SUMMARYA 27-year-old woman, who had received mitral valve repair for mitral regurgitation resulting from infective endocarditis, was admitted for a close examination of abnormal echocardiographic findings in the left atrium. Transthoracic echocardiography showed trivial mitral regurgitation with normal left ventricular contraction and dilatation of the coronary sinus. Auscultation revealed a grade 2 continuous murmur along the left sternal border. Transesophageal echocardiography demonstrated a marked dilatation of the coronary sinus just behind the posterior wall of the left atrium and turbulent blood flow in the dilated coronary sinus. Cardiac catheterization showed no significant step-up of oxygen saturation in the right heart and normal pulmonary artery pressure. Coronary angiography revealed a markedly dilated and tortuous circumflex coronary artery connected to the coronary sinus through a fistula. A left circumflex artery with a fistulous connection to the coronary sinus is extremely rare. (Int Heart J 2006; 47: 147-152) Key words: Coronary artery fistula, Coronary artery aneurysm, Circumflex coronary artery, Coronary sinus CORONARY artery fistula (CAF) is a rare congenital anomaly with a reported incidence of 0.1% to 0.2% in the adult population referred for cardiac catheterization.1) Fistulous connection into a cardiac chamber or major vessel often causes a marked dilation of the donor coronary artery leading to aneurysm formation. 2)Among various coronary artery anomalies, fistulous connection of the aneurysmal circumflex coronary artery to the coronary sinus has been previously reported as an extremely uncommon form. [3][4][5][6][7][8] In this paper, we describe a case of an aneurysmal circumflex artery connecting to the coronary sinus through a fistula, and discuss surgical management for patients with CAF, particularly for asymptomatic patients with a small left-toright shunt.From the

We retrospectively reviewed 41 patients with isolated iliac artery aneurysms presenting over a 21-year period. The mean age was 72 years. Mean aneurysmal diameter was 6.0 cm (range, 3.2-13 cm). The aneurysms were located in the common iliac artery in 31 patients, internal iliac artery in 7, and both arteries in 3. Rupture occurred in 20 patients (49%). The frequency of rupture of isolated iliac artery aneurysms was significantly higher than that of abdominal aortic aneurysms (8%) during the same period. The 30-day mortality was 9.8%; death in all 4 patients was due to rupture of the aneurysm. The surgical procedure was aneurysmectomy and replacement with a bifurcated prosthetic graft in 24 patients (59%), closure of the common iliac artery with a femorofemoral crossover in 7, minilaparotomy in 3, thromboexclusion in 6, and endoluminal stent-graft repair in one. In contrast to abdominal aortic aneurysms, isolated iliac artery aneurysms can be treated by various methods other than replacement with a bifurcated prosthetic graft. When selecting a strategy for such aneurysms, it is important to choose an approach appropriate to the location and risk, because of the frequency of rupture.

We define minimally invasive vascular surgery as surgery performed with a small abdominal skin incision that does not expose the intestine to air while providing a good operative field that does not place any undue stress on the surgeon.

We report a case of pancreatic injury, caused by a stab wound, in which ductal injury and wound depth were clearly identified by intraoperative ultrasonography. A 65-year-old woman was emergently admitted to our hospital after stabbing herself in the abdomen in a suicide attempt. Preoperative computed tomography (CT) and laboratory examination revealed liver and pancreatic injury with massive abdominal bleeding and free air. Operative findings included injuries of the stomach, small bowel, colon, liver, and pancreas. The pancreatic lacerations were 1 cm in length, in the body. Intraoperative ultrasonography enabled the diagnosis of a lacerated main pancreatic duct with no damage to the major vessels posterior to the pancreas. Distal pancreatectomy; simple repairs of the liver, small bowel, and stomach; exteriorization of the injured colon; cholecystostomy; gastrostomy; and jejunostomy were performed. The patient recovered and was transferred to a psychiatric hospital 87 days after surgery. In this patient, intraoperative ultrasonography was successfully used to identify the degree of injury to the pancreatic duct, as well as the depth of the stab wound. In conclusion, intraoperative ultrasonography should be routinely performed to detect main pancreatic duct injury in penetrating pancreatic trauma.

Venous thromboembolism is the most preventable illness among patients in hospital. We prepared guidelines for the prophylaxis of venous thromboembolism, based on previous experience of perioperative risk factors. The aim of this study was to evaluate the effectiveness of these guidelines. All 1,467 patients who underwent surgery for thoracic or cardiovascular disease between April 2002 and July 2004, before the prophylactic guidelines were implemented, were assigned to group A. Another 1,389 patients who had surgery between August 2004 and December 2006, after the guidelines had been implemented, formed group B. The incidences of venous thromboembolism perioperatively in the 2 groups were compared. Six (0.4%) patients in group A developed deep vein thrombosis or pulmonary embolism, whereas no patient in group B experienced thromboembolism. The difference between groups was significant, so we consider our guidelines for venous thromboembolism prevention in the perioperative period to be clinically useful.