Objectives & Methods: The presence of massive intestinal edema or a large intra-abdominal hematoma after repair of a ruptured abdominal aortic aneurysm (r-AAA) may cause an increase in intra-abdominal pressure following primary abdominal wall closure, resulting in the development of abdominal compartment syndrome (ACS) which is a fatal complication of r-AAA repair. When primary closure of the abdominal wall was not possible because of severe intestinal edema, we performed temporary abdominal closure using a vinyl sheet made from an intravenous feeding pack to prevent ACS. Relaparotomy was performed to release intra-abdominal pressure in the event of ACS developing after primary abdominal wall closure.
Results: We reviewed 36 patients who underwent r-AAA repair between January 2006 and December 2008 (including 2 patients with ruptured iliac artery aneurysms). Seven patients underwent temporary abdominal closure after r-AAA repair of whom 2 died of disseminated intravascular coagulation (DIC) and 1 died of intestinal necrosis, but these complications appeared unrelated to ACS. There were 4 patients who underwent abdominal closure without developing ACS and were discharged. Twenty-nine patients underwent primary abdominal closure after r-AAA repair and 26 of these did not require relaparotomy. Two patients died of multiple organ failure and 1 died of DIC, but these complications were unrelated to ACS. Three of the twenty-nine patients suffered ACS after primary abdominal closure and underwent relaparotomy. All patients were able to undergo abdominal closure without developing ACS. Two patients were discharged but one patient died of graft infection. Multivariate logistic analysis indicated that preoperative shock (systolic blood pressure<90 mmHg) (odds ratio (OR) 11.02, 95% confidence interval (CI) 1.14–106.6, p=0.04) serum creatinine (Cr) >2.0 mg/dl (OR 9.74, 95% CI 1.08–88.1, p=0.04) and base excess<–13 (OR 6.82, 95% CI 1.00–46.4, p=0.05) were risk factors associated with temporary abdominal closure.
Conclusion: Patients with these risk factors are likely to require temporary abdominal closure and need careful postoperative monitoring of their intra-abdominal pressure.

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Objectives: We successfully performed open stent-grafting (OSG) in distal arch aneurysm and reviewed the results. Methods: Between August 2000 and September 2008, OSG was performed in 30 patients with distal arch aneurysm in our hospital. In 15 of these, OSG was performed using the inclusion method (group I). Another 15 patients underwent OSG with total aortic arch replacement (group T). Results: There were no statistically significant differences between the 2 groups. No endoleakage was noted in group T, but did occur in 3 patients in group I in the early postoperative period. Futhermore, in the postoperative mid-term, complications related to the stentgraft occurred in 4 patients in group I and in 1 in group T. Reoperation was performed in 3 of these patients (2; group I, 1; group T). Complications related to the stentgraft tended to occur frequently in I group during follow-up. Conclusion: The early and mid-term results of OSG with total aortic arch replacement are acceptable.

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The initial stage mortality rate in hospital of type B acute aortic dissection is still as high as 8.8 to 15%. The survival rate in cases in which rupture is cited as a cause is reported to be 50% or lower. We report that we were able to save the lives of 2 patients who had suffered ruptures, using the type B acute aortic dissection by the L-incision approach proposed by Tominaga et al.
Case 1 was a 60-year old man given a diagnosis of rupture according to the results of computed tomography (CT) obtained 3 days after the onset. Arch replacement was performed by an L-incision approach under deep hypothermic circulatory arrest and selective antegrade cerebral perfusion. The postoperative complication of left lower limb paresis improved and the patient was able to walk by himself when he was discharged.
Case 2 was a 43-year old man given a diagnosis of a rupture, according to the results of CT obtained after the onset of back pain. While being examined, he fell in to a semi-shock state. Extracorporeal circulation was established by an upper left partial sternotomy for proximal aortic perfusion, after which left anterolateral thoracotomy was also performed in combination with arch replacement. No postoperative complication occurred and the patient was discharged.
Since the L-incision enables both a median incision of the sternum and left thoracotomy, it is possible to promptly establish antegrade extracorporeal circulation, which enables the selection of the most appropriate prophylactic measures against cerebral and cardiac complications. Therefore, the L-incision is expected to contribute to an improvement in survival in cases of type B acute aortic dissection.

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Popliteal arterial injuries which accompany blunt traumas around the knee joints are rare, but often inevitably result in the amputation of the lower extremities. The present report describes a case of popliteal arterial injury associated with blunt trauma around the knee joint that with a successful outcome achieved by following prompt revascularization protocols. A 37-year-old woman hyper-extended her right knee joint while practicing on a trampoline. Immediately after the injury, she experienced sensory and motor impairment in her right lower extremity, and was immediately transported to our hospital. A CT angiogram of the right lower extremity showed a bone fracture of the proximal end of the right tibia and occlusion of the right popliteal artery. An emergency operation was performed immediately after examination. During surgery, a crushed and twisted portion of the right popliteal artery (about 2 cm) in length was found behind the fracture site. The affected portion of the artery was resected, and the right popliteal artery was repaired by end-to-end anastomosis. The postoperative outcome was excellent, which justified our emergency repair of the popliteal artery to avoid amputation of the lower extremity in the present case.

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A 73-year-old woman was admitted with shortness of breath on exertion. Echocardiography revealed a dilated sinus of Valsalva with aortic regurgitation. Cardiac catheterization and angiography showed an extracardiac extension of an aneurysm of the right coronary sinus of Valsalva, right coronary ostial stenosis and severe aortic regurgitation. An aortic root replacement was performed with a full root stentless valve, the Freestyle aortic bioprosthesis (Medtronic, Inc, Minneapolis, MN, USA) implantation combined with single coronary artery bypass grafting (CABG) to the right coronary artery (RCA). The pathological findings strongly suggested congenital microfibrillar disease.

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Aneurysms of the iliofemoral venous system are rare. In particular, primary aneurysmal dilatations of the vein without evidence of prior trauma, inflammatory disease, arteriovenous communication or abnormal pressure within the system have been described in only a few reported studies. We report a surgically treated case of a saccular aneurysm of the external iliac vein. A 29-year-old woman in excellent general health was admitted to a gynecological clinic for investigation of infertility. The patient was found to have a pulsing cystic mass beside her right ovary on ultrasonography, and was subsequently referred to our hospital for further evaluation. Doppler ultrasound examination revealed aneurysmal dilatation of the right external iliac vein with mural thrombosis (3×4 cm in diameter). An ascending phlebogram showed a venous aneurysm with no evidence of stenosis, occlusion or rich collateral circulation of the iliofemoral venous system or the inferior vena cava. Angiography of the pelvic and femoropopliteal arterial system did not reveal any abnormal arteriovenous connection. The patient underwent surgery, and exposure of the venous aneurysm was obtained through a right lower quadrant retroperitoneal incision and a vertical right femoral incision. The venous aneurysm was opened longitudinally. After the mural thrombus within the aneurysm had been removed, the aneurysmal wall was cut, and the external iliac vein was reconstructed using a patch of the autologous great saphenous vein with a continuous 7-0 polypropylene suture. The patient received anticoagulation therapy postoperatively consisting of 6 months of warfarin and 1 subsequent year of aspirin without any recurrence of symptoms. Two years after the operation, ultrasonography showed no recurrence of the aneurysm, mural thrombus or stenosis of the right external iliac vein.

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Aortic dissections can occur during aortic surgery, and their occurrence is due to a variety of contributing factors such as acute onset and surgical intervention. We report a 59-year-old woman who was admitted with a sudden onset of epigastralgia. The diagnosis, based on a thoracic CT scan was aortic dissection of acute thrombotic-type (Stanford A, DeBakey II) and immediate surgical intervention was required.
No differences in preoperative arm or leg blood pressure were observed on either side of the body, no anisopiesis was detected, and there was no difference in the bilateral pulse, which was good in the brachial and femoral arteries on both sides. Cardiopulmonary bypass was performed through the right femoral artery, using the bilateral superior venal caval with inferior vena cava cannulation and femoral perfusion. We cross-clamped the ascending aorta at the normal distal site, and after resection of an ascending aortic tear, we replaced the ascending aorta with a vascular prosthesis measuring 24 mm in diameter. Perioperatively, the hemodynamics of the patient remained stable, and no increase in arterial blood flow impedance, decrease in peripheral arterial pressure, or decrease in venous drainage was seen. Her blood biochemistry did not reveal any problems and the urine volume remained stable.
Postoperatively, impaired hepatic and renal function was found, and thoracoabdominal CT findings led to a diagnosis of DeBakey type III dissection. In this case, it occurred during ascending aortic replacement surgery for a DeBakey type II dissection, suggesting the possible involvement of retrograde femoral arterial blood flow in aortic dissection. We report a rare case in which the symptoms abated with conservative treatment.

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We encountered an aortovenous fistula which caused vomiting, diarrhea and lower limb pain. A 78-year-old man complained of nausea, diarrhea and left lower limb pain. A blood test revealed acute renal failure, hepatic insufficiency and increased creatine kinase. An abdominal aortic aneurysm was found on plain computed tomography, however there was no evidence of rupture. Enhanced CT showed an aortovenous fistula, and emergency surgery was performed. The postoperative course was satisfactory. Aortovenous fistula is rare, but it can cause various types of symptoms and dysfunction in multiple organs. Therefore, it is important to consider the possibility of fistula.

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We report a case of aortocaval fistula (ACF) caused by a ruptured abdominal aortic aneurysm (AAA), presenting with symptoms of acute cardiac failure. A 63-year-old man complained of severe lumbago which was temporarily relieved with NSAIDs. However, a dull pain remained in his back accompanied by cough, bloody phlegm and general fatigue leading to admission to our hospital 4 days later. The initial diagnosis on admission was acute cardiac failure. A contrast-enhanced CT scan revealed an ACF caused by an AAA rupturing the inferior vena cava (IVC) and inducing high-output cardiac failure. At operation, upon opening the aneurysm, we found a ruptured orifice 15 mm in diameter in the aortic wall. The fistula was closed while controlling the venous bleeding from the ACF by digital compression, and the aneurysm was replaced with a Y-shaped prosthetic graft. The postoperative course was uneventful and the patient was discharged on the 16^th postoperative day. Aortocaval fistula is a rare complication of AAA, and its preoperative diagnosis is challenging but essential, because early diagnosis and prompt surgical repair improve not only the operative result but also the outcome.

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A 73-year-old man underwent emergency surgery under a diagnosis of impending rupture of infected abdominal aortic aneurysm. The infected aneurysm and surrounding tissues were resected en bloc and replaced with a rifampicin-soaked bifurcated dacron graft. The prosthesis and anastomoses were covered with the harvested omental flap. Citrobacter freundii was identified in a blood culture and on the aneurysmal wall. The postoperative course was uneventful without any infectious complications, and he was discharged 25 days after surgery.

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