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A 10-year-old girl having bilateral subclavian steal associated with severe coarctation of the thoracic aorta and an aberrant right subclavian artery was found, on admission, to have no difference between upper and lower extremity blood pressure, but echocardiography revealed severe thoracic aorta coarctation and systolic blood pressure in the carotid arteries exceeding 200 mmHg estimated by Doppler ultrasonography. Magnetic resonance imaging and angiography demonstrated bilateral subclavian steal without esophageal compression. We reconstructed the aortic arch using the left subclavian artery and a reversed Blalock-Park procedure, then repaired the coarctation with a 14 mm woven double velor vascular graft. The girl was symptom-free following uncomplicated recovery from surgery. Doppler ultrasonography 2 weeks after surgery showed the pressure gradient across the aortic arch had decreased from 180 mmHg to 60 mmHg. This residual gradient at the anastomosis between the ascending aorta and left subclavian artery may improve as native vessels grow.

A 21-year-old man with an oropharyngeal abscess admitted to our institution was initially treated with systemic antibiotics but was referred to our department when his condition rapidly deteriorated. His respiratory insufficiency required circulatory support. A computed tomographic scan showed a parapharyngeal abscess descending into the mediastinum with multiple right-side capsulized empyema and pericardial effusion. We conducted emergency surgery through a mediansternotomy using a pedicled omental flap. Postoperative clinical and radiologic assessment showed a normal chest X-ray and primary wound healing without sternal dehiscence. Mediansternotomy using a pedicled omental flap offers excellent exposure for a complete one-stage operation with debridement of all affected tissues of the subauricular region, the mediastinum, and both pleural cavities. We conclude that this method yields good results for patients with acute widespread descending necrotizing mediastinitis.

A 56-year-old man admitted to our hospital for cardiac tamponade due to dilated cardiomyopathy did not respond to treatment by usual medical means or surgery. Pericardio-peritoneal drainage was conducted using a subcostal approach. Seven months later, the patient remains well and free of signs of pericardial tamponade. This method has proved to be safe and effective in patients with persistent massive pericardial effusion.

A 33-year-old female with adult form of extreme coarctation underwent axillo-femoral bypass grafting. The postoperative hemodynamic improvement was remarkable. The patient spent excellent quality of life without any hypotensive drug or anticoagulant agent for 14 years until pseudoaneurysms of the bypass graft ruptured. The patient was saved by an emergency operation with 2 steps of surgical procedures. The first step was making the new axillo-femoral bypass at the contralateral side, then the diseased graft was replaced by a new graft as the second step. The postoperative catheterization revealed no pressure gradient between the upper and lower extremities, and the bilateral API's were over 100%. The pseudoaneurysm of the graft seemed to be caused by the stabbed needle holes for the dearing of the graft and the instrument for the partial occlusion of the graft. We learned from this experience that the needle holes of the graft should be repaired by plegeted sutures, and Fogarty clamp or the clamp with rubber sheath should be used for clamping graft. The axillo-femoral bypass is, of course, not a first choice procedure for extreme coarctation, but the hemodynamic improvement was achieved in our case. Therefore, it may be still useful for the compromised host as an alternative procedure to the radical correction.