An 83-year old man who had used bilateral axillary crutches for 67 years was referred to our hospital for acute left upper limb ischaemia. He underwent successful recanalization through emergent catheter thromboembolectomy. However, a crutch-induced left brachial artery aneurysm was subsequently detected by computed tomography. Therefore, we performed aneurysm exclusion and subsequent saphenous vein bypass grafting. When a crutch user presents with upper limb ischaemia, a high index of suspicion and early identification of the crutch induced vascular injury are mandatory for appropriate treatment.

Diabetes mellitus (DM) is an important risk factor for adverse outcomes of coronary artery bypass grafting. The bypass grafts harvested from patients with DM tend to go into spasm after their implantation into the coronary circulation. To clarify the contribution of 5-hydroxytriptamine (5-HT) and angiotensin II (AngII) in the bypass graft spasm, we examined the contractile reactivity to 5-HT or AngII of isolated human endothelium-denuded saphenous vein (SV) harvested from DM and non-DM patients. The 5-HT-induced constriction of the SV was significantly augmented in the DM group than in the non-DM group, which is similar to our previous report. AngII-induced constriction of the SV was also significantly augmented in the DM group than the non-DM group. Especially in the non-DM group, the AngII-induced maximal vasoconstriction was markedly lower than the 5-HT-induced one. Meanwhile, the increasing rates of AngII-induced vasoconstriction in the DM group to the non-DM group were significantly greater than those of 5-HT-induced vasoconstriction. These results indicate that 5-HT is a potent inducer of SV graft spasm in both DM and non-DM patients, while AngII is a potent inducer of SV graft spasm only in patients with DM. Furthermore, the protein level of AngII AT1 receptor (AT1R), but not the protein level of 5-HT2A receptor, in the membrane fraction of the SV smooth muscle cells of DM patients was significantly increased as compared with that of the non-DM patients. These results suggest that the mechanism for hyperreactivity to AngII in the SV from DM patients is due to, at least in part, the increase in the amount of AT1R on membrane of the SV smooth muscle cells.

An 81-year old woman with high fever and a history of hospital admission because of pyelonephritis 3 months previously was transferred to our hospital. Contrast-enhanced computed tomography revealed a mycotic pseudoaneurysm in the ascending aorta and a massive pericardial effusion. We resected the ascending aorta and the proximal part of the brachiocephalic artery and performed in situ revascularization with a prosthetic vascular graft. Bacterial examination proved that the causative micro-organism was Escherichia coli. The prosthetic graft was wrapped with a pedicled omentum following completion of the aortic reconstruction. Her postoperative course was uneventful. She was discharged from the hospital 1 month postoperatively.

No abstract

A 75-year-old man, who presented with acute myocardial infarction and cardiogenic shock underwent emergency cardiac catheterization, assisted by catecholamine administration, respiratory support with intubation and intra-aortic balloon pumping (IABP). The coronary arteriogram showed a high-grade obstruction of two main branches of the left coronary artery. The occlusion of the left anterior descending coronary artery required immediate treatment. As it was heavily calcified, the cardiologists were forced to use Rotablator®, but the device became stuck and the drive-shaft broke. An emergency coronary artery bypass grafting (CABG) with left internal thoracic artery and saphenous vein graft and mitral valve annuloplasty was performed successfully. The patient was weaned off IABP on the fourth postoperative day, and a defibrillator was implanted on the 81st postoperative day because of heart failure. After these procedures, his general state improved gradually and he was able to leave the hospital, walking alone on the 101st postoperative day. Various reports have appeared describing residual foreign bodies in coronary arteries, and almost 90% of these cases can be dealt with by intravascular procedures, but some need removal by open-chest surgery. An early decision by the cardiologists to go to surgery is recommended to save lives. There has been no previous report of emergent CABG after a stuck Rotablator® tip due to a 'broken drive-shaft'. However, because damage is possible even with reliable devices, there should be no hesitation converting to open-heart surgery in such cases.