Background: Patients with abdominal aortic aneurysm (AAA) often have complication of coronary artery disease (CAD) and surgical strategy has a great impact on outcome. Our objective was to evaluate our surgical strategy for patients with AAA and CAD based on the surgical outcomes. Methods: From January 1, 2002 to April 30, 2006, 323 patients underwent solitary CABG and surgery for AAA was performed in 317 patients. Thirty-nine patients with CAD and AAA were surgically treated, 33 men and 6 women with a mean age of 74 ± 7.2 years old (54-87 years). Emergency cases were excluded. Patients with an AAA diameter of 55 mm or more or proximal LAD lesions underwent concomitant operation and the others had additional PCI or prior CABG. Concomitant CABG and AAA operation was performed in 22 patients (combined group), AAA operation following CABG in 8 (prior CABG group), and AAA operation with additional PCI in 9 (additional PCI group). Concomitant operation included OPCAB in 14 patients and MIDCAB in 8 as CABG procedures. Eight patients with prior CABG had AAA operation at a mean of 6.3 ± 4.5 weeks after CABG (3-16 weeks). PCI was carried out before AAA operation in 6 patients and after operation in the remaining cases. The preoperative, intraoperative, and postoperative factors were compared among the 3 groups. Follow-up was carried out for 1.7 ± 1.2 years (2 weeks-3.9 years). Results: Hospital mortality was 2.6%: one patient with concomitant operation who had preoperative renal dysfunction, anemia, and low platelet count, died of acute renal and hepatic failure. Morbidity in all other patient was not significantly different. No AAA rupture was noted in the patients with treatment for CAD before AAA operation. Conclusion: Surgical treatment for patients with CAD and AAA was performed with acceptable outcomes. Meticulous surgical strategy is required in high-risk patients.

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A 51-year old male with a strongly compressed thorax due to blunt trauma was admitted to our hospital. A radial pulse was not palpated at the left wrist, and was barely detected with a Doppler stethoscope. Initial computerized tomography scan demonstrated a hematoma in the circumference of the left subclavian artery, and bleeding from the left subclavian artery was suspected. Emergency angiography was performed and showed the left subclavian artery was occluded. The left vertebral artery was filled in a retrograde direction and the distal left subclavian artery could be visualized by filling from the left vertebral artery. There was no extravasation of contrast agent. As bleeding was controlled and blood flow to the left hand was maintained, we did not perform an operation. If a symptom due to the subclavian steal phenomenon had developed, we would have performed revascularization; however, as it was not observed he became an outpatient for follow-up. In this case the left subclavian artery was occluded due to blunt trauma, with the resulting hemodynamics showing subclavian steal phenomenon. We experienced a rare case that had been treated for traumatic occlusion of subclavian artery with just conservative treatment.

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A 68-year-old man with an abdominal aortic aneurysm and horseshoe kidney is reported. Preoperative multi slice computed tomography(MSCT) revealed an accessory renal arteries arising from the aortic bifurcation to the isthmus of the kidney. The urinary tract and the aorta were detectable by CT at the same time. We operated taking a medial transperitoneal approach. The aneurysm was successfully replaced by a knitted Dacron bifurcated graft without resection of the renal isthmus. The accessory artery flowed back from the left common iliac artery bypass. The patient was discharged on the 25th day after the operation. Postoperative CT scan showed no sign of renal infarction and confirmed the patency of the reconstructed accessory renal artery. MSCT was useful to reveal aberrant renal arteries and urinary tract of the horseshoe kidney.

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We encountered a case of middle mesenteric artery during abdominal aortic aneurysm repair. This third mesenteric artery arose from the ventral surface of the aneurysm between the superior and inferior mesenteric arteries and supplied the transverse colon; it anastomosed with the oral and anal marginal arteries. This is the eleventh report of this rare anomaly.

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Venous stasis ulcer is a disease which is often encountered on medical examinations. It is difficult to treat and has a high rate of recurrence. We experienced a case which good wound healing was able to be obtained by using vacuum-assisted closure (VAC) for an intractable infected venous stasis ulcer. A 78-year-old obese female who had a history of primary varicose veins in her left lower limb complicated by a venous stasis ulcer. The ulcer was not covered by bandage and conventional gauze dressing for 1 year or more and it was accompanied with gangrene. Staphylococcus aureus and Morganella morganii ssp were detected from incubation of specimens of the wound.
After having done surgical debridement of the sphacelus, we performed ligation to the sapheno-femoral junction and 2 lower perforating veins under local anesthesia. We started VAC for the ulcer from the past postoperative day (POD 1). Good granulation of the ulcer was accelerated on POD 10, and the reduction of the ulcer was recognized. Furthermore, the epithelization of the wound progressed on POD 20. She was discharged on POD 27 and the complete healing of the ulcer was at 2 months postoperatively.
We were able to obtain the comparatively early healing of a venous stasis ulcer by using VAC. It was considered to be a useful method for venous stasis ulcer.

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We report a case of secondary aortoduodenal fistula which occurred 5 years after an abdominal aortic aneurysm repair. A 54-year-old man was admitted with sudden loss of consciousness after massive hematemesis. He underwent Y-graft replacement for abdominal aortic aneurysm 5 years previously. Computed tomography scanning demonstrated adhesion of the aorta-duodenum at the proximal anastomosis of the prosthetic graft and angiography showed a leakage of contrast medium in the region of the infrarenal aorta. An emergency operation was performed under a diagnosis of a secondary aortoduodenal fistula. At laparotomy the duodenum was firmly attached to the pseudoaneurysm and a fistulous communication was also observed at the site of proximal anastomosis. After the duodenal defect was closed following excision of the contaminated graft, operative reconstruction was performed via the anatomical route using the interposition of a new prosthetic graft, and the greater omentum was used to fill defects surrounding the anastomosed site. His postoperative course was uneventful, he has been doing well for 9 years.

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We report a case of intravenous leiomyomatosis extending to the inferior vena cava. The patient was a 74-year-old woman, who had a history of total hysterectomy due to uterine leiomyoma about 30 years previously and upper lobectomy of the right lung due to lung cancer about 7 months before. Computed tomographic scan showed that an intravenous tumor extended from the right internal iliac vein to the inferior vena cava. We resected the intravenous tumor which was shown to be a leiomyoma, positive for estrogen receptor.

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We encountered a rare a case of isolated internal iliac aneurysm-rectal fistula. The patient was an 86-year-old man and his chief complaint was irregular bowel movement. Upon admission, he developed fresh melena. Contrast-enhanced computed tomography demonstrated a 4.5-cm-diameter right internal iliac arterial aneurysm and an adherent cystic mass 6 cm in diameter compressing the rectum. An aorto-enteric fistula was highly suspected and emergency surgery was performed. Pseudoaneurysm from the right internal iliac aneurysm adhered tightly to the rectum and aneurysm wall and the rectum was resected en-bloc. Branches of the internal iliac aneurysm were closed from inside the aneurysm. The abdominal aorta was reconstructed with Y-shaped ePTFE graft and a Hartmann operation was done. His postoperative course was uneventful. Pathological examination revealed rupture of the right internal iliac aneurysm penetrating into the submucosal layer of the rectal wall. The rectal mucosa became ischemic, suggesting that herald bleeding might have been due to mucosal bleeding caused by ischemia.

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We describe a case of successful surgical treatment for abdominal angina which involved the celiac artery, superior mesenteric artery (SMA) and inferior mesenteric artery (IMA). A 45-year-old woman who had been suffering from intermittent abdominal pain for a year was admitted. We failed to confirm the blood flow of these three arterial trunks on a preoperative angiogram. It showed that the blood supply of intestine was coming from the collateral circulation via the left internal iliac artery. We recognized paleness of the intestine as well as the pulseless thin arteries during the operation. We established a temporary axillo-femoral artery bypass first to preserving the blood flow of mesenterium through the iliac artery. Subsequently we accomplished reconstruction of SMA and IMA, using a Dacron graft (6 mm in diameter) between the infrarenal aorta and these arteries. We also resected the small intestine because its segment still remained pale and was stenotic. Histological examination revealed severe fibrosis and micro-capillary proliferation in the subserosa of the intestine, as well as marked atherosclerosis in these arteries, which strongly suggested the cause and result of long-term ischemia of the intestine. She had a very good clinical course and her abdominal symptoms disappeared postoperatively. Three-dimensional CT scanning showed good graft patency without any deformations such as kinking or compression.

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