surgical repair because of the unclear and short natural history. Here we present 12- and 15-year-old siblings diagnosed with mucolipidosis who underwent aortic valve replacement. The senior sibling received redo-aortic valve replacement for prosthetic valve dysfunction 11 years after the initial surgery. A few surgical valve replacements in patients with mucopolysaccharidosis have been reported, however, there is no published case of aortic valve replacements in two siblings with mucolipidosis.

A 71-year-old man presented to our hospital with sudden-onset epigastric pain. He reported a history of undergoing the following operations : aortic valve replacement for aortic regurgitation 11 years earlier and graft replacement of the ascending aorta for acute type A aortic dissection, 1 year earlier. His systolic blood pressure was 70 mmHg, and computed tomography revealed a pseudoaneurysm of the distal anastomosis of the ascending aorta with a connection to the right pulmonary artery. Cardiopulmonary bypass was established with cannulation of the right axillary artery and the right femoral vein, and systemic cooling was initiated before sternotomy. We identified an area showing 3 cm dehiscence at the distal aortic anastomosis after hypothermic circulatory arrest and selective cerebral perfusion. The ascending aorta was replaced as hemiarch replacement, and the defect in the right pulmonary artery was closed with bovine pericardium. The patient's postoperative course was uneventful, and he was transferred to a rehabilitation hospital on the 22nd postoperative day.

In acute Stanford type A aortic dissection, except for some thrombosed false-lumen types, graft replacement is a standard treatment. On the other hand, thoracic endovascular aortic repair (TEVAR) might be considered for high-risk patients with retrograde type A aortic dissection when entry is in the descending aorta, although its efficacy in a case of an extensive thrombosed false lumen without obvious entry is unknown. We report a case of successful zone 3 TEVAR using RelayPro NBS for Stanford type A aortic dissection with a localized CT-enhanced false lumen in the proximal descending aorta. An 83-year-old woman was admitted for acute Stanford type A aortic dissection with a thrombosed false lumen of the ascending thoracic aorta. She was initially treated conservatively because of being a high-risk patient for open surgery. One week after hospitalization, the ascending aorta diameter increased and the false lumen in the proximal descending aorta grew sporadically in a CT image. We suspected that the ascending aorta was enlarged due to a partially patent false lumen of the descending thoracic aorta, and performed zone 3 TEVAR using RelayPro NBS to close a possible entry in the proximal descending aorta even though there was no obvious entry. The patient had a good postoperative course and was discharged 15 days after TEVAR. Shrinkage of the false lumen in the ascending aorta was observed in CT images two months after TEVAR.