We describe a novel method for repeat median sternotomy. We have successfully used ‘finger’ lifting resternotomy technique and achieved zero major cardiovascular injury/catastrophic hemorrhage events at reoperation. After general anesthesia, all patients were placed in the supine position and two external defibrillator pads were placed on the chest wall. We perform a median skin and subcutaneous incision along the previous sternotomy incision extending 3 cm distal to the sternum. The sternal wires that had been used for the previous closure were left in place but untied. Using a long electric cautery, right thoracotomy was performed under the right costal arch approach. Then, the operator could approximate the sternal wires in the retro-sternal space. At the same time, the operator could confirm the retro-sternal adhesion status which by touching with a finger. Resternotomy was performed using an oscillating saw pointed toward the operator's finger, which allowed safe re-median sternotomy from the lower to the upper part of the sternum. This technique of finger-lifting resternotomy has been employed in 50 cardiovascular reoperations and resulted in 0 incident of major cardiac injury or catastrophic hemorrhage. The finger-lifting resternotomy technique is safe and simple in reoperation procedures and yield excellent early outcomes.

We describe a 77-year-old woman with severe aortic stenosis, porcelain aorta and coronary artery disease, who underwent apicoaortic bypass with coronary artery bypass grafting. The patient, who had a history of aortitis syndrome had dyspnea. Cardiac echocardiography showed severe aortic valve stenosis (aortic valve pressure gradient (max/mean) = 115/74.4 mmHg, aortic valve area = 0.48 cm²). Coronary angiography showed severe stenosis of right coronary artery orifice (#1.90%) . Computed tomography showed severe calcification of the thoracic aorta and surgical manipulation for ascending aorta was impossible. We did not perform ordinary aortic valve replacement. Instead, apicoaortic bypass with coronary artery bypass grafting was performed. We approached by a left anterolateral thoracotomy at the 6th intercostal level. Apicoaortic valved conduit (valved graft : Edwards Prima Plus Stentless Porcine Bioprosthesis 19 mm + UBE woven graft 16 mm) was implanted. Saphenous vein graft was harvested and coronary bypass grafting (valved conduit-#4AV) was performed in the same operative field. Postoperative cine MRI showed that most of the cardiac stroke volume flowed through the conduit (44.4 ml/beat, 92.3%), with the flow via the aortic valve accounting for 3.69 ml/beat, 7.7%. Postoperative enhanced CT showed that the coronary artery bypass graft was patent. Apicoaortic bypass is a good surgical option for aortic stenosis with severe calcification aorta and coronary artery bypass grafting can also be performed in the same view.

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.

A 61-year-old man underwent thoracic aortic graft replacement and abdominal aortic graft replacement because of a dissecting aneurysm. He presented with a ruptured residual dissecting thoraco-abdominal aortic aneurysm and underwent emergency thoraco-abdominal aortic graft replacement in February 2007. An inverted bifurcated graft was fashioned by cutting one of the two graft legs and creating an elliptical patch, like a cobra-head. In order to prevent paraplegia after the operation, it was necessary to shorten the duration of spinal cord ischemia. Once the elliptical patch was sutured to the orifices of the internal costal arteries with running sutures, selective intercostal arterial perfusion was initiated by using a cardiopulmonary bypass. After the operation, he did not suffer paraplegia.

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.

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 42-year-old man noted a left hypothenar mass about one week after hitting the palm of his left hand. Although he did not seek treatment, numbness and cyanosis of the left 2nd, 3rd, 4th, and 5th digits appeared suddenly about one year later. A computed tomography scan revealed an ulnar artery aneurysm with a mural thrombus, with a maximal diameter of 20mm, at the site where the ulnar artery passed near the hamate bone. The aneurysm was excised, and the ulnar artery was reconstructed with direct end-to-end anastomosis. Traumatic ulnar artery aneurysm is commonly seen in workers who use the hypothenar eminence of their hands as a hammer, and is usually accompanied by finger ischemia.

From 1995 till 1998, 21 cases of Stanford type A dissecting aortic aneurysm with a closed false lumen of the ascending aorta were treated in our institute. The patients were medically treated if the diameter of their ascending aorta stayed less than 50mm without recurrent dissection. Patients were categorized into three groups: Groups I, II and IIIR (retrograde dissection), according to the location of the entry analyzed by means of CT, angiography and operative findings. Seven cases of intramural hematoma (IMH) were included in this study. One case in Group II died of rupture and one case in Group IIIR died of multiple embolism caused by atrial fibrillation in the acute phase. One case in Group II died of stroke and one case in Group I died after surgery in the chronic phase. Four cases in Group I and II underwent surgery in the acute phase and five cases in Group I and II underwent surgery in the chronic phase, but only one case of Group IIIR required surgery. Six cases of IMH required surgery. The rates of freedom from operation at four years was 25%, 21% and 83% respectively (p=0.07). Essentially, Stanford type A dissection should be treated surgically even though the false lumen is thrombosed. However, in the case of retrograde dissection accompanied by an entry in the descending aorta, medical treatment may be a strategy option.

A 36-year-old man was transported to our hospital with severe anterior chest and abdominal pain of sudden onset which was diagnosed as Stanford type B acute aortic dissection with visceral ischemia. Aortogram revealed occlusion of celiac, superior mesenteric and inferior mesenteric arteries with aortic dissection. At first, fenestration of the abdominal aorta above the inferior mesenteric artery was immediately carried out, but the abdominal pain continued. Therefore, bypass grafting for the superior mesenteric artery with saphenous vein was performed the next day. The patient's postoperative course was complicated with acute renal failure and paralytic ileus, which were treated medically and he was discharged in good condition.