Infected aortic aneurysms are life-threatening and these diagnosis and treatment are challenging. We describe our experience with 7 patients who had infected aortic aneurysms treated at our hospital between January 2000 and December 2005. Three patients had thoracic aortic aneurysms (TAA), 2 had thoracoabdominal aortic aneurysms (TAAA), and 2 had infra-renal abdominal aneurysms (AAA). Four patients had ruptured aneurysms, including pseudoaneurysms. Positive results were obtained for blood cultures in 2 patients, pericardial effusion in 1, and intraoperative tissue specimens in 2; no organisms were identified in the other 2 patients, probably because of prior antibiotic therapy. Three patients had Staphylococcal infections, and the others had Klebsiella and Salmonella infections. Antibiotics were given on establishing the diagnosis of infected aortic aneurysm. Operations were done 11.7 ± 8.2 (0-21) days after admission to our hospital. Two patients with TAA underwent aortic patch plasty with autologous arterial grafts. One patient with TAA received in situ reconstruction with a Dacron graft covered with the greater omentum. TAAA extra-anatomical bypass was performed in 2 patients. The aortic stump was closed off after excision of the aneurysm, and the visceral branches were revascularized with saphenous vein interposition grafts. One patient with AAA received in situ reconstruction with a Dacron graft, and 1 patient with AAA underwent axillobifemoral bypass because of occlusion of the abdominal aorta. Long-term antibiotic treatment was given postoperatively. Hepatic abscess, sepsis, and postoperative paralysis developed in 1 patient with TAAA, and pneumonia and perforation of colon, both of which were treated successfully, developed in another with TAAA. There was 1 in-hospital death. The other 6 patients were followed up on an outpatient basis. Our experience suggests that our strategies for the management of infected aortic aneurysms, surgical treatment based on location and type of aneurysms, and intensive antibiotic therapy can achieve good long-term results.

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We examined the surgical results and late outcome of the extra-anatomic bypass for infected abdominal aortic aneurysm. Seven patients, all male, underwent operations in our institution and had a mean age of 68.4 years (ranging from 56 to 87 years). Our surgical procedure was an extra-anatomic bypass grafting (6 axillo-bilateral femoral bypasses and 1 bilateral axillo-femoral bypass). At the first phase of the operation, we resected the aneurismal wall and debrided all infected tissue. Aortic and iliac arterial stumps were closed by direct sutures and covered by the greater ometum. All patients had fever, 5 had leukocytosis and positive blood culture was revealed only in 4 cases. The CT (computed tomography) findings revealed saccular or pseudoanurysm in all patients. The CT examination was the most useful method in diagnosing infected abdominal aortic aneurysm. Infected abdominal aortic aneurysms were caused by Salmonella in 4 patients, Bacteroides in 1 patient, Klebsiella in another and unknown the cause was in another. The post-operative early complications consisted of an aortic stump disruption due to retroperitoneal abscess in 1 patient, infected thoracic aortic aneurysm, ureteral injury and liver damage in the others. There were no hospital deaths and all patients went home. A late event was a left renal abscess in 1 patient who underwent left nephrectomy and drainage 14 months after his aneurysm operation. Unilateral bypass graft occlusion occurred in the bilateral axillo-femoral bypass graft, and he underwent femoro-femoral crossover bypass grafting 12 months after his operation. Late death occurred with 1 patient due to cerebral vascular disease, but the other patients have been followed-up for 15 to 132 months after their operations. No one had aortic stump disruption, recurrence of infected aneurysm or limb ischemia. We concluded that the extra-anatomic bypass for infected abdominal aortic aneurysm is a safe and reliable method.

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Background: It has become increasingly important to evaluate the cost effectiveness of alternative interventions. The aim of this study was to assess the clinical results and costs of endovascular repair (EVAR) and open surgical repair (OSR) of thoracic aortic aneurysms. Methods: The case-control study included 14 patients treated by EVAR and 9 patients who underwent OSR. Early and midterm outcomes as well as costs were examined. A decision tree model was also developed to evaluate the costs of EVAR and OSR of the descending thoracic aortic aneurysms under the Japanese Diagnosis Procedure Combination based payment system. Clinical outcome data derived from current Japanese reports were used for this model analysis. Results: In the case-control study, no midterm difference was observed between EVAR and OSR regarding hospital mortality or aneurysm-related mortality. The hospital cost of EVAR was significantly less than that of OSR (¥2,620,000 ± 169,000 versus ¥6,942,000 ± 861,000, p < 0.01). In the model analysis, the total cost estimate of EVAR was consistently less than that of OSR over a range of sensitivity analyses. In addition, EVAR appeared no worse than OSR in view of the clinical outcome based on Japanese reports. Conclusion: These results suggest that EVAR is a cost-effective alternative compared with OSR for the treatment of thoracic aortic aneurysm.

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Severe dialysis access associated steal syndrome (DASS) occurs in around 3-5% of case of arterio-venous fistulae (AVF). We report successful treatment of a severe DASS case with a brachio-radial artery bypass. A 56-year-old man presented with a non-healing ischemic ulcer at the amputated ends of the left fourth and fifth fingers as a result of DASS. The diabetic patient had an AVF between the left brachial artery and basilar vein, and a long history of AVF related troubles. Arteriography revealed multiple severe stenoses in the ulnar artery, and a long occlusion of the proximal radial artery. The palm was mainly blood-fed by the distal radial artery, which was opacified by the collateral vessels. The proximal anastomosis on the brachial artery was located 5 cm upstream from the AVF, while the distal anastomosis was on the radial artery 2 cm proximal from the wrist joint. The operation increased the radial artery blood flow, mitigated the ischemia, and led to successful limb salvage.

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A nonspecific aneurysm, commonly considered as an atherosclerotic aneurysm, of the superficial femoral artery is relatively unusual. A 71-year-old man was admitted because of a pulsatile mass in the left thigh. Enhanced computed tomography revealed a 53-mm infra-renal abdominal aortic aneurysm and a 40-mm aneurysm of the left superficial femoral artery. The pathological findings showed the superficial femoral artery aneurysm to be caused by atherosclerosis. Since an aneurysm of the superficial femoral artery is difficult to detect due to the deep structure of the superficial femoral artery in the thigh, the incipient symptom is occasionally rupture. We need to be able to recognize aneurysm of the superficial femoral artery and perform early detection and surgical treatment before complications.

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A 73-year-old man was referred because of sudden abdominal pain. Abdominal computed tomography revealed an abdominal aortic aneurysm with an increase of ventral and lateral aortic wall thickness. The patient underwent endovascular aneurysm repair (EVAR) under general anesthesia with a diagnosis of impending rupture of the inflammatory abdominal aortic aneurysm (IAAA). The postoperative course was uneventful and the patient was discharged from the hospital on the 9th postoperative day. Follow-up CT scan 18 months after the EVAR revealed shrinkage of the aneurysmal sac and regression of periaortic fibrosis.
EVAR for IAAA is technically feasible and safe with low risk of complications such as bleeding and injury to adjacent structures. Moreover, the method may be able to not only exclude the aneurysm but also to reduce perianeurysmal fibrosis.

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Spontaneous iliac vein rupture is rare and only several cases have been reported. We encountered an additional case in a 83-year-old woman, who had been suffering from abdominal pain and hypotension. The preoperative computed tomography scan demonstrated massive hemoperitoneum, a normal arterial system and an intraluminal thrombus at the left common iliac vein. An emergency laparotomy was performed revealing rupture of the left external iliac vein. The ruptured vein was ligated and the postoperative course was good. The preoperative diagnosis of spontaneous iliac vein rupture is difficult, but the presence of intraluminal thrombus in the iliac vein may be a specific finding of this disease.

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