A 76-year-old man who suffered from consistent back pain was admitted for anti-hypertensive therapy to strictly manage the early thrombosed acute type A aortic dissection (AAAD). On admission, his blood pressure could not be controlled well ; soon he complained of recurrent severe back pain. The second thoracoabdominal enhanced computed tomography revealed the progression of AAAD from DeBakey type II to type I with thrombosed pseudolumen at the descending thoracic aorta ; therefore, emergent surgical intervention by primary central repair was conducted. Paraplegia was diagnosed eight hours after surgery, then cerebrospinal fluid drainage and intravenous administration of Naloxone were started immediately followed by keeping the systemic blood pressure more than 120 mmHg. However, paraplegia had never improved and been persistent with neurological deficit of the lower extremities. We herein report a complicated surgical case of an AAAD patient with paraplegia and review the complex clinical settings.

Endovascular treatment is a first-line treatment for renal arteriovenous malformations (AVMs). Endovascular treatment might be effective in patients with aneurysmal-type renal AVMs, which involve one feeding artery and one drainage vein, because control of the feeding artery, rather than the aneurysm itself, could have a therapeutic effect. Herein, we describe two cases of patients with renal AVM with multiple renal artery aneurysms, who were treated by controlling the arterial inflow alone. In Case 1, the patient was a 76-year-old woman with renal AVM discovered during examination for another medical condition. A computed tomography scan revealed four renal aneurysms (φ38/44/24/35 mm) ranging from an intimal defect in the right renal artery to the drainage vein running into the inferior vena cava (IVC). Although we had planned to use a covered stent in the right renal artery to cover the intimal defect without embolization of the aneurysms, a minor artery proximal to the aneurysm was found near the orifice of the right renal artery. Therefore, we used a covered stent in the right renal artery after embolization of the most proximal aneurysm was performed. In Case 2, a 78-year-old man was referred to our facility because a renal AVM was found during examination for lower back pain. The distal posterior branch of the right renal artery attached to the multiple aneurysms and directly drained into the IVC, which was diagnosed as an aneurysmal-type renal AVM. Because there were no arteries arising from the aneurysms in the right renal artery, which fed the renal parenchyma, embolization of only the inflow artery was performed. For both patients, renal blood flow was maintained without any decrease of the renal function. In these patients, although renin-angiotensin system activity was within the normal range, and blood pressure became better controlled postoperatively. In addition, there was significant improvement in the brain natriuretic peptide (BNP) levels postoperatively. Thus, we believe that unstable hypertension and/or high-output heart failure as well as the aneurysmal size should be assessed in the management of renal AVMs.

We report 3 cases of ascending aorta-abdominal aorta bypass for atypical coarctation with Takayasu's aortitis. We performed an extra-anatomical bypass from the ascending aorta to the terminal abdominal aorta. The graft was arranged to pass through the diaphragm from the pericardium, behind the left lobe of the liver and the stomach, to the front side of the pancreas to the terminal abdominal aorta. Although the graft was exposed in the abdominal cavity in part behind the stomach, it was completely covered with the great omentum thus avoiding direct contact between the graft the abdominal organs. Decrease in the pressure gradient between the ascending aorta and the abdominal aorta was achieved using a large prosthetic graft 14-16 mm in diameter. There are several advantages with this technique. (1) Positional change during surgery can be avoided. (2) Anastomosis can be performed in non-diseased vessels. (3) This bypass graft can be branched off to visceral arteries if necessary. Reduction of the after load on the left ventricle and long-term graft patency by using a large diameter prosthetic graft were anticipated. The postoperative courses of all cases were satisfactory. Case 1 died of another disease 11 years and 11 months postoperatively, but the graft to was still patent.

A 53-year-old man presented with a painful, non-healing ischemic ulcer of the left fifth toe. The patient was initially treated conservatively for 4 months with local debridement and medication with antiplatelet therapy but his symptoms and the ulcer was refractory. A computed tomography revealed a bulky, irregular, gritty, localized calcification of the infra-renal aorta and was compatible with the so-called “coral reef aorta”. Angiography confirmed the findings of the CT scan, and there was no evidence of occlusive lesions in the distal runoff vessels. A diagnosis of blue toe syndrome secondary to infra-renal coral reef aorta was made. In order to prevent further embolization, the patient underwent aortic excision with PTFE grafting via a retroperitoneal incision. In order to increase the microcirculation of the toe and to aid in the healing of the ulcer, a lumbar sympathectomy was performed simultaneously. The ulcer healed completely on postoperative day 47. The treatment method for coral reef aorta depends on the presence or absence of global ischemia of the lower extremity and embolic complications.

Abnormalities of the skeleton and joint as well as ophthalmic symptoms and cardiovascular abnormalities are found in Marfan's syndrome, one of the connective tissue diseases associated with autosomal dominant inheritance. A 34-year-old man was operated on for Stanford type A acute aortic dissection that developed 13 years after sternal turnover surgery for funnel chest. After approaching by median incision made on the sternum, composite graft replacement and aortic arch replacement were performed. After surgery, the sternum at the site of reflections became unsteady, causing flail chest, which required internal fixation with an artificial respirator for 15 days. A patient with Marfan's syndrome may undergo cardiovascular operation twice or more throughout his lifetime. Where a longitudinal incision is made on the sternum after operation on the funnel chest, care should be exercised even if it is a long time after surgery. In this sense, minimal invasive surgery with a steel bar inserted percutaneously, a surgical technique that has come to be used recently, should be useful.

Because of the improved safety of cardiovascular surgical techniques, the small incision approach, called minimally invasive cardiac surgery (MICS), has recently been employed. In some cases of MICS, however, prolonged extracorporeal circulation time is required, and it is not minimally invasive in some aspects. It has been reported that the most prominent advantages of MICS is reducing the adverse consequences of conventional full-sternotomy, such as pain, bleeding and risk of mediastinitis, therefore it is helpful to reduce the period of hospitalization and costs. The small incision and cosmetic advantage is one of the objective advantages of MICS, so we interviewed 139 patients who underwent cardiac surgeries, to find out how they think of their operation scar. Most (61.9%) of the patients were not bothered by their scar, and the presence of keloid lesions mattered move than the size of their wound. What the patients considered to be most important were less pain after operation and shorter hospital stay, not to mention good results of the operation. The size and place of the wound ranked low in importance. It is important to be aware of the difference in thinking between the operative wound by patients and by the healthy medical staff. Furthermore it is important to recognize the difference between minimaly invasiveness and small incisions in cardiac surgery.

A 22-year-old woman was admitted to our hospital with high fever and lumbar pain. Echocardiography revealed mitral regurgitation due to prolapse of the anterior mitral leaflet. On admission, her white blood cell count was high and results for C-reactive protein were positive. The blood culture was positive for hemolytic streptococcus. After the white blood cell count and C-reactive protein level were normalized, and the blood culture had become negative following treatment by multiple antibiotics, she underwent valvular surgery. Because the infectious lesion was limited to the mitral leaflet and chordae, mitral valvuloplasty was performed with a satisfactory postoperative result. The operative technique consisted of resection of the infected valvular tissue, implantation of artificial chordae with e-PTFE, and suture annuloplasty. To conclude, mitral valvuloplasty should be the operative method of choice in patients with infective endocarditis, especially in young women with the potential of future pregnancy and labor.

A 53-year-old woman was admitted with cardiac failure due to aortic regurgitation (AR) and pseudocoarctation of the aorta associated with Takayasu's aortitis. It was revealed that her hypertension of upper extremities was based on Takayasu's aortitis at her 37-year-old age. But at that time there was no sign of inflammation, only drug therapy for hypertension had been employed. She started to complaint of dyspnea on exertion and palpitation when 47 years old, ultrasonic echocardiography and cardiac catheterization revealed that her symptoms were based on pseudocoarctation and AR. Despite of drug therapy, her symptoms progressed and reached NYHA class III. Detailed examination showed progressed AR and occurrence of mitral regurgitation (MR). Surgical treatment, ascending aorto-terminal aortic bypass, aortic valve replacement (AVR), and mitral valvuloplasty was performed at the age of 53 years old. In instituting the extracorporeal circulation, an arterial cannula was placed in the graft that anastomosed to the terminal aorta, in addition to the arterial cannula to the ascending aorta, to prevent low perfusion of the organs distal to the pseudocoarctation. The postoperative course was uneventful. Special attention should be paid to prevent low perfusion of the organs in such case with presence of pressure gradient in the aorta.

During a twelve-year period (1982-1993), 15 axillo-femoral bypass surgeries have been performed for aortoiliac occlusive disease. All patients were men, with an average age of 71.2 years. Axillo-bifemoral bypass was performed in 10 cases, and axillo-unifemoral bypass in 5 cases. In Additional femoro-popliteal bypass was required 3 cases. All cases had some accompanying disease, so they were considered to be high risk cases for anatomic bypass surgery. In the 12 elective cases, 2 hospital deaths (16.7%) occured due to the accompaning disease (atrial fibrillation and lung canser). At discharged leg symptoms had improved in 10 patients. In the long term postoperative phase, 4 patients died due to accompanying disease, and one was lost to follow up. Excluding these patients, the long term patency in the 5 surviving patients was 100%. In this series, we encountered a case of perigraft seroma, which is rare. The intractable perigraft seroma disappeared after the reoperation with another material graft. Axillo-femoral bypass is preferable for high risk patients with aortoiliac occlusive disease. In cases of severe respiratory dysfunction, it can be performed under epidural and local anesthesia.

Three cases of isolated iliac aneurysms were reported. The first case was a 28-year-old man who was transferred to our hospital in shock. The ruptured left iliac aneurysm was replaced with a prosthetic graft. It was assumed to be a rupture of a false aneurysm. The second case was a 60-year-old man who complained swelling of his right leg and dyspnea on exertion. Angiography revealed tht those symptoms were due to right iliac aneurysm with AV fistula. The aneurysm was replaced with a bifurcating graft and the AV fistula was closed concurrently. The third case was a 55-year-old man who had no symptoms. He had been followed up for hepatitis type C with periodical echogram. The echogram showed dilatation of his bilateral iliac arteries. On a diagnosis of bilateral iliac aneurysms, bifurcating graft replacement was performed. All of these three cases recovered successfully and were discharged. Because the greater part of the cases of isolated iliac aneurysms have few symptoms, many cases were first diagnosed through the event of its rupture. The number of cases of isolated iliac aneurysm with no symptoms will increase with advanced availability of abdominal echogram and CT scanning.