The patient was a 37 year-old man. We diagnosed Loeys-Dietz syndrome based on his physical characteristics that were widely spaced eyes and brachycephaly etc. Since he developed De Bakey III b aortic dissection 3 months later, he needed surgical repair for saccular-shaped distal arch aortic aneurysm. We performed total aortic arch replacement for the aneurysm and valve-sparing aortic root reconstruction for dilatation of the Valsalva sinus. Furthermore we performed the frozen elephant trunk technique for residual aortic dissection at the same time. After 18 months from the operation, we were able to recognize by computed tomography that the false lumen of the aorta next to the stent graft was thrombosed and absorbed and finally disappeared. The stent graft treatment for patients with connective tissue disease might be an effective method and deserves more attention.

We performed aortic valve reconstruction (AVrC) using autologous pericardium for a patient with severe aortic stenosis and chronic renal failure, prior to kidney transplantation. The patient received kidney transplantation in the early phase after cardiac surgery. The case was a 61-year-old man with severe aortic valve stenosis who received dialysis due to chronic renal failure. We performed AVrC using autologous pericardium for the following reasons. Anticoagulant therapy is not desirable because of the need to perform kidney transplantation in the early phase after cardiac surgery. Implantation of prosthesis was not desirable because the patient requires oral immunosuppression therapy after kidney transplantation. There was no significant postoperative pressure gradient of the aortic valve orifice or aortic valve regurgitation (AR). The patient received kidney transplantation 113 days after surgery. AVrC using autologous pericardium was feasible for aortic stenosis patients in a patient waiting to receive kidney transplantation because anticoagulation therapy is not necessary after AVrC.

The saphenopopliteal junction (SPJ) is found at various levels and has various patterns compared with the saphenofemoral junction. Although this can cause difficulty in the surgical treatment of varicose veins and affect the outcome, there have been few reports on preoperative assessment of the small saphenous vein (SSV) regarding this point. This study was undertaken to evaluate three-dimensional CT venography with dual-route injection for the preoperative assessment of a small saphenous-type varicose vein. We examined a total of 15 legs in 15 patients with a small saphenous-type varicose vein, which were preoperatively evaluated by CT venography and then surgically treated. The patients included 4 men and 11 women with ages ranging from 50 to 80 years old (mean age, 66 years). The grading of varicose veins according to the CEAP classification was C2, C3, C4, and C5 in 3, 4, 6 and 2 legs, respectively. The CT imaging was performed with contrast medium diluted ten-fold, which was injected into the great and small saphenous veins simultaneously. CT venography clearly visualized the lower extremity veins. Whereas the popliteal vein coursed deep above the level of the femoral intercondylar groove, it followed a shallow course below the level of the knee joint. In 11 legs (74%), the SPJ was located in the shallow portion, whereas it was in the deep portion in 4 legs (26%). Among the former group, the SSV was connected to the great saphenous vein via the Giacomini vein in 2 cases, and the gastrocnemius vein was connected to the SSV before the SPJ in 3 cases. Among the latter group, a localized large venous aneurysm with thrombus before its termination was found in one case. In another case, the SSV showed branched termination in the deep portion. Our three-dimensional CT venography with dual-route injection provides more accurate information on venous anatomy in the lower extremity. The accuracy of images acquired by CT venography with dual-route injection was verified by intraoperative findings. Although Doppler ultrasound is essential for examining the presence of regurgitation in the veins and locating the course of a varicose vein in the surgical field, all 15 cases had scheduled surgery under local anesthesia based on accurate preoperative diagnosis. This study suggests that CT venography with dual-route injection is beneficial in preventing undesired complications during surgery and avoiding additional procedures for recurrent varicose veins.

A 61-year-old man who had hypertension and renal dysfunction (serum creatinine : 1.5-2.0 mg/dl) was referred to our hospital for an abnormal shadow on chest roentgenogram. Chest CT scan with contrast revealed a distal aortic arch aneurysm (maximum diameter 52 mm) and left subclavian artery aneurysm (maximum diameter 30 mm). For the surgical treatment of the aneurysms, left hemi-collar incision and left subclavian incision followed by median sternotomy were performed. After the left subclavian artery was secured distal to the aneurysm, a ringed dacron graft was anastomosed with the distal left subclavian artery. Cardiopulmonary bypass was commenced, and selective cerebral perfusion was instituted at 25°C. The aorta was transected at the origin of the left common carotid artery. A 30 mm stent graft (length 13 cm) was inserted and was fixed on the transected aorta using 4-0 Prolene continuous suture. Then a branched dacron graft was sewn onto the transected aorta and the stent graft. The left common carotid artery and the brachiocephalic artery were anastomosed onto side branches of the graft. The left subclavian artery was reconstructed by anastomosing the ringed bypass graft onto one of the side branches. The left subclavian artery was ligated between the aneurysm and the origin of the vertebral artery, thereby interposing the subclavian artery aneurysm. After proximal anastomosis was done and the heart was reperfused, the patient was weaned from cardiopulmonary bypass. The patient was discharged without any major complication. Two years after the operation, the patient is doing well and there is no evidence of aneurysmal dilatation or endoleak. In conclusion, frozen elephant trunk technique provides an alternative to conventional graft replacement, resulting in complete exclusion of these aneurysms in a single stage. However, long-term follow up is warranted in order to ensure the durability of the stent graft.

A 65-year-old man had received closure of the entry and false lumen Stanford type B acute aortic dissection via left thoratectomy 23 years previously. The patient underwent emergency graft replacement for a ruptured aneurysm of the thoraco-abdominal aorta 10 years previously. Enhanced computed tomography (ECT) revealed that the residual aortic dissection of the distal arch and the descending aorta were dilated. Reoperation via left thoracotomy usually requires a long cardiopulmonary bypass time and intraoperative bleeding. So we selected to perform open stent-grafting through median sternotomy alone, avoiding a left thoracotomy.

An 82-year-old woman fell into a state of shock during the treatment for a urinary tract infection. Computed tomography and transthoracic echocardiography revealed massive pericardial effusion. Pericardiectomy was performed in the operating room and hemorrhagic effusion was observed. Emergent sternotomy was performed, and the bleeding site was located at the posterior portion of the left ventricular outflow. We diagnosed a rupture of a left ventricular outflow tract pseudoaneurysm after infectious endocarditis. A pericardium patch closure of the pseudoaneurysm and an aortic valve replacement were performed. The patient was discharged 35 days after the operation without recurrence of infection. Left ventricular outflow tract pseudoaneurysms is an uncommon complication following infective endocarditis, aortic valve surgery or chest trauma. Transesophageal echocardiography and multidetector-row computed tomography (MDCT) is useful for identifying such lesions.

Acute aortic dissection is a formidable disease because of complications such as rupture or visceral ischemia. Early diagnosis of these conditions is essential. The patient was a 40-year-old woman with acute type B aortic dissection, suspected to have Marfan syndrome. We first treated her with medical therapy, but 5 days later she suffered from repeated abdominal angina. This was thought to be probably predictive of malperfusion, so we decided to perform an operation. We maintained an elevated blood pressure (about 140mmHg), used heparin and Prostaglandin E₁ for the prevention of angina, until total aortic arch replacement and open stent grafting was performed. She has been doing well since.

We successfully treated a case of extra-anatomical revascularization using an extrathoracic approach for what is called subclavian steal syndrome, and we describe the operative method. A 65-year-old man with dizziness was examined by digital subtraction assessment and given a diagnosis of subclavian steal syndrome by occlusion of left subclavian artery. He was relatively young for his age with good general condition, and no lesion were detected in aortic arch branches and cerebral arteries except for left subclavian artery. Therefore we performed left common carotid artery-subclavian artery bypass using a prosthetic graft. The preoperative symptoms and difference in blood pressure among arteries of the upper limbs disappeared, and he was discharged 15 days after surgery.

We encountered a case of ruptured penetrating atherosclerotic ulcer (PAU) that previously had focal ulceration. A 82-year-old man was followed on a diagnosis of distal arch true aneurysm with a diameter of 4.5cm on CT examination. He was admitted with sudden onset of back pain, but he had experienced no previous symptom. CT scan showed a ruptured penetrating atherosclerotic ulcer, therefore we performed emergency replacement of the thoracic descending aorta. The postoperative course was good. CT scan showed the thoracic descending aorta had focal ulceration with a width of 11mm and depth of 7mm at 6 months, however the width was 11mm and the depth was 11mm 1 month before rupture of the PAU. This suggested progression of the focal ulceration caused the PAU rupture.

A case of successful surgical revascularization for mid-aortic syndrome is reported, with discussion of the operative method. A 10-year-old boy with headache and vomiting was admitted to our hospital for excessive hypertension. A diagnosis of mid-aortic syndrome with severe stenosis of abdominal aorta and stenosis or occlusion of bilateral renal arteries was made. His hypertension did not respond to conservative treatment. Therefore we performed aorto-aorta bypass using a prosthetic graft and revascularization of the bilateral renal arteries. The preoperative symptoms disappeared, his blood pressure became controllable, and he was discharged on the 21st day after surgery. At present, he attends school and has a normal blood pressure without hypotensive medication.