[Giant Right Coronary Artery Pseudoaneurysm:Report of a Case].

Giant coronary artery aneurysm is very rare and there is no clear consensus regarding its treatment. Herein, we report a case of this unusual entity. The patient was a 75-year-old man in whom follow-up coronary angiography showed leakage of contrast agent from one of the #4 posterior descending( #4PD) branch of the right coronary artery. Enhanced computed tomography (eCT) revealed a giant pseudoaneurysm with a maximum diameter of 55 mm. Percutaneous balloon angioplasty had been performed in the same vessel for angina pectoris 20 years earlier. We excluded the pseudoaneurysm from arterial perfusion by closing both the wall defect and the culprit branch under cardiopulmonary bypass. There was no need for revascularization because there was another #4PD branch nearby. No adverse events were observed after surgery. Postoperative eCT scans confirmed that the aneurysm was completely thrombosed with no leakage.

[Aortic Regurgitation and Stanford Type A Aortic Dissection with Antiphospholipid Antibody Syndrome:Report of a Case].

Antiphospholipid antibody syndrome (APS) is associated with high morbidity and mortality resulting from hemorrhagic or thromboembolic events and compromised host immunity due to steroid use. We reported a successful surgery for aortic valve regurgitation (AR) and dissecting aortic aneurysm (DAA) in the ascending aorta in a patient with APS. A 75-year-old woman with AR and primary APS was transferred to our institute because of fever and dyspnea. She was given a diagnosis of pneumonia and congestive heart failure (CHF). Enhanced computed tomography (CT) incidentally revealed chronic DAA. After medical treatment for CHF and pneumonia, elective surgery to replace the aortic valve and ascending aorta was performed. We paid special caution to intraoperative hemostasis and perioperative anticoagulation management. No adverse event was observed in this patient's postoperative clinical course, and she was discharged home.

[Floating Thrombus in Descending Aorta;Report of a Case].

We report a very rare case of floating thrombus in the thoracic descending aorta (TDA). A 54-yearold man complaining of severe lower abdominal pain was admitted to our facility. Enhanced computed tomography demonstrated a filling defect in the TDA, embolism of the superior mesenteric artery (SMA), and bilateral renal infarction. Transesophageal echocardiography revealed that the mass in the TDA was pedunculated, floating, and multiple with maximal diameter of 30 mm. To avoid bowel necrosis, we proceeded with emergent thrombectomy of the SMA. The TDA, including the mass, was removed en bloc for diagnostic confirmation and replaced with prosthesis under cardiopulmonary bypass for prevention of recurrent embolism. The postoperative course was uneventful. On histological examination, the mass proved to be a blood clot on the atherosclerotic wall. No recurrent thrombosis was observed during the 1-year follow-up period.

[Surgical Treatment of Systemic and Left Circumflex Coronary-pulmonary Artery Fistulas with Aneurysm;Report of a Case].

Congenital coronary-pulmonary artery fistulas complicated by continuity to a systemic artery and aneurysm are extremely rare. A 78-year-old woman was admitted to our hospital with a complaint of chest discomfort. Coronary angiography showed a coronary aneurysm and coronary-pulmonary artery fistula arising from the left circumflex artery and entering into the right lower pulmonary artery. Computed tomography angiography revealed a left subclavian artery-pulmonary artery fistula communicating with the coronary-pulmonary artery fistula. Myocardial scintigraphy showed ischemia in the inferolateral wall, indicating a coronary blood steal phenomenon because of the fistula. Endovascular therapy involves a potential risk of life-threatening complications, such as myocardial infarction, and is not recommended for aneurysms with anatomical features, such as the extreme tortuosity of the fistulous tract. Therefore, fistula ligation and aneurysmal resection were performed under cardiopulmonary bypass with cardiac arrest. The postoperative course was uneventful. The coronary steal phenomenon disappeared on postoperative scintigraphy.

[Cardiac Angiosarcoma with Acute Myocardial Infarction due to Tumor Embolism;Report of a Case].

We report the case of a 28-year-old man with a rare angiosarcoma complicated by acute myocardial infarction secondary to tumor embolism. He was transported to our emergency unit because of sudden onset of chest pain. The echocardiography showed a 42×60 mm mass in the left ventricle, and the coronary angiography showed embolic occlusion of the proximal left anterior descending and circumflex arteries. Emergent surgical removal of the mass was attempted under cardiopulmonary bypass, concomitant with double coronary artery bypass grafting and mitral valve replacement with a mechanical prosthesis. However, complete tumor excision was impossible. The postoperative pathological examination revealed undifferentiated angiosarcoma. Twenty days after the operation, the patient suffered acute cerebral hemorrhage from a metastatic tumor in the brain. He died at 37 days after the initial cardiac surgery.

[Aortic valve replacement and ventricular septal defect closure after previous bilateral internal thoracic artery bypass grafting; report of a case].

The patient was a 74-year-old man with a history of ventricular-septal defect (VSD). He underwent coronary artery bypass grafting (CABG), which was performed using the bilateral internal thoracic artery (ITA) 9 years ago. Since 2009, he experienced heart failure, and in 2011, he started administration of tolvaptan, vasopressin V2 receptor antagonist. In 2011, he developed fever, and follow-up echocardiography revealed moderate aortic regurgitation and vegetation around the VSD and the aortic valve. Therefore, we performed redo-aortic valve replacement (AVR) and VSD closure. Both ITAs were carefully dissected and were clamped during cardiac arrest. The patient was discharged on the 36th postoperative day, without tolvaptan. AVR and VSD closure after bilateral ITA bypass grafting is a challenging procedure if the patent ITA crosses the midline. Patent ITA should be occluded to avoid cardioplegia washout during aortic cross-clamping. Multi-detector-row computed tomography (MDCT) enables excellent imaging for dissecting ITA grafts.

[Infected implantable cardioverter-defibrillator lead extraction under deep hypothermic circulatory arrest; report of a case].

We performed infected implantable cardioverter-defibrillator lead extraction under deep hypothermic circulatory arrest in a 58-year-old man. Venogram during the implantation of the lead had revealed complete obstruction of the innominate vein. Preoperative trans-esophageal ecocardiogram revealed intracardiac vegetation with a diameter of 20×13 mm. Because of advanced adhesion and large vegetation, we performed lead extraction under cardiopulmonary bypass. The leads were adherent to the wall of the superior vena cava( SVC) and the innominate vein and could not be extracted. So we converted to deep hypothermic circulatory arrest. We performed venotomy in the SVC and the innominate vein to achieve complete visualization. The leads were extracted under direct vision. Postoperative course was uneventful without recurrence. Extraction of implantable devices is highly recommended when infection occurs. When adhesion of the lead is suspected, safe extraction can be performed by venotomy of the innominate vein under deep hypothermic circulatory arrest.

[Rectal metastasis from lung cancer; report of a case].

A 70-year-old male underwent left pneumonectomy for lung cancer in November 2008. Although he was diagnosed as pT2bN1M0 (stage II B) after the operation, adrenal metastasis was found 8 months later. Positron emission tomography (PET) revealed accumulation in the adrenal gland and rectum. Gastrointestinal tract examination revealed a type 1 tumor in the rectum. Histological examination of biopsy specimens obtained from the lesion suggested papillary adenocarcinoma of rectum. Abdominoperineal resection was performed. The resected rectal tumor was reported immunohistochemically as metastasis from primary lung cancer.

[Total arch replacement using a long elephant trunk for chronic dissecting aneurysm of a distal aortic arch].

A 74-year-old man was diagnosed with Stanford type B early thrombosed aortic dissection. Computed tomography (CT) 2 years later revealed that an aneurysm of the distal arch had enlarged from a maximal diameter of 47 mm to 62 mm and involved the descending aorta. Total arch replacement using a quadrifurcated arch graft proceeded through a median sternotomy under deep hypothermic cardiopulmonary bypass (20 degrees C) and selective brain perfusion. The long elephant trunk of another prosthesis was inserted into the descending aorta and a distal anastomosis was constructed immediately after the left common carotid artery. The post-operative course was uneventful and CT at that time revealed complete thrombo-exclusion of the aneurysm surrounding the long elephant trunk. This method was very useful for reducing the duration of circulatory arrest and bleeding, as well as the risk of postoperative complications.

Luminal surface design of electrospun small-diameter graft aiming at in situ capture of endothelial progenitor cell.

If endothelial progenitor cells (EPCs), which circulate in blood flow, are captured on the luminal surface of an implanted artificial graft and sooner or later proliferate to form a fully endothelialized surface, such a small-diameter artificial graft must exhibit a high patency rate. This study aimed at designing a luminal surface of elastomeric electrospun mesh graft, which is capable of selective capture of EPCs under arterial flow and has a high antithrombogenic potential until full endothelization is achieved. The designed luminal surface layer is composed of a photopolymerized gelatin gel layer that enables the release of impregnated heparin and selective adhesion of circulating EPCs via complexation between surface-fixed vascular endothelial growth factor (VEGF) and cellular VEGF receptor. Human mononuclear cells seeded and cultured on such a gel layer expressed endothelial cell surface markers. Confocal laser scanning microscopy observation revealed that VEGF is highly surface-enriched, and heparin is homogeneously distributed in the gel layer. A continuously slow release of heparin was observed. Thus, a prototype luminal surface was fabricated on electrospun segmented polyurethane tubes for in vivo study.

Endovascular stent-grafting for infected iliac artery pseudoaneurysms.

We report two cases of acutely infected pseudoaneurysms of the iliac arteries, successfully treated with endovascular stent-grafting. Two patients underwent stent-graft treatment for erosive rupture of the iliac artery caused by surrounding infection. The first case is that of a 61-year-old man who had undergone Miles' operation for an advanced rectal cancer. Postoperatively, he developed intrapelvic abscess formation, from which methicillin-resistant Staphylococcus aureus was cultured, followed by rupture of the right external iliac artery. The second case is that of a 60-year-old man who had a pseudoaneurysm of the left common iliac artery, which was contiguous with a left psoas muscle abscess, from which Streptococcus agalactiae was cultured. Both patients were successfully treated with only a stent-graft and antibiotic therapy, and remained symptom-free 12 months and 10 months later. Although endovascular stent-grafting should not be considered standard therapy for infected aneurysms, our cases suggest that it can result in repair of infected aneurysms even in the uncontrolled active stage.