We report our experience of 2 cases with a conversion to laparotomy when diameter reduction of aneurysm was once recognized after stent grafting, but somehow it became larger again. The advancement of stent graft expands more choices of aortic aneurysm treatment and the long-term favorable outcomes are also reported so far. However, the number of retreatment requirement cases with complications such as endoleak has been increasing. In the present study, we have experienced a conversion to laparotomy in two cases. We preoperatively evaluated both cases as type II endoleak, but actually diagnosed it as type IIIb endoleak in the intraoperative finding. Type IIIb endoleak caused by defect of inserted fabric device is still a rare case up to the present.

We report a case of critical limb ischemia in a 72-year-old man with essential thrombocythemia (ET) who was treated with hydoroxycarbamide. He came to our hospital due to necrosis of his right toe. Angiography demostrated occlusion of the right anterior tibial artery, the peroneal artery, and the plantar artery. We planned bypass surgery after the optimal control of the platelet count. However, necrosis progressed rapidly, we performed femorodistal bypass using an autologous vein graft despite of poor platelet control. After the operation, antiplatelet agents (aspirin and clopidgrel) and anticoagulants (apixaban and heparin) in addition to hydroxycarbamide were useful for ET patients to prevent graft thrombosis.

Ruptured aortoiliac aneurysm to vena cava is a rare, but life-threatening disease requiring immediate treatment. Treatment is usually performed by open surgery with direct closure of arteriovenous fistula and graft replacement of the aortoiliac lesion. As high morbidity and mortality with open repair, endovascular treatment has been motivated and reported in certain patients recently. A 70-year-old man was admitted to our department with progressive heart failure and contrast enhanced CT scan revealed to right isolated common iliac artery aneurysm associated with an iliocaval fistula. Endovascular stent-graft repair with coil embolization of right internal iliac artery was successfully performed to achieve exclusion of the fistula and restoration of normal hemodynamics. Postoperative CT scan showed a minor AV communication due to endoleak, which was terminated by the additional radiological intervention. Postoperative residual shunt due to endoleak is significant; therefore, complete graft sealing and complete coil embolization of branched arteries are absolutely essential in endovascular treatment for AV fistula in aortoiliac aneurysm.

An 81-year-old man with a complaint of abdominal pain and vomiting was admitted to our hospital. Computed tomography revealed that the third portion of the duodenum was obstructed between the superior mesenteric artery (SMA) and the abdominal aorta. Just below the obstruction site, a 60-mm abdominal aortic aneurysm (AAA) was observed. The patient was diagnosed as having SMA syndrome (SMAS) due to AAA. We performed abdominal aorta artificial blood vessel replacement. As the patient had a history of cholecystectomy, the mesentery was adhered strongly and the mobility of the SMA was limited. Soon after repair of the AAA and adhesion, the symptoms of SMAS improved, and the postoperative course was good. SMAS caused by AAA is rare, and this is the first reported case of SMAS due to not only AAA but also mesenteric adhesion.

A 74-year-old man underwent successful descending aortic replacement for two saccular type descending thoracic aortic aneurysms. Delayed paraplegia appeared 1 days after the operation, and spinal cord ischemia was considered to be the cause. In addition to continuous cerebrospinal fluid drainage (CSF-D), the pain control of fentanyl was stopped, and the administration of D-mannitol, corticosteroid and continuous intravenous injection of Naloxone were started. Moreover, mean blood pressure was controlled over 90 mmHg. He recovered from paraplegia in a day after the initial treatment. The continuous injection of Naloxone and blood pressure control could be considered effective treatments in this case with spinal cord ischemia after descending thoracic aortic replacement.

To date, an open surgery for thoracoabdominal aortic aneurysm (TAAA) remains to have high mortality and complication rates. However, we accomplished an open surgery for an 80-year-old patient with TAAA and severe aortic valve stenosis (AS) using axillary artery perfusion. He presented with left lateral chest pain and his CT showed saccular TAAA with a maximum diameter of 98 mm which was located from diaphragm to the celiac artery (Modified Crawford Classification Extent 5). The diagnosis was impending rupture of TAAA. Five years ago, he underwent endovascular repair for abdominal aortic aneurysm with Endurant, and the bare stent of Endurant was positioned near the TAAA. Consequently, we clamped only the descending aorta but occluded the abdominal aorta with a balloon. During the procedure, we used femoral vein to axillary artery bypass, to prevent cardiac accidents related to severe AS and rupture of TAAA because femoral perfusion cannot support cardiac output after clamping the descending aorta. In terms of an operative method, the minimum extent of the aortic aneurysm repair was selected to shorten clamping time and minimize invasiveness of this procedure. In conclusion, we believe that using axillary artery perfusion and choosing the appropriate procedure are most important issue when performing open surgery for TAAA with severe heart complications.

Critical limb ischemia seems to have occurred due to inappropriate endovascular therapy. An 81-year-old Japanese man underwent bypass surgery and endovascular therapy for Peripheral artery disease at another hospital. He presented with an ulcer on the right second toe. Contrast-enhanced computed tomography showed stent occlusion in the external iliac to common femoral arteries and bypass graft occlusion in the femoral to popliteal arteries. There was hardly any great saphenous vein remaining. We performed a femoro-femoral bypass, a bypass in the right graft to below-knee popliteal with an expanded polytetrafluoroethylene graft (ePTFE). The wound did not heal. Angiography showed occlusion in the right posterior tibial artery. Therefore, we performed a posterior tibial-posterior tibial bypass with saphenous vein graft and amputation of the right second toe. The wound completely healed and the patient was discharged. There is a possibility that stenting on a non-stenting zone produced critical limb ischemia.

Tracheo-innominate artery fistula (TIF) is a rare but fatal complication of tracheostomy. We describe a patient with secondary TIF. A 76-year-old woman had undergone a tracheostomy three years previously for disordered consciousness after traumatic brain injury and subarachnoid hemorrhage. She was transferred to our hospital due to massive bleeding from the tracheostomy during exchange of the tracheostomy tube. The hemorrhage was controlled by inflating the cuff. Contrast-enhanced computed tomography confirmed TIF, for which emergency resection of the damaged innominate artery was performed via a median sternotomy. Confirming a sufficient level of stump blood pressure of the right carotid artery (64 mmHg), reconstruction of the innominate artery was abandoned. The postoperative course was not complicated except the wound infection that required surgical drainage on the tenth postoperative day. The worsening of consciousness level was not detected throughout the acute phase. Control of hemorrhage, prevention of infection, and cerebral ischemia are critical issues related to TIF. In addition to the simplicity and rapidity, resection of the innominate artery has an advantage in management of infectious complications. This procedure is a feasible option for the management of TIF, although maintaining the carotid artery stump pressure is necessary to prevent cerebral ischemia.

A 67-year-old man was diagnosed as having localized dissection of the abdominal aorta. The patient has a medical history of transverse colon resection owing to transverse colon cancer 2 years previously. One year after the initial operation, follow-up abdominal CT scans demonstrated exponential enlargement of the abdominal aorta. He strongly indicated his preference to undergo endovascular aneurysm repair (EVAR). EVAR was performed uneventfully including blood transfusion. The following day after the operation, bloody stool was observed and total colonoscopy revealed flare of the mucous membrane and traversing ulcer on the sigmoid colon. The patient was managed conservatively, and his symptoms resolved immediately after fasting therapy. Postoperative ischemic colitis after EVAR is rare compared with replacement of the abdominal aorta under laparotomy. However, it is necessary to consider that when we perform EVAR on a patient after gastrointestinal tract resection and extensive lymph node dissection, ischemic colitis can occur.

We report a rare case of acute Stanford type B aortic dissection (AAD (B)) occurring after a retropharyngeal hematoma (RH) with a literature review, since no other examples of this rare condition have been reported in Japan. A 66-year-old man visited another hospital with respiratory distress occurring 2 hours after a fall from a height of 2 m. A computed tomography (CT) examination showed a RH that was compressing the patient’s respiratory tract, and the patient was transferred to our hospital. During the transfer, he became dyspneic, and an emergency intubation was performed after arrival at our hospital. A follow-up CT scan after intubation revealed a non-communicating AAD (B). Conservative treatment was started, but the refractory pain and hypertension persisted resulted in the aneurysm expansion and development of a re-communication between the thrombosed false lumen and the true lumen. After the enlargement of the RH stopped, the pain and hypertension became controllable. However, the aneurysm expansion at the level of the false lumen communicating with the true lumen persisted, so we performed a thoracic endovascular aortic repair (TEVAR) for AAD (B) after the size of the RH had decreased. The postoperative course was uneventful, and the patient was discharged home. TEVAR is reportedly superior to open aortic replacement as a surgical treatment for AAD (B) with fatal complications regardless of the timing, and TEVAR might be the first choice for the surgical treatment of AAD (B) even in cases where the AAD (B) has occurred after a RH.