While the elective surgical treatment of an abdominal aortic aneurysm (AAA) has now become a relatively safe operation, the mortality associated with a ruptured abdominal aortic aneurysm (RAAA) remains high. In this study, we describe our treatment for RAAA and clinical results. Thirty-eight patients with RAAA were admitted to our hospital between July 1998 and December 2005. Twenty-five cases were in a preoperative shock state. The hospital mortality rate following the RAAA operation was 26.3%. In this series, the factors associated with a poor prognosis were preoperative shock state, disturbance of consciousness, and intra-operative blood transfusion. Causes of surgical deaths were bleeding (n=5), multiple organ failure (n=2), myocardial infarction (n=2), and respiratory failure (n=1). An expeditious diagnosis and treatment are important for improving the outcomes of RAAA patients.

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Material defects, both in grafts and sutures, are important contributing factors to the formation of an anastomotic aneurysm. With the advent of modern polypropylene monofilament suture, primary failures have become uncommon. However, we have used monofilament polyamide sutures prior to the use of polypropylene suture. We report a case of anastomotic aneurysm occurring due to fragmentation of a monofilament polyamide suture. A 75-year-old man had undergone open surgical repair of an abdominal aortic aneurysm 15 years previously. He was referred to our hospital with profound hemorrhagic shock and underwent emergency surgery: it revealed a pseudoaneurysm rupture due to the extravasation of blood in the fibrous capsule surrounding the vascular prosthesis. Half the proximal aortic suture line and the entire distal aortic suture line were disrupted. We removed the fragment of the degraded suture and analyzed it in detail. Based on this analysis, it was concluded that deterioration of the monofilament polyamide suture was the primary cause of anastomotic aneurysm rupture.

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Primary malignant tumor of the aorta is extremely rare. We report herein a case of intimal angiosarcoma of the distal aortic arch. A 38-year-old man with hoarseness, was referred for impending aneurysm of the distal aortic arch. At emergency surgery, a horizontal intimal tear was recognized and the aortic wall was dissected. Prosthetic replacement was employed during partial bypass. The postoperative course was uneventful. Three months after the surgery, routine computed tomography revealed tumor-like lesions in multiple organs. Needle biopsy of the kidney was carried out and metastatic malignant tumor was diagnosed. Although the patient underwent chemotherapy, he died of multiple organ failure due to systemic metastases. On autopsy examination, the final diagnosis was intimal type of angiosarcoma originating from the distal aortic arch with multiple metastases.

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Abdominal aortic aneurysm (AAA) surgery is frequently complicated by gastro-intestinal events, but ileus caused by small intestinal, especially duodenal, obstruction is far more uncommon. We reported a case of the duodenal obstruction following ruptured aortic aneurysm resection which was caused by a perigraft seroma. A 77-year-old man with a ruptured AAA underwent aortic repair using an aorta-biiliac graft. The operation was uneventful, but the patient vomited frequently just after he commenced on oral intake. Computed tomography showed compression of the duodenal third portion by an aneurysm sac filled with low density fluid and remarkable dilatation of the proximal duodenal lumen. He was treated conservatively with total parenteral nutrition (TPN) and naso-gastric tube aspiration. Dietary intake was restarted on the 33rd postoperative day and he was weaned from TPN without any trouble. The patient was discharged 45 days after operation. We consider that duodenal obstruction caused by a perigraft seroma would resolve spontaneously, and thus should be treated conservatively.

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A 98-year-old woman was referred to our hospital for the treatment of a thoracic aortic aneurysm. Although she was at an advanced age, she had clear consciousness, and strongly wished to be operated on. We judged it was possible to perform endovascular stent-grafting in terms of the anatomical aspect. The right femoral artery and left axillary artery were exposed, and we inserted the stent-graft by the tug-of-wire technique under heart arrest using adenosine triphosphate. The operation was completely successful, and no endoleak was detected on postoperative enhanced computed tomography imaging. On the 10th postoperative day, she went back to the former hospital. The conventional operation for thoracic aortic aneurysm is highly invasive for elderly people, and it which is contraindicated in quite a few cases. Endovascular stent-grafting is less invasive, and considered to be very effective, because it can widen the therapeutic choices.

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A 68-year-old woman was transported to our hospital with abdominal pain of sudden onset which was diagnosed as Type IIIb acute aortic dissection. The examination of 3D-CT and MD-CT revealed the occlusion of the superior mesenteric artery with abdominal malperfusion due to aortic dissection. We performed an emergency operation, consisting of bypass grafting between the left common iliac artery and superior mesenteric artery using a saphenous vein. The postoperative course was uneventful and she was discharged in a good condition.

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A 59-year-old man presented with left upper limb ischemia and significant hypotension. He had undergone coronary artery bypass grafting using a left internal thoracic artery (LITA) graft 18 years previously. Angiography revealed stenosis of the left subclavian artery and visualization of only the proximal half of the LITA. Complete recanalization of the left subclavian artery was achieved by an endovascular treatment, and the left anterior descending artery distributing from the LITA became well visualized.

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