Atheroembolism is an emerging problem in cardiovascular surgery, especially in elderly patients. Severe atherosclerosis of the thoracic aorta usually reflects systemic atherosclerosis. Aggressive preoperative and intraoperative evaluation of the aorta using enhanced CT, transesophageal echocardiography and epiaortic ultrasound is important in elderly patients as well as those with systemic atherosclerosis. To prevent atheroembolism, it is important to select an adequate arterial perfusion site and to avoid touching the diseased aorta until circulatory arrest. In atherosclerotic aortic arch aneurysm, central cannulation under ultrasound guidance and directing the dispersive cannula toward the aortic root is a simple and effective perfusion strategy. Axillary perfusion is useful as an alternative to central cannulation in atherosclerotic aortic disease, but special care is necessary to avoid complications when the patient has a small axillary artery or flail atheroma around the arch vessels. In femoral artery perfusion, retrograde perfusion may induce paradoxical cerebral embolism, but the incidence of stroke is comparable with axillary perfusion when there is adequate preoperative screening using transesophageal echography. Circulatory arrest with/without cerebral perfusion is another important strategy when the aorta has severe atherosclerosis. Recent literature has shown that mild hypothermia may be safe for anterior cerebral perfusion during circulatory arrest, but optimal flow rates and time limitations are unknown. A simple calcified aorta called "porcelain aorta" may be managed by circulatory arrest, local debridement and the clamp method. Several surgical options are proposed for this clinical entity but their use will diminish in the future because of transcatheter valve replacement.

Management of infective endocarditis (IE) with cerebrovascular complications is difficult due to absence of concrete evidence. These patients usually have multiple neurological deficits and the optimal timing for cardiac operation remains controversial. The aims of this study were to present cases and discuss the treatment options for IE with cerebrovascular complications. From 1998 to 2010, 51 patients underwent operations for IE at our institution. From a review of medical records, 10 patients (19.6%) with preoperative neurological complications were identified. Data on these 10 patients were analysed. Cerebrovascular complications included cerebral infarction (n = 4, 40.0%), mycotic aneurysm (n = 1, 10.0%), mycotic aneurysm plus cerebral infarction (n = 3, 30.0%), meningitis (n = 1, 10.0%) and mycotic aneurysm with cerebral haemorrhage plus meningitis (n = 1, 10.0%). Of 5 patients having mycotic aneurysms, 3 underwent clipping before cardiac operations. The mean interval from craniotomy to cardiac operations was 26.7 ± 21.8 days. A cardiac operation was performed initially on seven patients. The mean interval from the onset of neurological deficit to cardiac operation was 7.4 ± 9.8 days. The mortality rate was 10.0%. Postoperative deterioration was not observed. Management of IE with cerebrovascular complications should be based on case-by-case multidisciplinary assessment of potential risks and benefits of intracranial and cardiac operations.

Purpose: A mycotic aneurysm is an uncommon disease associated with a high mortality rate when managed surgically. This study reviewed our experiences in the surgical management of mycotic aortic aneurysms.Methods: In total, 26 patients who underwent surgery for a mycotic aneurysm were retrospectively reviewed. The mycotic aneurysms involved the thoracic aorta in 9 patients, the thoracoabdominal aorta in 4 patients, and the abdominal aorta in 13 patients. An overt aortic rupture in the mediastinum or retroperitoneal space was detected in 4 patients. Patients were classified into one of two groups, febrile or afebrile, and background characteristics, surgical intervention, and early and late mortalities were all compared.Results: There were 19 patients who underwent open surgery, and 7 patients underwent endovascular repair. No significant differences in the clinical characteristics were found between the two groups; however, the incidence of postoperative complications was significantly higher in the febrile group than in the afebrile group (P=0.024). Overall mortality was 15.4% (4/26), and 30-day mortality was 7.7% (2/26).Conclusion: Although febrile patients had a higher incidence of postoperative complications, surgical mortality from a mycotic aneurysm was within an acceptable range. Each patient should be thoroughly evaluated and treated on a case-by-case basis, using conventional open repair, endovascular repair, or a combination of both approaches.

Acute limb ischemia is a critical condition with high mortality and morbidity even after surgical or endovascular intervention. Early recognition is important, but a delayed presentation is not uncommon. Viability of the limb is assessed by motor and sensory function and with interrogating Doppler flow signals in pedal arteries and popliteal veins as categorized by Rutherford. Category IIa indicates mild-to-moderate threat to limb salvage over a time frame without revascularization. Limb ischemia is critical without prompt revascularization in category IIb. Because the risk of reperfusion injury is high in this group of patients, perioperative management is important. In category III, reperfusion is not indicated except for embolism within several hours of onset. Intimal injury should be avoided by careful tactile control of a balloon with a smaller size catheter and under radiographic monitoring. Adjunctive treatment with catheter-directed thrombolysis or bypass surgery is sometimes necessary. Endovascular treatment is a promising option for thrombotic occlusion of an atherosclerotic artery. Ischemia-reperfusion injury is a serious problem. Controlled reperfusion with low-pressure perfusion at a reduced temperature and use of a leukocyte filter should be considered. The initial reperfusate is hyperosmolar, hypocalcemic, slightly alkaline, and contains free radical scavengers such as allopurinol. Immediate hemodialysis is necessary for acute renal injury caused by myoglobinemia. Compartment syndrome should be managed with assessment of intra-compartment pressure and fasciotomy.

VTE during pregnant women is safely managed by anticoagulant therapy. Massive pulmonary embolism during pregnancy can be managed safely by surgical embolectomy using cardiopulmonary bypass, but the rate of fetal loss remains high.