A 61-year-old man was admitted with acute cardiac failure associated with atypical aortic coarctation and severe left ventricular hypertrophy. Angiography and MRI showed that all branches from the aortic arch were occluded, and that cerebral circulation was supplied via collateral flow from small aortic branches either proximal or distal to the coarctation and by the right vertebral artery receiving retrograde flow from the right internal thoracic and right thoracodorsal arteries. Cerebral CT revealed massive cerebral infarction in the perfusion area of the right mid-cerebral artery. Aortitis syndrome was diagnosed from these findings, and ascending-abdominal aortic bypass grafting with aorto-right subclavian bypass was performed after successful conservative treatment for cardiac failure. Because of remarkable increase in the aortic blood pressure on partial clamping of the ascending aorta, proximal aortic anastomosis was performed under extracorporeal circulation. Near infrared spectroscopy (NIRS) was used to monitor the intraoperative cerebral circulation. The perfusion flow rate was maintained in order not to reduce the regional brain oxygen saturation below the critical level. No cerebral complication was encountered postoperatively. Cases of aortitis syndrome with occlusion of all arch branches are rare. NIRS was suggested to be useful to evaluate cerebral circulation during operation in such cases in which cerebral blood flow can be severely affected.

A 53-year-old woman had dyspnea on effort since half a year previously and was categorized as NYHA II. She had suffered from chronic atrial fibrillation (AF) for three years. She had undergone aortic valve replacement using a Starr-Edwards ball valve (SEV) for aortic regurgitation and mitral commissurotomy for mitral stenosis 29 years previously. Echocardiography revealed mitral stenosis with an orifice area of 0.9cm² and neither dysfunction of the SEV nor abnormal findings on the valve itself. She underwent mitral valve replacement and left atrial maze procedure for AF. Because of the intraoperative findings of the cloth wear-covered SEV cage, redo aortic valve replacement was performed simultaneously. St. Jude Medical valves were used for valve prostheses. There was no complication and the ECG returned to sinus rhythm postoperatively. These has been no report of a patient with such a long period between SEV implantation and replacement in Japan. This experience made us realize again the importance of attention to the cloth wear covered cage during long term follow up for SEV.

Gelatin-resorcin-formalin (GRF) glue has been generally applied in the surgical treatment of acute aortic dissection. Recently, midterm or late redissection and false anastomotic aneurysm following the use of this adhesive have been reported in several articles and the toxicity of its component has been suggested to be involved in this complication. We herein report 2 cases of aortic root redissection a few years after the initial surgery for type A acute aortic dissection. In another hospital, a 57-year-old man had undergone total arch replacement for acute dissection in which the proximal end was repaired using GRF glue. The aortic root was revealed to be redissected by computed tomography (CT) 2 years after the intervention and continued to enlarge since then. This aortic complication was treated by composite graft replacement. The intraoperative findings of marked degeneration in dissected root tissue were impressive. The other patient was a 71-year-old man. He had undergone prosthetic replacement of the ascending aorta associated with aortic valve resuspension using GRF glue for acute dissection. Three years later, symptoms of cardiac failure due to aortic regurgitation (AR) occurred and necessitated surgical correction. The AR was due to the redissection of the non-coronary cusp sinus. Repair of the coronary sinus and aortic valve replacement was performed. The postoperative course was uneventful in both cases. Other papers have cautioned that this tissue adhesive should not be used in aortic valve resuspension. Intensive long-term follow-up is required for aortic dissection patients surgically treated using this glue.

A 73-year-old man underwent initial below-knee femoro-popliteal bypass (FPBK) using an autologous saphenous vein graft (SVG). Six years later, a sudden leg pain developed in his right lower extremity and an emergency angiography disclosed total occlusion of the external iliac artery as well as SVG. Because sufficient arterial perfusion was not obtained even after emergent thrombectomy, redo FPBK was performed using a synthetic graft. For the distal anastomosis, we reused a segment of the previous patent SVG that had been still open at the distal anastomotic site. After cutting down the SVG at the non-thrombosed part, which was 1cm long from the distal anastomosis, 6mm ringed expanded polytetrafluoroethylene (ePTFE) graft was anastomosed to the stump in an end-to-end fashion. The proximal anastomosis was completed between the ePTFE graft and common femoral artery in an end-to-side fashion. The postoperative angiography demonstrated no stenosis of the distal anastomotic site and no occlusion of previous SVG. In a patient requiring redo FPBK, if previous SVG is not completely thrombosed at the distal anastomotic site, reutilizing the graft is one of the options to complete the redo operation in a safe and simple way. Because the long term patency of this type of composite graft has not been established, further careful observation is needed.

Purpose: The objective of this study was to investigate whether body fat rate (BFR) and triceps skinfold thickness (TSF) are associated with estimated fentanyl absorption in patients treated with the fentanyl transdermal matrix patch for moderate to severe cancer pain, by measuring the residual content of fentanyl in used matrix patches. Methods: Adult Japanese inpatients experiencing chronic cancer-related pain and receiving treatment for the first time with a transdermal fentanyl matrix patch (Durotep®MT patch) were included in the present study. During the initial application period, BFR was measured using a body fat scale, and TSF was measured by an experienced nurse with an adipometer. One patch was collected from each patient. The residual fentanyl content in used matrix patch was determined by high-performance liquid chromatography. The transdermal fentanyl delivery efficiency was estimated based on the fentanyl content of the used matrix patches. Results: Fifteen adult patients (5 males and 10 females) were included in this study. Nine patches with a release rate of 12.5μg/h and 6 patches with a release rate of 25μg/h were collected. The application site was the chest or upper arm. BFR and TSF both showed a significant positive correlation with delivery efficiency. Conclusion: In malnourished or low-body fat patients receiving DMP, pain intensity should be more carefully monitored, and fentanyl dose adjustment may be required. Additional parameters, such as nutritional status including body fat change, the degree of dry skin, and plasma fentanyl concentration, also require detailed evaluation. Palliat Care Res 2010; 5(2): 206-212