Background:We previously reported that a Rutherford classification level 3 or 4 (R3, R4) was a prognostic factor correlating with survival after repair of a ruptured abdominal aortic aneurysm (RAAA). In this study, we describe our surgical strategy and clinical results for R3 and R4 level patients. Methods: RAAA repair was performed in 48 cases from 1996 to 2007, including 18 cases in the first period (1996 to 2000) and 30 cases in the second period (2001 to 2007). R3 and R4 levels were detected in 6 cases in the first period and in 14 cases in the second period. In R3 and R4 level patients, who are in severe shock, we evaluated postoperative complications, hospital mortality rate, and cause of death. Descending thoracic aortic cross-clamping for immediate recovery from severe shock state and temporary abdominal closure for prevention of abdominal compartment syndrome (ACS) were performed as surgical strategy R3 and R4 level patients in the second period. Of those 14 cases, 9 (64.3%) underwent descending thoracic aortic cross-clamping. Twelve cases (85.7%) underwent temporary abdominal closure, of which the first two cases underwent abdominal wall closure of the skin only without fascial closure, followed by two cases of closure with latex, and two cases using the vacuum-assisted closure (VAC) technique on latex. The 6 most recent cases underwent closure by the VAC technique only. Results: The rate of incidence of postoperative bowel necrosis and renal failure were significantly lower in the second period than in the first period (0% vs. 50%, P=0.007, 0% vs. 66.7%, P=0.001, respectively). The hospital mortality rate of R3 and R4 patients was significantly reduced in the second period than in the first period (14.3% vs. 66.7%, P=0.019). The causes of death in cases of R3 and R4 were low cardiac output syndrome (LOS) (n=2) and multiple organ failure (n=2) in the first period. LOS (n=2) was the only cause of death in the second period. Conclusion: Our results suggest that the surgical strategies of descending thoracic aortic cross-clamping for immediate recovery from severe shock state and temporary abdominal closure for prevention of ACS are effective in improving the outcome in of patients with RAAA in a state of severe shock.

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Objectives:We used an expanded polytetrafluoroethylene (ePTFE) graft for abdominal aortic aneurysm (AAA) surgery hoping to reduce the incidence of postoperative inflammatory reactions compared to that observed when using a sealed graft. Patients and methods: From May 1998 to September 2006, 138 AAA patients, including 21 emergency patients, with an average age of 70.9 years underwent replacement surgery with an ePTFE graft. Results: There were 5 fatalities (4 operative deaths and 1 hospital death) and 1 severe morbidity (sigmoid colon necrosis) among the emergency patients. Homologous blood transfusions were needed in 18.8% of the scheduled cases. On average, the peak body temperature was 37.7℃, and the white blood cell count on the first postoperative (PO) day was 9400/mm³. The serum C-reactive protein (CRP) level was elevated from 7.1 mg/dl on the first PO day to 14.4 mg/dl on the fourth PO day. A gradual decrease in temperature, white blood cell count, and serum CRP level was then observed, the values becoming 36.7℃, 6300/mm³, and 1.8 mg/dl, respectively, by the 12th PO day. No biphasic-inflammatory pattern, like that observed with sealed grafts, was recorded. Late angiographic findings (average of 1180 days after surgery) showed a patency of 97.6% and 87.9% in the external iliac artery and the internal iliac artery, respectively. New aneurysmal changes in the residual internal iliac arteries were found in 2 patients, and perigraft seromas were noted in 10 patients. Conclusion: The use of an ePTFE graft in AAA surgery is advantageous in terms of no postoperative abnormal inflammatory reaction, no loss of hemostatic control, and good patency rate.

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Background:Duodenal obstruction caused by abdominal aortic aneurysm (AAA) and abdominal wall or superior mesenteric artery (SMA), is relatively rare. We report 2 cases of obstruction of duodenum sandwiched by AAA and SMA or abdominal wall and a review of literatures. Cases: Case 1: the 81-year-old man, with a chief complaint of frequent vomiting. He was referred by a local doctor. On computed tomography (CT) scan, obstruction of the duodenum sandwiched by AAA (maximum diameter 75 mm) and SMA was diagnosed. Case 2: 71-year-old man with frequent vomiting after oral intake as a chief complaint. A pulsatile mass in the abdomen was found. On CT scan, the obstruction of duodenum sandwiched between the AAA (maximum diameter 65 mm) and the abdominal wall was found. Results: In both cases, bifurcated graft replacement surgery was performed and the symptoms subsided. Conclusion: Both cases of ileus due to obstruction by an AAA and abdominal wall or SAM were successfully treated.

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Introduction:We report two cases of traumatic aortic rupture (TAR). We also reviewed the medical literature for Japanese cases of TAR to analyze clinical presentation and outcome in Japan. Patients and Methods: Both of our cases underwent urgent surgical repair using left heart bypass, recovered uneventfully and was discharged after treatment of the associated lesion. They did not require treatment for the associated lesion prior to the repair of TAR. A total of 162 patients have been treated for TAR in Japan. Results: Of these, 142 patients were treated surgically, the other 20 patients were treated with endovascular stent grafting. The mortality was 6.3% (9 of 142 patients) in the surgical group and 10% (2 of 20 patients) in the endovascular group. The most common cause of death in acute cases was cerebral complication (40%). Conclusion: In TAR, the mortality was relatively good if the patients did not have serious organ injury, especially brain damage, or if associated lesion could be managed prior to the repair of TAR. Reports of endovascular stent grafting for TAR have been increasing, and this might be one therapeutic option for TAR.

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Background:Although cases with abdominal aortic aneurysm and common iliac arterial aneurysms are common, a case with an aneurysm conjugated with an abdominal aortic aneurysm and common iliac arterial aneurysms are not frequently reported. Case: Abdominal aortic aneurysm was diagnosed by ultrasonography in a 71-year-old woman during a medical check-up. Imaging modalities could not identify either common iliac artery. Due to the size of the aneurysm, she underwent an abdominal aortic replacement. Results: The operative findings showed that the form of the aneurysm incorporated two spheres. All of both external iliac arteries and both internal iliac arteries were arose directly from the aneurysm. Conclusion: Because a congenital absence of the common iliac artery is quite a rare abnormality, the aneurysm was thought to be formed by an abdominal aortic aneurysm and bilateral common iliac arterial aneurysms.

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Background:Concerning abdominal aortic aneurysm (AAA) repair in case of horseshoe kidney, it is controversial whether transection of the isthmus should be performed. We performed AAA repair with a horseshoe kidney with transection of the isthmus. Case: A 76-year-old man was referred to us for AAA repair. Preoperative abdominal CT revealed a horseshoe kidney, of which the isthmus had no pyelocaliceal systems. No aberrant renal arteries (ARA) were revealed preoperatively. At operation, the abdomen was explored via a long midline incision. After transection of the isthmus, we found one ARA from the AAA wall to the lower right side kidney. The AAA was replaced with a woven bifurcated graft, and the ARA was reconstructed. Results: Postoperative hemotological examinations showed no sign of renal dysfunction, and we visualized the patent reconstructed ARA with the postoperative MR angiography. Conclusion: Transection of the isthmus was a beneficial method to replace AAA in this case with horseshoe kidney, facilitating exposure of the entire AAA and to confirm an existence of ARAs. We were able to perform AAA replacement and reconstruction of ARA easily with a good operative view.

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Background: Acute obstruction of the mesenteric artery induced by aortic dissection frequently causes life-threatening visceral organ ischemia. We report a case of emergency endovascular stent graft placement with Stanford type A dissection with visceral ischemia. Case: A 66-year-old man with severe chest and back pain of sudden onset was transported to our hospital. After admission, he had abdominal pain and repeated vomiting. Arterial blood gas analysis showed progressive acidosis. Contrast-enhanced computed tomography indicated that the true lumen was severely compressed by the false lumen, and occlusion of the origins of the celiac artery and the superior mesenteric artery. Since the entry was located at the proximal descending aorta, we performed emergency endovascular stent graft placement for entry closure. Results: After the procedure, the mesenteric ischemia improved rapidly, and the postoperative course was uneventful. Conclusion: Our experience suggests that emergency endovascular stent graft placement can provide an option that is less invasive, more prompt and effective treatment for patients with mesenteric ischemia resulting from acute aortic dissection.

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