We report a new approach through a median sternotomy for the primary reconstruction of extensive distal aortic arch. Cardiopulmonary bypass was established by cannulating the ascending aorta, and either the femoral or right axillary artery. We opened the left pleura extensively from the aortic arch to the diaphragm and moved the left lung to the right side, together with the heart. Most of the descending aorta was visible from a high-angle view. At the aneurysmal site we skeletonized and resected the descending aorta and anastomosed the distal end of a four-branched graft by the ‘turn-up’ method. This technique includes eversion of the ends of the graft, which allows excellent cross-sectional exposure of the aorta and the graft. In our experience of 24 cases with distal aortic arch aneurysm and downstream extension, total arch replacement was achieved through median sternotomy without the need for left anterolateral thoracotomy. This procedure reduced perioperative bleeding and resulted in satisfactory clinical outcomes.

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Klinefelter syndrome is the most common major abnormality of sexual differentiation in men, with 2 or more X chromosomes. The occurrence of venous stasis leg ulcers is frequent in patient with Klinefelter syndrome, but it is often overlooked. However, Klinefelter syndrome must be considered in the differential diagnosis of patients with stasis dermatitis, refractory leg ulcers, but with no confirmed underlying disease. We report 4 cases of refractory leg ulcers complicated with Klinefelter syndrome over a period of 6 years from 2004.

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A 65-year-old man was referred for a popliteal artery aneurysm with severe knee pain. Computed tomography revealed a popliteal artery aneurysm in the right knee area. His laboratory data showed severe inflammatory findings, but not bacteremia. Semi-urgent surgery was performed because of uncontrollable pain in the right knee area, of a successful autologous saphenous vein graft replacement of the popliteal artery aneurysm. The pathological findings of the resected tissue revealed inflammation without bacterial infection. When the clinical course was taken into consideration, inflammation of the popliteal artery had progressed to a popliteal artery aneurysm. This patient was discharged without any neurological deficit.

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A 66-year-old woman presented with complaints of bilateral arm weakness, numbness, and dizziness. Preoperative aortography revealed bilateral subclavian artery obstruction and a patent left vertebral artery with retrograde flow. Coronary angiography did not reveal any significant stenosis. Due to severe diffuse calcification of her thoracic aorta, the patient underwent extra-anatomical bypass grafting from the left common femoral artery to both arteries of the bilateral upper extremities (left axillary artery and right brachial artery), subcutaneously. Her symptoms of subclavian steal syndrome resolved with a patent graft 3 years after surgery. Extra-anatomical bypass grafting with the common femoral artery used as an inflow site may be an alternative procedure for bilateral upper extremity revascularization in patients with severe calcification of the thoracic aorta.

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We report the successful surgical treatment of an aortocaval fistula caused by rupture of an abdominal aortic aneurysm (AAA). A 71-year-old man was admitted upon presenting with abdominal pain. Abdominal computed tomography revealed rupture of an AAA with communication between the aneurysm and the inferior vena cava (IVC). The maximum dimension of the AAA was 57 mm. The ruptured AAA was complicated by an aortocaval fistula, and therefore indicated emergency surgery. We introduced an occlusion balloon catheter from the right femoral vein into the IVC. The abdominal aorta was clamped, and we opened the aneurysm to reveal a large fistula of 46×16 mm in maximum dimensions communicating with the IVC. We inflated the occlusion balloon catheter in the IVC at the fistula, and the bleeding from the IVC was thereby completely controlled. We closed the aortocaval fistula with a polytetrafluoroethylene patch and replaced the abdominal aorta with a knitted Dacron bifurcated graft. The patient recovered without any complications. The surgical repair of a large aortocaval fistula between an AAA and the IVC is often complicated by massive bleeding from the fistula, which can result in hemorrhagic shock. Venous occlusion achieved by inflating an occlusion balloon catheter in the IVC can control the bleeding from the fistula, which was useful to prevent massive bleeding in the present case.

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We report a case of the treatment of a postoperative prosthetic graft infection, which is one of the most challenging complications. The patient was a 70-year-old diabetic woman who underwent a right femoropopliteal bypass and received a polytetrafluoroethylene (PTFE) graft. However, after the procedure she developed a graft infection and was re-admitted. We opened the wound for drainage and rinsing as initial treatment. Vacuum-assisted closure (V.A.C.) therapy was initiated 17 days after re-admittance. After 18 days we closed the wound. The patient was discharged 78 days after re-hospitalization with a preserved and patent graft. V.A.C. therapy and wound cleaning were effective for granulation tissue formation and infection control, even of the exposed graft. We found that V.A.C. therapy had therapeutic benefits for an infected prosthetic.

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We report a case of multiple visceral artery aneurysms in a 72-year-old woman. We resected the common hepatic artery aneurysm and reconstructed the artery by end-to-end anastomosis. The splenic artery aneurysms were then resected and the splenic artery was ligated. However, a complication of peripancreatic abscess developed postoperatively, and therefore we drained the abscess for several months, with resulting complete resolution of her symptoms and improved computed tomography findings. The surgical results in elective open repair for visceral artery aneurysms are reportedly good, however, it is important to consider postoperative intra-abdominal abscess in the surgical treatment of visceral aneurysms in a peripancreatic lesion.

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Infection of bare metal stents in the vasculature is rare, but is associated with significant morbidity and mortality. We report a case of infected aneurysm due to bare metal stent infection. A 77-year-old man who had previously undergone the placement of bilateral lower extremity bare metal stents in the left common iliac artery and left superficial femoral artery (SFA) was readmitted with fever, anorexia, generalized malaise and multiple erythematous and macular lesions on his left leg. Blood cultures yielded Staphylococcus aureus and a computed tomographic scan showed aneurysmal dilation of the left SFA with contrast material filling the lumen outside the wall of the stent, which is consistent with pseudoaneurysm formation and elevated intensity of the tissues surrounding the SFA stent. We undertook immediate removal of the infected aneurysm. The left distal SFA was found to have a pseudoaneurysm associated with purulent fluid and a thrombus surrounding the bare metal stent. The wound was left open and was prepared for negative pressure wound therapy. Blood culture findings from the surgery were positive for Staphylococcus aureus. Eight days after first operation, the patient underwent revascularization from the proximal SFA to the below-knee popliteal artery with an in situ great saphenous vein graft. The patient was then discharged on a 6-week course of antibiotics. Infections of bare metal stent are potentially life-threatening complications and must be addressed urgently, including possible surgical intervention. Given the high morbidity and mortality of this fatal complication, as well as the minimal harm and cost involved in prophylaxis, prophylactic antibiotics should be administered in the standard fashion.

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We report a case of subacute pulmonary thromboembolism that was successfully treated by pulmonary thromboendarterectomy. A 45-year-old woman without any underlying heart disease was admitted due to symptoms of progressive shortness of breath with episodic exacerbations, and a history of more than 2 months. Contrast-enhanced computed tomography revealed the presence of a large filling defect in the right proximal and left upper pulmonary arteries. We administered heparin sodium, urokinase and tissue plasminogen activator, but these were ineffective. Due to the presence of hypoxemia and pulmonary hypertension and the ineffectiveness of antithrombotic therapy, we performed thrombectomy under extracorporeal circulation. Her postoperative course was uneventful, and her clinical condition improved markedly. In the present case, pulmonary thromboendarterectomy was beneficial for the treatment of subacute pulmonary thromboembolism.

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Spontaneous isolated dissection of the superior mesenteric artery (SMA) is rare, especially when not associated with aortic dissection. The standard therapeutic strategy is either a surgical approach, which is the most frequently adopted in cases with abdominal symptoms, or medical treatment in asymptomatic cases. In this report we present 2 cases of spontaneous isolated dissection of the SMA treated medically and which resulted in the disappearance of a pseudolumen. Asymptomatic isolated SMA dissection can be treated medically, and computed tomography was very useful in the present cases.

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