We encountered 94 ruptured aneurysms of the abdominal aorta in the past 14 years, with 10 patients dead on arrival at the emergency room. Since 1994, we have adopted a rapid diagnostic triad (abdominal or back pain on acute onset, shock or loss of consciousness, and aneurysm detected by ultrasonograghy suggests a ruptured aneurysm) and non-heparin technique as a key strategy for aortic aneurysm rupture. The purpose of this study is to clarify the severity of continuous hemorrhagic cases and the effect of prehospital diagnosis on outcome.We examined the results of 84 operation cases classified according to Fitzgerald's classification (F-1, F-2, F-3, and F-4), and they were divided into two groups according to the prehospitalization diagnosis: U-group (undiagnosed group) and D-group (diagnosed group). The continuous hemorrhagic cases were defined and classified into three types: E-type (with extravasation of the contrast medium recognized on computed tomography), P-type (with progressive abdominal extension demonstrated by intraoperative findings compared to the preoperative examinations), and H-type (with in-hospital rupture before urgent operation).The number of cases of [F-1 : F-2 : F-3 : F-4] were [8 : 9 : 57 : 10], the proportion of shock (BP < 80 mmHg) cases were [13% : 56% : 86% : 90%], and the mortality rates were [0% : 0% : 32% : 40%]. Except for F-1 cases, there were 36 cases of U-group and 40 cases of D-group. Although there were no significant differences in perioperative data other than admission-operation time (U-group, 114 minutes vs D-group, 60 minutes: p = 0.00003), the U-group showed significantly worse mortality (44% vs 15%: p = 0.005).As for continuous hemorrhagic cases, E-type had the worst mortality [E-type, 71%: P-type, 23%: H-type, 43%]. It is noteworthy that H-type had unexpectedly poor prognoses considering that swift operation (mean interval of 61 minutes from the onset) and aortic crossclamping (mean interval of 11.8 minutes from skin incision) were achieved. No one knows when each rupture case deteriorates and turns into deep shock or cardiac arrest, and there are cases with least survival chance regardless of whatever efforts vascular surgeons make. Nevertheless, we should make every effort for rapid diagnosis and transfer to the operating room and technical improvement for expeditious aortic crossclamping followed by certain and accurate aortic reconstruction.

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Fibromuscular dysplasia (FMD) is a non-atherosclerotic, non-inflammatory arteropathy of unknown etiology that affects small and medium sized arteries causing luminal narrowing and aneurisms. It is most common in renal arteries, but is also often observed in carotid arteries and very rarely in peripheral arteries. The present case is a 55-year-old man who smoked 20 cigarettes a day since the age of 15 and noticed ulcers and coldness in his fingers and toes. An intra-arterial angiography revealed blockage in both radial and posterior tibial arteries which led to a diagnosis of Buerger's disease. Cauterization was performed on the left thoracic sympathetic nerve and a sympathectomy was performed on the right lumbar sympathetic nerve in addition to a biopsy taken of the right posterior tibial artery. No organized clotting or venous thrombophlebitis could be observed in the pathology, so the patient was diagnosed with FMD due to hyperplasia in the tunica externa and media. The patient was given a diagnosis of Buerger's disease according to the diagnostic criteria of Shionoya but FMD was diagnosed in the peripheral arteries from the pathological findings. This case is a rare case of FMD in the peripheral arteries and was confirmed pathologically. Considering that Buerger's disease had been diagnosed before surgery, it is possible that FMD was present in some Buerger's disease cases in the past.

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We report a rare case of arteriovenous fistulas between the right common iliac artery and the left common iliac vein. The patient had no history of a surgical operation, arterial catheterization or penetrating injuries. His pre-operation computed tomography showed calcification at right common iliac artery faced left common iliac vein. At operation, after resection of the abdominal aortic aneurysm and closure of the right common iliac artery directly with mattress suture, a bifurcated aortoiliac bypass graft was inserted.

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Cystic adventitial disease (CAD) is a rare arterial disorder that can cause localized arterial stenosis or obstruction. This case report describes a 63-year-old woman presenting with right-sided intermittent claudication. Physical examination failed to identify any stigmata of generalized arterial disease. The right-sided ankle-brachial index at rest was 0.93. Color-coded Doppler sonography was diagnostic of a high-grade stenosis of the supragenicular popliteal artery, which was confirmed by computed tomography demonstrating the presence of a highly stenotic lesion in the right popliteal artery caused by protruding soft-tissue masses surrounding the artery. Magnetic resonance imaging revealed cystic lesions encompassing the right popliteal artery circumferentially. These cystic lesions exhibited low signal intensity on T1-weighted images and high signal intensity on T2-weighted images. Because of the characteristic location and clinical signs, CAD was suspected. Prior to surgery, we used Doppler sonography to determine our incision line. The popliteal artery was exposed via a posterior approach and showed circumferential enlargement. After complete resection of the adventitial layer, a yellowish-colored, pressurized, gelatinous, mucoid mass emerged. Arterial blood flow was fully restored by the end of the operation. The patient had an uneventful postoperative course and has remained free of symptoms for seven months.

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We report a rare case of critical limb ischemia due to Buerger's disease in which recanalization was confirmed in the popliteal artery with symptomatic improvement. A 42-year-old man who presented with critical limb ischemia was admitted to our hospital. He was found to have right popliteal artery occlusion due to Buerger's disease with skin ulcer and severe pain in his right foot. Conservative treatment such as anticoagulant therapy and lipo PGE1 infusion was started immediately, and the lumbar sympathectomy was performed on the day 12 after admission. Extensive recanalization was confirmed in the popliteal and peroneal arteries on arteriography performed on the day 17 after admission, and he was discharged without amputation or additional bypass surgery.

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A 66-year-old man underwent enhanced computed tomography (CT) and magnetic resonance imaging (MRI) for investigation of hypertension. These imaging studies revealed a 50-mm diameter abdominal aortic aneurysm (AAA) associated with retroperitoneal hematoma. No leg edema or deep vein thrombosis were present. At operation, two rupture sites were demonstrated; one on the right lateral wall of the abdominal aorta below the right renal artery near the inferior vena cava, and other on the posterior wall of the left common iliac artery. The latter exhibited a punched-out defect. Faint ulceration was visible on the aneurysm surface and this appeared to be involved in the onset of rupture. However it was the possibility of pseudoaneurysm due to the penetrating atherosclerotic ulcer was difficult to rule out.

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Acute myocardial infarction due to retrograde dissection of the aortic root reaching the coronary ostia is a potentially fatal condition. A 68-year-old man with a history of hypertension was hospitalized with sudden onset of chest pain and compression. He was admitted with cardiogenic shock with a systolic pressure of 70 mmHg under dopamine infusion. His electrocardiogram (ECG) demonstrated ST elevation in II, III and aVF leads and complete A-V block. Enhanced computed tomography showed a type A acute aortic dissection. These data strongly suggested malperfusion of right coronary artery. During preparation for emergency operation, catheter intervention was performed immediately. The coronary angiogram showed a 99% stenosis in segment 1-2. Stents were implanted in the right coronary artery to restore coronary blood flow. After stenting, his hemodynamic state became stable and chest symptoms was diminished. Then he underwent total arch replacement including the ascending aorta and coronary arterial bypass grafting using a saphenous vein graft. He suffered a cerebral infarction, but he was given an ambulatory discharged without any neurologic deficits on the 48th postoperative day. A bridge use of stents is considered useful to preserve hemodynamic stability until surgical treatment.

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A 77-year-old man suddenly developed severe pain, paresthesia and cyanosis in his left forearm and hand. The next day, he was referred to our hospital on a diagnosis of acute arterial occlusion in his forearm. Emergency thrombectomy of the left radial and ulnar arteries was carried out successfully. Soon after the operation, his left hand showed severe swelling and became pale again, so we diagnosed compartment syndrome of the hand. To salvage his hand, fasciotomy was immediately carried out through longitudinal incisions over the 1st and 2nd metacarpals, and the ulnar side of the 5th metacarpal, respectively. His postoperative course was uneventful and function of his left hand was well maintained. Upper extremity ischemia is a common consequence of acute arterial embolism. However, it is rare for fasciotomy of the hand to be needed after thrombectomy of the upper extremity. We should carefully observe patients after thrombectomy of the upper limb, prevent to any delay in the diagnosis of compartment syndrome of the hand. Prompt and appropriate treatment is necessary to avoid disastrous outcomes such as amputation or hand dysfunction.

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A 72-year-old man was admitted to our hospital with a diagnosis of abdominal aortic aneurysm (AAA). Abdominal and pelvic level computed tomography (CT) scans revealed an aneurysm of the right deep femoral artery in addition to known AAA. On May 12th 2006, graft replacement of the right deep femoral artery aneurysm using a 6-mm expanded polytetrafluoroethylene prosthetic graft was performed, in addition to graft replacement of AAA. The postoperative course was uneventful and histological findings revealed arteriosclerosis. It is rare for an asymptomatic deep femoral artery aneurysm to be found by pelvic CT scan.

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We describe an 87-year-old man with an arteriovenous fistula that arose due to the spontaneous rupture of abdominal aortic and right common iliac aneurysms into the right common iliac vein. Such arteriovenous communication is rarely associated with this atherosclerotic aneurysm, but it represents a life-threatening complication. The primary symptom in this patient was bilateral leg edema. He was admitted with abdominal distension and dyspnea. Echocardiography did not detect left heart failure, but the right atrium and inferior vena cava were enlarged. A pulsating mass with vascular bruit and thrill was located in the right lateral abdomen. Computed axial tomography confirmed that the mass was an aneurysm of 60 mm in maximal diameter in the right common iliac artery, and that the lower abdominal aorta and left common iliac artery were dilated. Surgery was perfomed to treat an arteriovenous fistula that had perforated the right common iliac aneurysm. After opening the aneurysm using a median laparotomy approach, we found an orifice 10 mm in diameter in the right common iliac arterial wall. The fistula was closed from inside the aneurysm using 2 interrupted sutures with 4-0 monofilament polypropylene. A Y-shaped prosthetic graft replaced from the abdominal aorta to the bilateral external iliac artery, and the right internal and left common iliac arteries were ligated. The surgical diagnosis was an arteriovenous fistula between the right common iliac artery and vein, which caused high output heart failure. These procedures improved both the bilateral leg edema and the heart failure.

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