We report herein the successful surgical treatment of a patient with high-output cardiac failure which developed from a high-flow hemodialysis arteriovenous fistula of the Brescia-Cimino type. Banding correction of the venous limb of the fistula with a woven Dacron prosthesis resulted in marked improvement of the cardiac failure. An ultrasonic study showed the fistula flow of 3.2 l/min to be as high as 40% of the resting cardiac output, or 8.0 l/min, before banding, while an intraoperative electromagnetic study was useful for controlling the degree of banding and showing the decrease of fistula flow from 3.7 l/min to 1.4 l/min.

akayasu's arteritis is a primary, chronic, progressive, vascular inflammatory disease that causes stenosis and/or aneurysmal dilatation of the aorta and aortic arch branches, and in 50-80% of cases the pulmonary arteries as well. 1 However, isolated pulmonary Takayasu's arteritis is very uncommon. We present a case of isolated pulmonary Takayasu's arteritis and describe the successful surgical treatment of this rare condition. Case ReportA 67-year-old woman with a 6-month history of progressive exertional dyspnea was referred in January 2003. Laboratory examination showed an erythrocyte sedimentation rate (ESR) of 36 mm at 1 h and 70 mm at 2 h; C-reactive protein, 0.8 mg/dl; white blood cells, 9,800 / l; platelets, 42×10 4 / l. Rheumatoid factor, antinuclear antibody and Wasserman reaction were all negative. Human leucocyte antigens (HLA) were B52, A24 and DR2.Pulmonary perfusion scintigraphy revealed complete absence of perfusate in the left lung and no defects in the right lung. Magnetic resonance imaging revealed remarkable wall thickness of the pulmonary trunk and proximal right pulmonary artery ( Fig 1A). Magnetic resonance angiography (MRA) demonstrated severe stenosis of the right main pulmonary artery and obstruction of the left main pulmonary artery (Fig 1B). The aortic arch and its primary branches were normal. Cardiac catheterization showed that the systolic pressure of the main pulmonary artery was 85 mmHg and 25 mmHg in the right pulmonary artery, and the arterial pressure gradient was 60 mmHg. There was no stenosis of the coronary arteries and no incompetence of the aortic valves. A diagnosis of Takayasu's arteritis based on the angiographic findings was confirmed by the laboratory, although the inflammatory response was mild.In March 2003, the patient underwent surgical treatment. Exposure was obtained through a median sternotomy and total cardiopulmonary bypass, involving cannulation of the superior and inferior vena cava through the right atrium and of the ascending aorta, was instituted. Inflamed tissues were found in close contact with both the aorta and right pulmonary artery. Under cardioplegic cardiac arrest, the main trunk and bifurcation of the pulmonary artery were Circ J 2005; 69: 500 -502 (Received February 16, 2004; revised manuscript received May 21, 2004; accepted June 2, 2004 CASE REPORTS

The advantage of completely closing the pericardium after a coronary artery bypass grafting is the avoidance of injury of the heart and grafts during a re-operation. However, it would obviously be counterproductive to close the pericardium with a substitute that is predisposed to infection. This study was designed to evaluate the safety of ePTFE surgical membrane in comparison to native pericardium or autologous tissue. Between January 1992 to March 2003, 695 coronary artery bypass graftings were performed. The hearts and grafts were covered with ePTFE surgical membrane (474 cases: ePTFE group), or autologous pericardium and/or other autologous tissue (221 cases: non-ePTFE group). Often, a bilateral dissection of the internal thoracic artery was performed, which lengthened the surgery, the cardiopulmonary bypass, and the aortic clamp, in the ePTFE group. But there was no difference between the ePTFE group (2.1%) and the non-ePTFE group (3.2%) in the development of postoperative mediastinitis. There was also no difference between the two groups in the organism type of the infection. Methicillin resistant Staphylococcus aureus (MRSA) is the most common organism cultured from sternal wound infections; there were five cases in the ePTFE group, and four cases in the non-ePTFE group. In the ePTFE group, the hospital mortality due to postoperative mediastinitis was zero, and there was also no significant difference between the ePTFE group and the non-ePTFE group in time from the drainage operation to discharge; 74.3 days in the ePTFE group, and 81.0 days in the non-ePTFE group. The clinical use of ePTFE surgical membrane for a coronary artery bypass grafting does not appear to be a risk factor for mediastinitis.

Computed tomography in a 74-year-old man with intermittent claudication revealed an abdominal aortic aneurysm, retroperitoneal hematoma, vertebral erosion, and total aortic occlusion. Surgery was delayed for 9 months after definitive diagnosis of contained rupture of the aortic aneurysm to allow treatment for ischemic heart disease and cardiac failure. After interposing a Y-shaped woven Dacron graft, the intermittent claudication was alleviated. The postoperative course was uneventful.

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