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The patient underwent sigmoidectomy with D3 lymph node dissection and partial bladder resection for sigmoid colon cancer(cT4bN1M0, cStage Ⅲa), after preoperative chemotherapy with mFOLFOX plus panitumumab, and FOLFOXIRI plus bevacizumab. Postoperative adjuvant chemotherapy was performed by 8 courses of CAPOX. He relapsed hilar lymph nodes and peritoneal dissemination after 13 months after surgery, he underwent resection of the recurrent lesions. Four months after, he developed recurrence in liver and peritoneum. Although he was treated with FOLFIRI plus ramucirumab or aflibercept, resulted in progression of disease, then he received trifluridine tipiracil hydrochloride plus bevacizumab. At this point, the Japanese health insulance had started to cover pembrolizumab, this therapy was started as the fourth chemotherapy after the diagnosis of high frequency microsatellite instability(MSI), and then tumor markers rapidly declined. He underwent 38 courses of pembrolizumab, the recurrent lesions both liver and peritoneum disappeared. He had stoma closure, peritoneal dissemination disappeared not only intraoperatively but also in histologically from the peritoneal scar. He has received pembrolizumab for 4 years without another recurrence. Here, we report a case of MSI-high sigmoid colon cancer in which long-term survival was achieved by pembrolizumab for recurrent lesions resistant to conventional chemotherapy.

Phosphorus is necessary for bone mineralization. Although adequate phosphorus intake is essential for skeletal mineralization, it is reported that excessive phosphorus intake can induce deleterious effect on bone. Recently, since the Japanese diet has been westernized, phosphorus intake by the meat and dairy products has increased. Furthermore, along with the development of processed foods, excessive intake of inorganic phosphorus from food additives has become a problem. An adverse effect on parathyroid hormone (PTH) secretion from high phosphorus intake was seen only when calcium intake was inadequate. Dietary calcium to phosphorus ratio can be considered as one of the indicators that can predict the health of the bone.

Osteoporosis is one of the main diseases of the locomotive syndrome. Exercise therapy is a basic approach for prevention and treatment of osteoporosis, and is effective for increasing bone mineral density and preventing fall. Single foothold standing with the eyes open for one minute and squatting by "rokotore" are recommended as exercises that are easy for elderly people. Strengthening of back muscles is also useful for prevention of round back due to osteoporosis. We suggest that improved outcomes may be achieved by combining some of these exercises.

Background: Even though allergic diseases continue to increase among children, it is unclear as to how many of these children are receiving appropriate medical care., Purpose: To establish the number of schoolchildren being diagnosed and receiving consultation for their allergic diseases and to determine if their disease status is associated with their total and allergen-specific IgE levels. Additionally, the study examined whether providing information on the total and allergen-specific IgE levels to the parents resulted in improvement of the medical care their children received., Methods: A total of 618 out of the 627 (94.5%) parents of 11-year-old schoolchildren living in Ohmi-Hachiman City, Shiga, Japan, answered a questionnaire designed to determine the presence of allergic diseases (bronchial asthma, atopic dermatitis, allergic rhinitis, and allergic conjunctivitis) and the status of medical care in their children. Levels of total IgE, mite-specific IgE, and three pollen-specific IgEs were measured at the same time that the questionnaires were filled out. Information from the questionnaires was used to analyze the relationships between the questionnaire data and IgE levels. After parents were given the IgE results, medical consultations were recommended for those children having allergic symptoms and positive allergen-specific IgEs. One year after providing the information, a follow-up survey was performed to determine whether parents took any actions in response to their children's test results., Results: The mean total IgE level was 138 IU/ml, with a total of 62.8% of the children sensitized to one or more allergens. Even among those without any allergic disease, 49.2% or the children sensitized to one or more allergens. In children with bronchial asthma, diagnosis and consultation rates were 100% and 81%, respectively. However, the diagnosis and consultation rates among those with other types of allergic diseases were significantly lower, ranging from 44 to 88% for diagnosis and 28 to 52% for consultation. A total of 63% of the parents with children having allergic diseases indicated they undertook further efforts designed to improve their child's allergy disease symptoms after they were informed of the total and allergen-specific IgE levels., Conclusion: Results of the present survey demonstrated that significant numbers of children with atopic dermatitis, allergic rhinitis or allergic conjunctivitis were not given appropriate medical care. In order to conclusively determine whether total and allergen-specific IgE screening at schools is useful in ensuring that children receive appropriate medical care, further evaluations will need to be conducted.

Although an increase in vitamin D has a small effect on bone mineral density, it has an influence on fracture prevention. This may be explained by a mechanism of improvement of bone strength that does not necessarily depend on bone mineral density. The level of serum 25 (OH) D is low in hip fracture patients compared with non-fracture controls, which suggests that a background of vitamin D insufficiency may be involved in hip fracture. Vitamin D acts on skeletal muscle and nerve cells, and it has been reported that this has an effect on fall prevention. Furthermore, recent reports suggest a role of vitamin D in cognitive function and in other tissues not involving bone.

Background: The Japanese Society of Anesthesiologists (JSA) has maintained records of the annual incidence and characteristics of perioperative pulmonary thromboembolism (perioperative PTE) since 2002. The aim of this paper was to provide recent results of the JSA annual study conducted in 2008, and to determine the current factors that tend to prevent perioperative venous thromboembolism (VTE) in Japan., Methods: A comprehensive questionnaire designed by the JSA PTE working group was mailed to all institutions certified as teaching hospitals by JSA. The data tics of patients with perioperative PTE, such as types of diseases and surgeries, age, sex, methods used for the prevention of VTE (in some cases), and prognosis of perioperative PTE., Results: The rate of effective responses was 56.1% (634/1116), and 1,177,626 surgeries were registered during the study period. There were 324 patients who were reported to have had PTE, and the incidence was 2.75 per 10,000 surgeries. The incidence of perioperative PTE in 2008 did not change significantly from that in 2005-07. The surgeries that most commonly resulted in perioperative PTE were limb and/or hip joint surgery (5.71 per 10,000 surgeries), craniotomy (4.64 per 10,000), and thoracotomy with laparotomy (3.46 per 10,000 surgeries). The mortality rate of perioperative PTE in 2008 was found to have significantly decreased from that in 2005-07 (15.6% vs. 22.4%; P = 0.01). Further, the rate of patients who received anticoagulant drugs in 2008 was significantly higher than that in 2005-07 (17.6% vs. 10.8%; P = 0.0018). Individual guidelines for the prevention of perioperative VTE were adopted in 55.4% of the training institutions., Conclusions: The increase in the percentage of patients who received anticoagulant drugs around the time of the operation, and the decreased mortality of patients with perioperative PTE suggested that the prophylaxis for perioperative VTE with anticoagulant drugs reduces perioperative mortality.

Background: This study aimed to investigate the annual incidence and characteristics of perioperative pulmonary thromboembolism (PTE) in Japan from 2005 through 2007, and to compare the current trend with that observed in our previous studies conducted since 2002., Methods: In the 3-year study period, a questionnaire was annually mailed to every institution certified as a training hospital for anesthesiologists by the Japanese Society of Anesthesiologists (JSA). The survey included the parameters of age, sex, type of surgery, and the risk factors in patients who were operated upon., Results: The average rate of effective responses was 55.1%, and a total of 825 cases of perioperative PTE were registered in the 3-year study period. The incidence of perioperative PTE was 2.79 per 10,000 cases in 2005, 2.25 per 10,000 cases in 2006, and 2.57 per 10,000 cases in 2007. The incidence of PTE in all the 3 years was significantly lower than that observed in 2002-03 (P < 0.01). In addition, the incidence of fetal PTE in 2006 and 2007 was also significantly lower than that in 2002-03. The incidence of PTE in older persons (66-85 years) was approximately twice (4.70 per 10,000 cases) and that in the oldest persons (> 86 years) was approximately thrice (6.28 per 10,000 cases) the incidence in middle-aged individuals (2.17 per 10,000 cases). PTE was found to be more frequent in females than in males (males, 1.89 per 10,000 cases; females, 3.75 per 10,000 cases). The types of surgery that most commonly resulted in perioperative PTE were limb and/or hip joint surgery (5.57 per 10,000 cases), thoracotomy with laparotomy (5.19 per 10,000 cases), and spinal surgery (4.49 per 10,000 cases). Perioperative PTE was fatal in 185 patients (22.4%), and the mortality rate of patients who had not received prophylaxis was significantly higher (37.8%) than that of patients who received anticoagulant drugs (20.8%). Guidelines for prevention of perioperative PTE were accepted by 58% of all training institutions., Conclusions: The incidence of perioperative PTE and fetal PTE has currently decreased; however, prophylaxis with anticoagulant drugs may have reduced the mortality in some cases.

Nutrition education is a very important tool for the promotion of human health. Epidemiological studies showed a strong association between postprandial glycemia and the cardiovascular risk. White rice is the staple food in Japan, but it is a high glycemic index diet. In our study, postprandial glucose levels were suppressed when viscous meals and barley were used as the side dishes and staple food with average-sized portions, respectively. Thus, information on the association between the traditional Japanese diet and health is still quite limited at this point. In conclusion, further human studies on food function are required in order to provide the public with accurate information.

The therapeutic effects of phosphodiesterase type 5 inhibitors in patients with pulmonary arterial hypertension (PAH) were reviewed. A double-blind, placebo-controlled study named SUPER-1 showed that sildenafil improved exercise capacity, WHO functional class, hemodynamics, and quality of life. Two randomized, double-blind, crossover studies, showed that sildenafil improved exercise tolerance and quality of life, and reduced estimated pulmonary artery systolic pressure. The dose independent effects of sildenafil on PAH are controversial. There are few case-reports that show vardenafil and tadalafil have benefits in PAH patients. A double-blind study of tadalafil in PAH patients is ongoing.

Microarray analysis demonstrated lung gene encoding osteopontin (OPN), a soluble secreted phosphoprotein, was significantly elevated in rats with hypoxic pulmonary arterial hypertension (PAH). Since OPN enhances vascular smooth muscle cell proliferation, we hypothesized that OPN played a role in the pathogenesis of PAH. Some patients with idiopathic PAH showed increased expression of plasma OPN and lung OPN gene. OPN overexpression in mice caused pronounced pulmonary hypertension and vascular remodeling under hypoxic conditions. A PPARgamma ligand, pioglitazone, which was reported to inhibit OPN gene expression in vitro, attenuated hypoxia-induced increase in lung OPN gene and pulmonary vascular remodeling in rats. These findings indicate that OPN may be responsible for pulmonary vascular remodeling and could be a therapeutic target for PAH.

We considered the effect of vitamin D on fall and fracture prevention, since it has been suggested that vitamin D acts on cellular receptors in the muscles and nervous system to reduce muscle weakness and body sway, thereby preventing fall. Bone strength is defined by the bone mineral density plus bone quality, and vitamin D is also thought to improve bone quality and increase bone strength, although its effect on bone mineral density is only small. Vitamin D insufficiency is prevalent at a high rate in senior citizens and we suggest that vitamin D supplementation in this population is useful for prevention of fracture and fall.

Recently the relationship of vitamin D insufficiency and fracture is noticed in elderly people. Vitamin D nutritional status is evaluated by measuring serum 25 (OH) D. Higher prevalence of vitamin D insufficiency is observed in the patients with hip fracture. This suggests that vitamin D insufficiency is one of fracture risk factor and improvement of vitamin D status reduce fracture risk. With the results of recent studies, we would like to discuss about fractures from the viewpoint of vitamin D insufficiency.

To study the protective function against oxygen radicals in the mesangial area, we assessed extracellular superoxide dismutase (EC-SOD) production in mesangial cells (MCs) in vitro. These cells have a major protective function against oxygen radicals in the extracellular space. In two different kinds of culture conditions: "growth medium" with fetal cow serum, and "differentiation medium" with reduced growth factor, and four extracellular matrixes; type I collagen, type IV collagen, laminin and fibronectin, were added to the MC culture. With the difference in the culture media, differentiation medium induced EC-SOD hyper-production associated with the both of the slowing down of cell proliferation and the suppression of IL-6 and IL-8 production. With difference in the extracellular matrix, the presence of type VI collagen and laminin promoted higher production of EC-SOD than fibronectin and type I collagen. Type IV collagen and laminin associated with the physiological condition of the glomeruli promoted EC-SOD production compared with the presence of type I collagen and fibronectin dominantly located in pathological condition. Suppression of EC-SOD production in growth medium along with MC proliferation and chemokine hyper-production compared with production in differentiation medium might mimic reduction of the protective capacity against oxygen radical toxity during mesangial proliferation in the glomerular nephritis. MC proliferation with type I collagen and fibronectin might enhance oxygen radical toxity in the glomeruli, and accelerate glomerular sclerosis through the suppression of EC-SOD production.

A 47-year-old woman was referred to our hospital because of cardiomegaly and pericardial effusion. She complained of a cough. Computed tomography, echocardiography, and magnetic resonance imaging showed a mass on the pericardium. Exploratory surgery revealed a solid tumor invading the pericardium over the aortic arch and main pulmonary artery. Histological examination indicated primary malignant pericardial mesothelioma. After 58 Gy radiation, the size of the tumor was temporarily reduced and the patient's symptoms disappeared. However, the tumor enlarged and her symptoms reappeared 7 months after temporary improvement. Eighteen months after the development of cough, the patient died suddenly.

In contrast to the decreasing incidence of pulmonary thromboembolism in Western countries, the incidence examined as determined by autopsy, vital statistics, and clinical surveys is increasing in Japan. The combination of these data indicates the possibility of low diagnostic ability in Japan. The causes of the disease and the predictors of in-hospital death are summarized. The most popular congenital coagulopathies in Western countries, factor V Leiden and prothrombin G20210A mutation, have not been found in Japan. But recent reports showed that coagulopathy might have a greater contribution to the occurrence of the disease than was previously thought. We introduce reports that show a relation between the disease and life style.

Osteoporosis is characterized by fragile bone with decreased bone mass, resulting in fractures of vertebra, hip, distal radius and proximal humerus. Spinal deformities caused by multiple compression fractures and walking disability after hip fracture induce decreased QOL and limited ADL in elderly patients with osteoporosis. The goal of treatment for patients with osteoporosis is to improve ADL and QOL.

It is important to assess QOL in the patients with osteoporosis. Osteoporosis results in fractures of vertebrae and hips, consequently inducing spinal deformity and limited walking ability. These indicate that osteoporosis decreased QOL. The goal of the treatment for osteoporosis is to improve bone fragility as well as to maintain QOL. QOL questionnaire could be widely used.

In the present report, we reviewed articles on pulmonary angiography for patients with pulmonary hypertension. The use of a non-ionic, low-osmolarity agent and improvements in catheters reduced periprocedual complications, but attention should be paid to the pre-existing poorer physical state. Digital pulmonary angiography has similar diagnostic power to conventional angiography. Wedged pulmonary angiography could demonstrate distal lesions of the pulmonary artery which couldn't be detected by conventional pulmonary angiography. Typical pulmonary angiograms from pulmonary hypertension due to pulmonary embolism, primary pulmonary hypertension, collagen diseases, Takayasu's arteritis and porto-pulmonary hypertension were shown. Pulmonary angiography is relatively less valuable than before because of advances in other diagnostic imaging tools, but still remains the gold standard.

A 44-year-old woman had been diagnosed with progressive systemic sclerosis (PSS) at the age of 39 years old and mild pancytopenia was noted at that time. At the age of 41 years symptoms of dry mouth appeared. In April 1997, anemia was in progress (Hb 5.8 g/dl) and severe esophageal varices were found by gastrointestinal fiber scope, and massive splenomegaly by abdominal CT. Serological examination was negative for hepatitis virus and for anti-mitochondrial antibody. In addition, Indocyanine Green test was normal and typical findings of liver cirrhosis were not demonstrated by CT scan. Also, the bone marrow result was normal. Therefore hypersplenism with idiopathic portal hypertension (IPH) was suggested and the patient was referred for splenectomy with the aim of improving the pancytopenia. The weight of the spleen was 2100 g and the pressure of the portal vein was measured at 390 mm H2O. The diagnosis of IPH was determined because pathologically there were no findings for liver cirrhosis. After splenectomy, pancytopenia was remarkably improved (Hb 9.6 g/dl). Consequently, this case was diagnosed as IPH complicated with PSS and Sjögren syndrome.

Although the postoperative outcome in patients with incomplete atrioventricular septal defect (iAVSD) is excellent, deterioration of mitral valve regurgitation (MR) is still remained to be resolved. Therefore, this study was undertaken to compare surgical procedures for mitral cleft repair with their long-term results of MR. From 1991 to 1996, 52 patients underwent surgical repair of iAVSD. Age at operation ranged from 2 months to 62 years old with mean age of 14.2 years. Mean follow-up period was 8.6 +/- 4.4 years. All patients underwent patch closure of ostium primum defect. Two patients did not have cleft (Group A). Seven patients did not close the cleft at all (Group B), while 40 patients had the repair of valve by closing cleft near septal attachment only (Group C). The latest 3 patients had the complete closure of cleft from annulus to margin of leaflet where chorda is attached. MR was evaluated by echocardiography grading 0 to IV and regurgitation more than grade II was considered to be significant. In Group A, MR remained grade I. In Group B, MR was deteriorated in 5 patients (71%). Consequently, 6 patients (86%) had grade II or more regurgitation and 4 patients (57%) revealed grade III/IV regurgitation including one (14%) reoperation. In Group C, MR was deteriorated in 10 patients (55%). Consequently, 22 patients (86%) had grade II or more regurgitation and 5 patients (13%) had grade III/IV regurgitation including 3 (7.5%) reoperations. In Group D, no deterioration of MR was noted and all had grade I or less regurgitation. These results suggest that the closure of cleft near septal attachment is not sufficient to prevent MR in late phase and the complete closure of cleft from annulus to margin of leaflet, where chorda is attached, would be useful to prevent the deterioration of MR in late phase.

We report a patient with Marfan's syndrome who underwent replacement of the ascending aorta and the entire aortic arch for acute type I aortic dissection 4 years after the thoracoabdominal replacement. As a result, she underwent subtotal aortic replacement from the ascending aorta to the bilateral common iliac arteries in three stages. A 48-years-old female was admitted to our service because of acute heart failure and cardiogenic shock caused by acute DeBakey type I aortic dissection. She had undergone replacement of the descending thoracic aorta at the age of 44 and replacement of the remaining thoracoabdominal aorta with reimplantation of the four major abdominal branches at the age of 46 for a chronic expanding DeBakey type IIIb dissecting aneurysm. She successfully underwent replacement of the ascending aorta and the entire aortic arch with an aortic prosthesis provided with four branch grafts for reconstruction of the arch vessels. Considering the high incidence of new aortic lesion, extensive aortic replacement and careful postoperative follow-up are necessary in patients with Marfan's syndrome.

Dissection of the interventricular septum is an uncommon manifestation, which is rarely associated with infective endocarditis, aneurysm of sinus of Valsalva and thoracic trauma. We report a 34-year-old male case with aorto-left ventricular communication due to infective endocarditis. The patient had chief complaints of dyspnea on exertion and precordial discomfort. Preoperative laboratory data showed normal white blood cell counts, a slightly elevated CRP, and negative blood culture in bacterial examinations. Echocardiogram revealed progressive dissection of the interventricular septum and stenosis of the left ventricular outflow tract. Disturbance of conduction including progressive atrioventricular block and bundle branch block were found in the electrocardiogram. The dissection extended over 2 x 2 x 2.5 cm in diameter, with an entry located at the basis of the right coronary cusp and reentry communicated to the left ventricle. Operative procedures included the aortic valve replacement with prosthetic valve due to severe inflammation, in addition to resection of the dissecting cavity. Pathological examination of the resected tissue accorded with infective endocarditis in active phase, showing necrosis, small cell infiltration and microabscess. However, a bacterial colony was not found in the surgical specimen. Postoperative course was uneventful and the patient was discharged in satisfactory conditions.

We experienced 8 cases who required reoperations, including 2 re-redo operations, after repairs of infrarenal abdominal aortic aneurysms. Of 8 patients, one patient developed a new aneurysm due to atherosclerosis in thoraco-abdominal aorta involving all visceral arteries and other 7 patients had aneurysmal formations at proximal anastomotic sites, including 3 suprarenal, 2 juxtarenal and 2 infrarenal aortic lesions. Etiology at initial operation in patients who subsequently developed anastomotic aneurysms included vasculo-Behçet disease in 4, atherosclerosis in 2 and dissecting aortic aneurysms type III due to Marfan syndrome in 1. At reoperation, all who had vasculo-Behçet disease had ruptures of anastomotic sites and 2 patients underwent repairs of dehiscent patch, 1 extra-anatomic bypass between ascending and abdominal aorta and 1 interposition of graft. One patient who had graft infection after repair of abdominal aortic aneurysm required axillo-femoral bypass with removal of infected graft. A patient who had dehiscence of proximal anastomosis after repair of aortoiliac occlusive disease required interposition of graft. Two patients, Marfan syndrome and aneurysm in thoraco-abdominal aorta, underwent graft replacement of thoraco-abdominal aorta concomitant with reconstruction of all visceral arteries. There were 8 patients who required reoperations for aneurysms at distal anastomotic sites after repairs of abdominal aortic aneurysms. Five patients underwent repairs of new aneurysms, including replacement of total arch in 3, descending aorta in 1 and iliac artery in 1. In all cases, no hospital death was noted, however, late deaths were occurred in vasculo-Behçet disease, Marfan syndrome and graft infection. Thus, late result depends on etiology of disease. Although patients who requires reoperation after repair of abdominal aortic aneurysms have higher operative risk factors, early and late results are satisfactory compared to initial operations.

Selective cerebral perfusion (SPC) has become a reliable method for brain protection during reconstruction of the transverse aortic arch. However, arterial cannulation technique for the branches of the aortic arch varies among groups, and the necessity of perfusion for the left subclavian artery is controversial. To avoid atheroembolism to the brain and malperfusion of the vertebral arterial system, we carefully selected the arterial cannulation technique according to the result of preoperative ultrasonographic and angiographic evaluation of the branches of the aortic arch, and decided the necessity of perfusion for the left subclavian artery according to the dominance of the two vertebral arteries and the result of pressure monitoring of all three branches. In this report, we analyzed our clinical results of selective cerebral perfusion on 22 consecutive patients, which was performed between April 1992 and December 1993. There were 14 atherosclerotic aneurysms and 8 aortic dissections. The flow rate for SCP was controlled by a single blood pump separate from that for systemic perfusion, with the mean value being 13.1 ml/kg/min. Mean of minimum left superficial temporal arterial pressure was 51 mmHg, mean duration of SCP was 134 minutes, and mean of the lowest esophageal temperature was 17.9 degrees C. Blood pH was regulated with alpha-stat strategy. Arterial cannula for SCP was inserted directly into the vessels through a stab wound in most cases. In three of four patients in whom dissection extended to the branches, a balloon catheter was introduced through the lumen of the aortic arch.(ABSTRACT TRUNCATED AT 250 WORDS)

This article discusses physiological diagnostic methods in the intractable vasculitis, including Buerger's, Takayasu's and vasculo-Behçet disease. Clinical manifestations of these diseases depend on the lesions of the diseased arteries or veins such as obstruction of the extremities often occurring in Buerger's disease, the obstruction of aortic arch branches in Takayasu's disease and the deep vein thrombosis in vasculo-Behçet disease. Measurements of segmental blood pressure and flow allows a detection of peripheral vascular disease and non-invasive diagnostic techniques, such as the doppler ultrasonic techniques and strain-gauze plethysmography, permit accurate evaluation of arterial occlusive disease and estimation of its physiological significance. Noninvasive diagnostic techniques, together with clinical symptoms and physical examinations, make possible correct diagnosis and subsequently appropriate treatment.

A 66-year-old woman was diagnosed as a DeBakey type II dissecting aortic aneurysm with angiography and CT. Antibody screening revealed circulating anti-Jr(a) antibody. Preoperatively, erythropoietin was administered twice a week. Over 24 days, a total of 1200 ml of her blood was removed and stored for autologous transfusion. The dissecting ascending aorta was replaced with the aid of cardiopulmonary bypass. The post operative course was uneventful. By using erythropoietin, pre-donated autologous blood, cell saver, aprotinin and transfusion of fresh autologous blood, it was possible to perform cardiovascular surgery on this patient who had an abnormal antibody. This patient is the first case of repair or dissecting aortic aneurysm with anti-Jr(a) antibody in Japan.

Implantations of automatic implantable cardioverter defibrillator were performed in five patients with life-threatening ventricular tachyarrhythmias. Preoperative diagnoses of arrhythmias were sustained ventricular tachycardia (VT) in two cases, ventricular fibrillation (VF) in two cases and sustained VT+VF in one case. Four of five cases had basic diseases respectively (broad anterior myocardial infarction, dilated cardiomyopathy, arrhythmogenic right ventricular dysplasia, hypertrophic cardiomyopathy), and the other case was idiopathic. Preoperative CTR were 43-65% (mean 57.4%) and left ventricular ejection fraction were 26-76% (mean 51.2%). Implantation of AICD was indicated for patients who survived circulatory arrest or life-threatening VT. Median sternotomy (3) or left antero-lateral thoracotomy (2) were performed for implantation of large-small patch electrodes for defibrillation. AICD generators were implanted in the pocket under abdominal rectal muscle in all cases. Postoperatively myocardial insufficiency, pericarditis, pleuritis occurred in three cases respectively. In the follow-up periods (2-25 months, mean 13 months), AICD worked effectively in two patients with spontaneous VT (6 months, 1 year after operation) and no cardiac death was experienced. We concluded that AICD system is effective for the life-threatening ventricular tachyarrhythmias, although the further estimation in longer follow-up periods are warranted.

Now aneurysmectomy and graft replacement is the most popular surgical method of aortic aneurysm, but there are many opinions about surgical methods and assist circulation for emergency operation of ruptured aortic aneurysm. We experienced the case of ruptured thoracoabdominal aortic aneurysm with tuberculosis, and rescued the patient by extra-anatomic bypass (EAB). A 60-year-old woman, who had been treated with tuberculosis for about 40 years, was operated on for cold abscess of her left psoas muscle by other orthopedic surgeons. At that time, massive bleeding happened, and she was transferred to us under diagnosis of ruptured thoracoabdominal aortic aneurysm. EAB, as emergency operation, was done because we considered it was dirty and dangerous to replace the prosthesis beside the abscess. The postoperative course was almost uneventful except the evidence of Gaffky's first stage. We considered EAB was an useful method for emergency cases and some infectious aortic aneurysms.

Since 1980, two different operative strategies were employed during resection to provide distal aortic perfusion by temporary bypass (Group "TB", 39 patients) or partial extracorporeal bypass (Group "PEC", 39 patients) in the operation for the thoracic descending aortic aneurysms or the dissecting aortic aneurysms with DeBakey type III. No significant differences were found in the patient population or the operative procedures between two groups. Mean bypass flow in Group "PEC" was 1850 +/- 70 (ml/min), which is significantly higher than in Group "TB" (1000 +/- 240 ml/min). However, there were no significant differences in the distal aortic pressure between two groups, which was due to administration of vasodilators. Platelet counts in Group "PEC" were significantly lower in the postoperative courses, probably caused by the use of roller pumps or suckers. The incidence of the postoperative renal dysfunction was almost the same in two groups. Cardiac functions during temporary bypass were suppressed by the aortic cross-clamping, therefore, it is necessary to evaluate the cardiac function preoperatively in employing this method. Partial extracorporeal bypass has the disadvantages of the requirement for full heparinization, but it can be indicated to almost all cases, even to the patients with poor cardiac function. It also has the advantage to maintain the distal perfusion in the unexpected intraoperative situations. The method of distal aortic perfusion should be determined by patient-related and disease-related factors.

A total of 106 vascular reconstructions below the inguinal ligament including axillo-femoral and femoro-femoral bypasses were performed using 137 Dardik's human umbilical veins. The indication for surgery was limb salvage in 29%. The distal anastomosis was done with the popliteal artery above the knee in 53 cases, below the knee in 31, and with a tibial artery in 1. The axillo-femoral bypass was performed in 21 cases, and femoro-femoral bypass in 32. The accumulated graft patency rates of femoro-popliteal bypass at 1 yr./3 yrs./5 yrs. were 93%/75%/75%, those of femoro-femoral bypass were 85%/85%/85%, and those of axillo-femoral bypass were 54%/27%/27%. No special risk factor influencing patency rate was found from this study. In long term period, graft aneurysm was observed in 3 cases. It is concluded that the human umbilical vein is the graft material of choice for femoro-popliteal or femoro-femoral bypass when the saphenous vein is not available, and the careful follow-up is important because of the risk of graft aneurysm.

The diagnostic value of cine magnetic resonance imaging (cine-MRI) was evaluated in 10 patients with disease of great vessels. The parameters necessary to decide the appropriate treatment, such as presence and extension of intimal flap, DeBakey type classification, identification of the entry, differentiation between true and false lumen, and between thrombosis and slow flow were demonstrated in all patients with dissecting aortic aneurysm. However, abdominal aortic branches could not be demonstrated enough by cine-MRI, therefore conventional AOG was necessary to choose the operative procedure in these cases. In patients with thoracic aortic aneurysm (TAA), cine-MRI was valuable in demonstrating both blood flow and thrombus in the lumen of aneurysm, and AOG was thought to be unnecessary in most cases. Cine-MRI is a promising new technique for the evaluation of diseases of great vessels.

Despite improvements of the results of aortic aneurysm repair, technical difficulty and a high incidence of perioperative morbidity still remains in the thoracoabdominal aortic aneurysm surgery. In this paper, we reported 19 cases of operation for thoracoabdominal aortic aneurysm and retrospectively studied surgical technique, early results and late results after operation. Graft inclusion technique with direct vessel reattachment was mainly employed for aortic reconstruction, and for 2 cases of inflammatory aneurysm. Hardy's operation and extraanatomic bypass were performed. Mortality was 16% with a 13% mortality for elective repair and paraplegia occurred in 2 cases (10%). Current results with thoracoabdominal aortic aneurysm repair established its safety, but to prevent postoperative paraplegia completely, the consideration for operative adjuncts and mechanisms of paraplegia needs to be continued.

Two cases of "Inflammatory" aneurysm of the abdominal aorta and a review of this type of lesion were presented. The incidence of inflammatory aneurysm of the abdominal aorta in the literature is 2.5 to 15%, but there were no detail reports concerning with this in Japan. The pathogenesis is not clear, but it is evident both macroscopically and microscopically that the inflammatory aneurysms are different from athelosclerotic ones. They are characterized by perivascular peel of inflammatory fibrous tissue. It is possible that this type of aneurysms are merely a variant of Takayasu's disease. Until recently, the diagnosis of this type of aneurysm has not been made before surgery. The symptom of abdominal pain, weight loss, elevated ESR in a patient with abdominal aortic aneurysm are highly suggestive an inflammatory aneurysm. Characteristics of CT scan lead to more frequent preoperative diagnosis of inflammatory aneurysms of the aorta. It reveals a thickened often calcified aortic wall surrounded by a soft tissue mantle. Dynamic scanning shows an enhancing perianeurysnal mass. Graft replacement in these patients is often difficult and associated with increase in morbidity and mortality. At surgery, no attempt should be made to mobilize adjacent viscela in order to avoid injury. Arterial control should be obtained with as little as possible dissection. Some reports refer to successful steroid therapy resolving the inflammatory process and alleviating symptoms. Further research may resolve the treatment of choice for this type of lesion and optimize the timing of surgery.