During the past 4 years, we encountered 27 cases undergoing placement of inferior vena cava filter (IVCF) for prevention of pulmonary thromboembolism (PTE). In 12 cases, IVCF was placed for remaining deep vein thrombosis (DVT) after improvement of PTE with t-PA. In 6 cases, thrombolysis or thrombectomy was performed for floating DVT under IVCF. In 5 cases with abdominal tumor or bone fracture which generated DVT, tumor removal or bone reconstruction was performed under IVCF. In 4 cases with cerebral hemorrhage or advanced cancer which was contraindicated to anticoagulation, IVCF was placed for floating DVT. After placement of IVCF, X-rays, echography and computed tomography were periodically performed. As a result, a huge thrombus was found in 3 cases with temporary IVCF. Thrombolysis dissolved it in one case, but surgical removal of the thrombosed IVCF was required in 2 cases with its tilting or migration. In all of 27 cases including these 3, recurrence or occurrence of PTE did not happen during the mean follow-up period of 22 months. In conclusion, IVCF was effective for prevention of PTE, but careful observation is mandatory for temporary IVCF because of its susceptibility to dislocation, resulting in thrombus formation.

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Background: Due to the increase in the elderly population, nonagenarians who required emergency treatment for fatal aortic disease are occasionally reported. However, almost all these reports describe only one case of successful treatment. The actual outcome including unsuccessful cases or patients who refused aggressive treatment is unknown. Patients and Methods: We reviewed 8 consecutive nonagenarians with fatal aortic disease who were transferred to the emergency center of Kansai Medical University during the past 55 months. This study included 2 patients who suffered from Stanford type A acute aortic dissection, 2 patients with Stanford type B acute aortic dissection, 1 patient suffering from ruptured thoracoabdominal aortic aneurysm, 1 patient with open ruptured abdominal aortic aneurysm, 1 patient who suffered from contained ruptured abdominal aortic aneurysm and 1 patient with impending rupture of abdominal aortic aneurysm. Results: Although 2 of 3 patients suffering from abdominal aortic aneurysm had previously been given a diagnosis of abdominal aortic aneurysm, they refused surgery because of dementia. However, since the families of these 2 patients earnestly desired surgery after development of acute abdominal aortic emergencies surgical treatment was performed immediately. These 2 patients with dementia were restored to oral feeding, however, one patient died of aspiration pneumonia and the other one was complicated with hypoxic encephalopathy after cardiopulmonary resuscitation for cardiac arrest due to suffocation. One patient free from dementia recovered uneventfully after replacement of the abdominal aorta and bilateral iliac artery. Three of 5 patients with acute thoracic aortic emergency required immediate operation. One patient with Stanford type A acute aortic dissection recovered completely by surgery, however, another one died of cardiac tamponade during preparation for surgery. The patient with the ruptured thoracoabdominal aortic aneurysm died of heart failure due to severe aortic regurgitation without weaning from cardiopulmonary bypass. Two patients with Stanford type B acute aortic dissection were discharged uneventfully after intensive hypotension therapy. Conclusion: Although the outcome of nonagenarians suffering from acute aortic emergency is unsatisfactory, the first priority is attempt to save patients who suffered from devastating aortic disease even if they are nonagenarians, if they do not have dementia. Additional care concerning respiration management is important for elderly patients. On the other hand, if the patient is a nonagenarian complicated with dementia, the indications for emergency surgery must be carefully considered.

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Aorto-enteric fistula (AEF) is a well known complication after abdominal aortic surgery. However, it is often hard to diagnose because of its rare incidence and difficulty in detecting the bleeding point. Case 1: A 64-year-old man who had undergone aorto-bifemoral bypass grafting for aortic occlusion in April 2003 had abdominal pain and melena in August 2005. No cause was detected by gastrointestinal examinations, but he entered a state of shock after massive blood discharge and was performed emergency operation about 4 weeks later from his first episode of melena. Case 2: A 55-year-old man who underwent aorto-biiliac graft replacement for abdominal aortic aneurysm in October 1995 had abdominal pain and melena in July 2005. No cause was revealed by repeated gastrointestinal examinations. We suspected AEF because of the presence of pseudoaneurysm on computed tomography scan and performed on urgent operation about 5 weeks after his first abdominal pain. We should consider AEF if we encounter a patient with digestive bleeding of unknown cause after aortic surgery and decide on an emergency operation without a definitive diagnosis.

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We surgically treated a chronic mesenteric ischemia with thrombosed abdominal aortic aneurysm in an 87-year-old man. Preoperative 3-dimensional computed tomography revealed that the abdominal aortic aneurysm, 8 cm in diameter, was occluded with thrombus and the orifice of the celiac artery was stenostic and the root of the superior mesenteric artery was occluded. We successfully reconstructed the superior mesenteric artery in a retrograde fashion with abdominal aortic aneurysm repair and reconstruction of the right internal iliac artery. After the operation, the patient’s symptoms were completely relieved.

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A 69-year-old man was given a diagnosis with rupture of an abdominal aortic aneurysm associated with sigmoid and rectal colons ischemia. He was admitted to our hospital about 30 hours after rupture, and underwent an emergency operation. The infra-renal abdominal aorta was ruptured with a huge hematoma in the retroperitoneal space. Sigmoid and rectal colons were necrotic. The abdominal aortic aneurysm was replaced with a prosthetic Y-graft. The sigmoid and rectal colons were resected and colostomy was performed. He recovered from postoperative complications including acute renal failure, acute respiratory failure, and liver failure and was discharged in good condition 23 days after the operation.

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An 81-year-old man with sudden onset of back pain was urgently transported to a local hospital. An enhanced computed tomography demonstrated an acute Stanford type B dissection and conservative therapy was started. Bilateral limb ischemia and renal dysfunction appeared 9 day after onset because the true lumen was severely compressed by the false lumen. He was referred to our hospital for an emergency operation. After admission, we performed emergency endovascular stent graft placement for the entry closure. After the procedure, the limb ischemia and renal dysfunction improved, and he was transferred back to the local hospital.

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A 62-years-old woman had abdominal pain of unknown origin. Examinations showed a 19-mm saccular type inferior pancreaticoduodenal arterial (IPDA) aneurysm and dilatation in the posterior branch of IPDA, and also severe stenosis in the celiac axis. Selective superior mesenteric angiography showed dilatation and tortuosity of the IPDA with retrograde filling of the the celiac artery as a good collateral pathway. Increased blood flow may be an important etiologic factor for IPDA aneurysm and dilatation in its posterior branch. To reduce the risk of perioperative ischemia of the abdominal organs and prevent progression of collateral circulation, abdominal aortic common hepatic artery bypass with a reversed vein graft was done, and the IPDA aneurysm was resected. The intraoperative bypass blood flow rate was 500 ml/min. The postoperative course was uneventful. A 3-dimensional computed tomographic scan 1 year after operation showed the patency of the abdominal aorta-common hepatic artery bypass and no recurrence of the PDA aneurysm. We believe that resection of the IPDA aneurysm with aortohepatic artery bypass is a useful method for treatment of IPDA aneurysms with stenotic or occluded celiac axis.

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We report a surgical case of celiac artery aneurysm due to segmental arterial mediolysis. A 41-year-old woman was admitted with sudden abdominal pain and computed tomography (CT) revealed infarction of the spleen and both kidneys. Heparin (5000 units per day) was started and the pain resolved. However, follow-up CT indicated the disappearance of spleen cells and the appearance of a celiac artery aneurysm. She was transported to our hospital for surgery. We performed resection of the aneurysm and revascularization. The patient’s postoperative course was uneventful. The pathological finding was segmental arterial mediolysis (SAM), which is characterized by no inflammation, no arteriosclerosis, fusion of the tunica media, and degeneration of the vascular wall. Patients with SAM show various clinical courses. Virtually all cases are emergencies due to rupture, and this was a rare elective surgery case.

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In a 56-year-old man, computed tomography demonstrated a 58 mm aneurysm in the infra-renal abdominal aorta and the hilus of right kidney faced ventrally. There were two right renal arteries: the upper one separated from the abdominal aorta normally, and there was a lower ectopic one from the left common iliac artery. Each of these arteries supplied about a half of the right kidney. At operation, we performed bifurcated graft replacement and an anastomosis of the right lower renal artery to the right limb of the Y graft with continuous blood perfusion to the ectopic renal artery. The right lower renal vein, which ran along the right common iliac artery ventrally, drained into the left common iliac vein and could be preserved. Postoperatively this patient had an uneventful course without renal dysfunction. If renal ischemia is anticipated to be prolonged at operation, selective continuous blood perfusion to ectopic arteries is also useful for renal protection. In a case with a morphological anomaly of a kidney, renal veins as well as renal arteries are occasionally anomalous. Preoperative detailed evaluation by imaging is important to prevent injuring anomalous veins.

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A 73-year-old woman who visited her local physician with a principal complaint of pallor in her left finger, which two months after this first visit progressed into chills and weakness in her left upper arm, and she was referred to us when the symptoms started to interfere with her daily activities. We could not feel an arterial pulse in either of her upper arms, and since bilateral axillary artery occlusions were detected by angiography, a left subclavian-brachial artery bypass procedure was performed using the left basilic vein in January 2001. The symptoms in her left upper arm improved after surgery, but the weakness in the right upper arm became significant. As a result, a similar bypass procedure in her right upper arm was performed in March of the same year. The blood pressure ratio of the upper/lower arms before and after surgery was right 0.33→0.83 and left 0.41→1.01, and nothing prevented the patient from performing her daily activities after surgery. In addition, an improvement in the patient’s quality of life was also observed. The etiology of this disease was considered to be nonspecific vasculitis, and long-term patency was achieved.

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