Objectives: Aneurysms of abdominal visceral arteries are infrequently encountered. They often rupture and progress to serious morbidity or death. We reviewed our experiences of the management of visceral artery aneurysms (VAAs). Methods: A retrospective analysis of all VAAs diagnosed at Kyorin University Hospital between March 2005 and October 2008 was perfomed. Thirty VAAs in 30 patients (21 men and 9 women with an average age of 62.8 years) were entered into the study. Results: The arteries involved included 13 splenic, 5 pancreaticoduodenal, 5 celiac, 4 superior mesenteric, and 3 hepatic arteries. Seventeen patients were asymptomatic, whereas 13 patients were symptomatic. Treatments included detailed observation in 17 patients, transcatheter embolization in 10 patients and open surgery in 3 patients (ligation in 1 emergency case, resection and revascularization in 2 cases). The results of the surgical treatments were all successful and no severe complications or operative death occurred. There were no recurrences during the course of the observation period. Conclusion: Our policy of the treatment of VAAs seems reasonable. Endovascular treatment may be recommended, especially in small branch aneurysms.

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Due to progress in medicine, surgery for abdominal aortic aneurysm (AAA) can yield a safe and reliable outcome; however, the results of surgery of a ruptured aneurysm, or those in very elderly patients are still poor, and no standardized therapeutic strategies have been established. In the present study, the clinical course and therapeutic outcome of ruptured abdominal aortic and iliac aneurysms (RAAA) for patients aged 80 years or over at our hospital were evaluated. A total of 56 patients were brought to our hospital with RAAA between June 2001 and November 2008; and, excluding 14 who succumbed before surgery, 42 surgical cases were enrolled in the study. The patients were divided into group E (20 patients, 80 years or older) and group Y (22 patients, 79 or younger). The two groups were compared according to the various factors: Preoperative factors included co-existent diseases, aneurysmal diameter, Hardman factor (HF), time elapsed between the onset of the disease and arrival at the hospital and between arrival and surgery. Intraoperative factors included time required for surgery, time elapsed before aortic champing, duration of aortic clamping, amount of blood loss, amount of blood transfused, Szilagyi classification and surgical procedures. The postoperative factors were the length of hospitalization, complications and mortality. The mean ages in groups E and Y were 84 and 64 years. Replacement with artofemoral vessels was the basic surgical procedure in both groups. The surgical outcome was summarized as follows: intraoperative mortality, 0 in both E and Y groups: mortality immediately after surgery, 4 and 3; and in-hospital mortality after surgery, 5 and 5. Mortality following hospital admission (including those 9 E cases and 5 Y cases who died before surgery) was 14 and 10. No differences were noted in mortality or duration of hospitalization between these 2 groups. However, significant differences were noted in hemorrhage-related factors when those who survived the procedure were compared with those who did not. Moreover, a successful surgical outcome was noted in those patients who were able to survive shock with the aid of fluid infusions. We were convinced that the surgical outcome in RAAA is generally satisfactory at our hospital; and even in very elderly patients, surgical results and postoperative QOL similar to those in younger patients can be expected.

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In this case, a 74-year-old man who had undergone total gastrectomy 3 years previously was referred to us because of massive melena. According to computed tomography, we suspected an aortoenteric fistula and performed emergency laparotomy. During surgery we confirmed an aortoenteric fistula between an abdominal aortic aneurysm and his duodenum. We performed an en-bloc resection of the duodenum and abdominal aortic aneurysm wall, and then proceeded with aortic replacement. The patient recovered uneventfully and was discharged.

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A 59-year-old man with hypertension was referred to our hospital because of sudden lumbar pain. An emergency operation was performed because a computed tomographic scan revealed a ruptured abdominal aortic aneurysm. The aneurysm had ruptured into the retroperitoneal space, and an abscess of the iliopsoas muscle had formed. After debridement of the aneurysmal wall and surrounding infected tissues, a Y-graft replacement was accomplished using a woven Dacron graft. Peptostreptococcus was detected on culture examination of the blood and aneurysmal wall. A retroperitoneal abscess and empyema developed on the 24th, and 32nd postoperative days, respectively. The patient was discharged on the 98th postoperative day after successful treatment with antibiotics and drainage of the abscess. We encountered a case of ruptured abdominal aortic aneurysm caused by Peptostreptococcus infection.

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We confirmed the usefulness of aorto-iliac in-situ reconstruction with an autogenous femoral vein in a case of an infected abdominal prosthetic graft. Eleven years previously, a 59-year-old man had undergone replacement of a prosthetic aorto-bifemoral graft due to arteriosclerotic occlusion of the right iliac artery. Two years previously, he underwent replacement of the prosthetic graft due to a right femoral artery aneurysm. He was admitted because of an operation wound infection which was diagnosed as Methicillin-sensitive Staphylococcus aureus. Computed tomography revealed an accumulation of fluid around the prosthetic graft. We performed a total graft excision on the infected prosthetic graft and debridment on the surrounding areas of the infected graft. An aorto-left common iliac in-situ reconstruction with an autogenous left femoral vein and a left iliac-right femoral crossover bypass with an autogenous right saphenous vein were then performed. Furthermore, an omentopexy was performed on the anastomotic site of the abdominal aorta. We treated the patient with antibiotics postoperatively and his postoperative course was uneventful. Conclusion: We found that in-situ reconstruction with a femoral vein is a useful method in the treatment of prosthetic graft infection.

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We report a case of a 72-year-old woman who presented with a symptomatic pseudoaneurysm of the ascending aorta. Under a diagnosis of ruptured thoracic aortic aneurysm and cardiac tamponade, an emergency operation was performed. A ruptured saccular pseudoaneurysm, 3 cm in maximum dimension which was located 3 cm distal to the sino-tubular junction, resulted in hematoma formation in the anterior space of the right atrium. An abscess was found on the right side of the ascending aneurysm. After clamping the ascending aorta, a localized saccular pseudoaneurysm was treated by careful debridement of the infected tissue. The ascending aorta was reconstructed using direct suturing of the divided aortic wall. Streptococcus pneumoniae was isolated from cultures of the abscess, aneurysm sac and hematoma. The postoperative course was uneventful with no infectious complication. Antibiotic agents were administered for 12 weeks.

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A graft infection is one of the most fatal complications of surgical treatment for arteriosclerosis obliterans. Both re-do arterial revascularization for limb salvage and prevention of recurring infection are necessary for the treatment of infected prosthetic graft, therefore the selection of surgical strategy for this kind of post-operative complication is extremely challenging.
A 79-year-old man was admitted to our hospital complaining of high grade fever and unbearable pain in the left groin. He had undergone femoro-popliteal bypass (above the knee) using a prosthetic graft and a popliteal graft - posterior tibial artery bypass with autologous saphenous vein graft, 4 months previously. Computed tomography on re-admission revealed an abscess formation around the prosthetic graft in the left groin. He underwent removal of the infected prosthetic graft and re-do femoro-popliteal bypass using an ePTFE graft (Distaflo), followed by reconstruction of the newly bypassed route by penetrating an iliac bone. Although his general condition steadily recovered postoperatively, the surgical site infection recurred in his left thigh. After debridement of the infected area, sartorius muscle flap transposition was performed on the 39th postoperative day. Following this, plastic surgical procedure, vacuum-assisted closure therapy was performed, and the wound had completely healed by the 60th postoperative day. In performing re-arterial revascularization of a prosthetic vascular graft infection, reconstructing the newly bypassed route by penetrating an iliac bone is one of the most effective advantageous treatments, because this strategy can help selection of an accessible bypass route, isolate the infected site, and completely eradicate the infection to facilitate wound healing. To the best of our knowledge, this is the first report of prosthetic vascular graft infection in the groin successfully treated by penetrating an iliac bone as a new bypass route for re-do arterial reconstruction.

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A 71-year-old man underwent exclusion and bypass of both popliteal artery aneurysms due to peripheral artery embolism. Persistent aneurysm sac perfusion was present after exclusion. Five years later, follow-up MRI showed pseudoaneurysms adjacent to the original aneurysm sacs. He also suffered from neuralgia with sciatic nerve compression by the excluded aneurysm sac. Aneurysm sac extirpation and ligation of collateral vessels were successfully performed.

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We treated a 66-year-old man who had previously undergone a total esophagectomy with reconstruction of the gastric tube through the posterior mediastinal route and had received a permanent tracheostoma for esophageal cancer in 1995. In 2007, he suffered hematemesis and saburra was expectorated from the tracheostoma. On the day of admission, massive hematemesis occurred at midnight, and the patient immediately underwent emergency surgery, during which direct closure of the reconstructed gastric tube tracheal fistula and suturing hemostasis of the gastric tube ulcer were performed. During surgery, the brachiocephalic artery was injured and hemostatic suturing with a felt pledget was added. However, bleeding from the wound occurred 9 days postoperatively and re-operation was performed. In the second operation, a femoro-axillar arterial bypass was first performed with a Gore-Tex^® graft, then the brachiocephalic artery was closed at its origin and bifurcation was done. However, after surgery, the wound remained infected and hospitalization was extended but the bypass graft was effective, and neither rebleeding nor cerebral circulatory insufficiency occurred. To the best of our knowledge this is the first known report of extra-anatomical bypass surgery for bleeding after treatment for esophageal cancer.

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We report a case of superficial temporal arterial aneurysm complicated by von Recklinghausen disease. A 75-year-old woman visited our institution because of a pulsating tumor in her right temporal region. She had previously undergone a right nephrectomy for a pheochromocytoma, and a splenectomy for a splenic arterial aneurysm. Ultrasonography and computed tomography showed a dilatation of the right superficial temporal artery, and we made a diagnosis of superficial temporal arterial aneurysm. The patient underwent resection of the aneurysm to prevent rupture. The wall of the aneurysm was fragile, and pathological examination disclosed infiltration of spindle cells to the adventitia of the arterial wall, thinning of the media, tearing of elastic fiber, and thickening of the intima. Immunohistological staining showed S-100 protein on the surface of the spindle cells, which suggested that they originated from Schwann cells.

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