A 49-year-old male got his right thigh injured by the broken piece of a lawn mower. Radiographic examination showed a fragment of cutting saw in his right inguinal region. Surgeon opened up the wound to remove the metal fragment, but could not find it in the operative field. Angiography and computed tomography were subsequently performed to identify the location of metal fragment. The fragment was found to migrate into azygos vein, and successfully removed by thoracic surgery. To our knowledge, this is a first case report of metal fragment migration from great saphenous vein to azygos vein by blood stream.

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A 52-year-old man was refered to another institute for traumatic injury of left common iliac artery. Seven years after the initial left common iliac – left common femoral artery bypass, graft infection was complicated. Three times antianatomical revasculalization using refampicin soaked Dacron graft were performed, nevertheless infection has not been controlled. Chronic hemodialysis was induced for end stage renal dysfunction due to long time use of antibiotics, he was refered to our hospital from hemodialysis facility. Three skin fistulas were found along the infected graft and pus discharge were continued. Contrast enhanced CT revealed fluid collection around the graft and poor collateral source to the left lower extremity. Right common femoral artery – left above-knee popliteal artery bypass was performed via sub gracilis muscle route using ePTFE graft followed by resection of infected graft. Intravenous antibiotics administration continued six weeks after surgery. The patient is doing well without any signs of infection on oral antibiotics at 3 years after the last surgery.

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Although infected aortic aneurysm and aorto-esophageal fistula are considered conditions with high fatality rates, we report a case successfully treated with two-stage esophageal resection and digestive tract reconstruction after thoracic endovascular aneurysm repair (TEVAR) without aortic wall resection. The patient was a 74-year-old man who presented with swallowing difficulty, fever, and cervical subcutaneous hematoma, and was diagnosed with descending thoracic aortic aneurysm rupture. Gore TAG stent graft was deployed first. Campylobacter fetus was detected in the blood culture. The definitive diagnoses were infectious aortic aneurysm rupture and aorto-esophageal fistula. The postoperative infection was well controlled with antibiotic therapy. Esophageal resection and reconstruction, as well as omental implantation, were conducted on day 36 after TEVAR. Intravenous antibiotic therapy was continued for 1 month, and the patient was discharged on admission day 67 without any increase in inflammatory response. No exacerbation of infection was observed even after 1 year after TEVAR, and the patient showed satisfactory progress.

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A 78-year-old woman was admitted to our hospital with severe back pain. She previously underwent distal gastrectomy for gastric cancer at the age of 53. Contrast enhanced CT revealed acute type B dissection extending from distal arch aorta to abdominal aorta. False lumen was thrombosed and there were no main visceral artery stenosis or bleeding. She was treated medically with stable condition at admission. On 4th day after onset, she had dyspnea and hypotension requiring inotrope infusion and respiratory support. Contrast enhanced CT showed abnormal intramural gas in esophagus and fluid accumulation in the mediastinum with severe lung edema. Endoscopic examination revealed necrosis in esophagus. Immediately she underwent proximal esophagus closure and gastric tube drainage for esophagus rupture. However her septic shock and acute respiratory distress syndrome was worsening and she died of multiple organ failure on 22 days after admission. Acute esophageal rupture was thought to be caused by esophagus ischemia due to acute aortic dissection with thrombosed false lumen at descending aorta. Esophagus ischemia caused by acute aortic dissection is extremely rare but it should be considered as same as intesitinal ischemia.

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We report a patient who underwent an operation for an infectious Tuberculous multiple aortic aneurysm after intravesical bacillus Calmette-Guérin therapy. A 73-year-old man had intravesical BCG therapy for urinary bladder cancer. The man underwent medical examinations at our hospital because he had a fever at night and realized an abdominal mass. Computed tomography examination of the infectious abdominal aortic aneurysm and infectious thoracic aortic aneurysm. Computed tomography showed an expansion of the abdominal aortic aneurysm on the 4th day after admission. We performed graft replacement of abdominal aorta with rifampicin-bonded graft and omentopexy. The culture of an abscess in the aneurysm identified Mycobacterium bovis. The patient improved clinically with antituberculosis agents after operation. Computed tomography showed an expansion of the thoracic aortic aneurysm on the second week after first operation. We performed secondary operation graft replacement of descending thoracic aorta with rifampicin-bonded graft. He improved clinically with antituberculosis agents and left our hospital on the 10 POD of secondary operation. The patient is now asymptomatic, 14 months after the operation.

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A 68-year-old woman was urgently transported to the hospital due to a chief complaint of difficulty in breathing. On admission, she was found to have circulatory and respiratory failure. Based on the contrast computed tomography (CT) findings, we diagnosed the patient with acute pulmonary thromboembolism. Because of the difficulty of thrombus suction using an emergency catheter, a percutaneous cardiopulmonary support (PCPS) system was introduced and thrombolytic therapy was initiated. However, immediately after the setting of the PCPS system, continuous bleeding was observed at the cannulation site. A large volume of blood transfusion was needed to maintain the flow rate of PCPS. However, the circulatory and respiratory failures had worsened, and developed a bleeding tendency. On hospital admission day 2, by contrast CT pulmonary thrombus remained in the right main pulmonary artery, and therefore, a surgical procedure was considered to be necessary. Thus, the patient successfully underwent pulmonary thrombectomy using PCPS without a routine cardiopulmonary bypass to avoid further bleeding complications. The PCPS was withdrawn in the operating room at the same time. On postoperative day 15, the patient was successfully weaned from the ventilator. She was discharged well on postoperative day 45.

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Rapid hemostasis is vital to preserve life in cases of vascular trauma. In vascular trauma of the extremities, the functional prognosis needs to be considered. A 43-year-old man suffered an impalement injury to his right thigh with a metal rod while working. He was taken to the hospital in an air ambulance, simultaneously undergoing medical treatment. He required emergency surgery for hemorrhagic shock as his thigh injury continued bleeding on arrival at the hospital. The damaged right superficial femoral artery and vein were revascularized with great saphenous vein grafts. After surgery, the right lower limb did not show any swelling. He recovered locomotor function on rehabilitation and was subsequently discharged. Immediate hemostasis with a balloon catheter and rapid revascularization of the injured vessels with autologous vascular grafts enabled us to save his life and locomotor function without complications like compartment syndrome. In case of extremity vascular trauma, rapid hemostasis, revascularization, and preventing post-operative complications are vital for life saving and improving the functional prognosis.

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Infective endocarditis complicated by an infected aneurysm at the left colic artery in a patient with colon cancer has rarely been reported. An 80-year-old woman suffered from hemiplegia and high fever. Brain magnetic resonance image confirmed fresh cerebral infarction. An echocardiogram revealed severe mitral regurgitation with floating vegetations attached to both anterior and posterior mitral leaflets. Large vegetations enforced us to perform urgent mitral valve replacement. A blood culture grew no bacteria. Appetite loss and low grade fever continued after mitral valve replacement. Computed tomography identified a 5×3 cm infected aneurysm at the left colic artery and colon cancer. The patient accordingly underwent surgical resection of the infected arterial aneurysm and simultaneous ileocecal resection. Postoperative course was uneventful with no fever and regaining appetite.

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A 71-year-old woman presented with intermittent claudication of the right lower extremity, and cyanosis and coldness in the right toes. Enhanced CT showed two aneurysms above the right knee and in the popliteal fossa; the former extended close to the adductor hiatus, and the latter, a giant aneurysm, was thrombosed up to the trifurcation of the popliteal artery. She underwent surgery with a diagnosis of leg ischemia caused by thrombosed aneurysm of the right popliteal artery. First, the distal superficial femoral artery was exposed by incising the adductor magnus tendon via medial approach. Then, we performed aneurysmectomy, thrombectomy of the trifurcation vessels, and revascularization with saphenous vein graft in conjunction with posterior approach in a prone position. The postoperative course was uneventful and no complication was detected during the 8-month follow-up.

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Within splanchnic artery variations, the celiacomesenteric trunk occurs in 3.4%, and within splanchnic artery aneurysms, the celiac artery aneurysm occurs in 4%. We treated a rare case of celiac artery aneurysm concomitant with celiacomesenteric trunk. The patient was male and 76 years old. Computed tomographic angiography revealed a calcified saccular aneurysm at the celiac axis, which originated from the common trunk with the superior mesenteric artery. The operation was performed with the division of the origin of the celiac artery, and the reversed saphenous vein bypass from the superior mesenteric artery to the bifurcation of the celiac artery. The accurate operative procedure is needed in the treatment of the splanchnic artery aneurysm with anatomical variation.

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A 72-year-old man underwent EVAR with the Endurant II^TM stent-graft. Five months after, he felt lumbago and lower abdominal pain. Six months after the procedure, he had a fever and aggravated lumbago. By a nearby doctor, enhanced computed tomography shows a mantle sign at abdominal aorta. So, he was diagnosed as having infectious abdominal aortic aneurysm and administered antibiotics. However, he was referred to our department because his symptom did not improve with antibiotics administration. Complete blood count and blood chemistry findings showed inflammatory response, but the serum procalcitonin value was within normal limits and repetitive blood cultures were negative. Because inflammatory abdominal aortic aneurysm after EVAR was suspected, we started daily administration of prednisolone (10 mg/day), and 6 days of the steroid administration his symptom and inflammatory findings disappeared. We report a rare case of development of inflammatory abdominal aortic aneurysm after EVAR.

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A 68-year-old man with a pulsatile mass in his abdomen was admitted to our institution in 2013. He had undergone bifurcated graft reconstruction using a bifurcated Hemashield knitted Dacron graft for an abdominal aortic aneurysm 9 years prior, in 2004. Magnetic resonance imaging in 2010 showed a 44-mm mass around the body of the graft at a non-anastomotic site. The mass gradually expanded, similar to a pseudoaneurysm (56 mm in diameter in 2012, 69 mm in diameter in 2013), until extravasation of contrast media at the graft bifurcation was detected. This was diagnosed as a pseudoaneurysm due to graft disruption. Graft replacement was performed to prevent rupture of this pseudoaneurysm. During reoperation, the expanded preserved wall of the aneurysm, which was wrapped around the graft at the primary operation, and blood leakage at the bifurcation of the Dacron graft was found. We report a rare case of early disrupted bifurcation of a shielded Dacron graft that was implanted in 2000s, less than 10 years after the primary operation.

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We report an extremely rare case of Leriche syndrome with persistent sciatic artery (PSA) as collateral pathway to the lower limb. A 60-year-old woman was referred with chronic bilateral leg claudication. The ankle brachial pressure index (ABI) was reduced to 0.49 on the right side and 0.48 on the left side. Preoperative angiography and computed tomography (CT) revealed arterial occlusion extending from the infra renal aorta to the both common iliac arteries. CT also showed left PSA connecting to the popliteal artery. Although various collateral pathways maintained blood flow to the lower extremities, the left lower thigh was only collateralized by the PSA. The left superficial femoral artery and the deep femoral artery were atretic at distal portion and not connected to the popliteal artery. Aorto-bilateral femoral artery bypass grafting with Y-shaped graft and Left femoro-popliteal artery bypass grafting with the saphenous vein graft was performed. Her symptoms were disappeared postoperatively. ABI was improved to 0.98 on the left side and 0.97 on the right side. CT showed all grafts patent.

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