Popliteal artery aneurysms are common among the peripheral artery aneurysms but ruptured popliteal artery aneurysm has been rarely reported. We report a surgically treated case of a ruptured popliteal artery pseudoaneurysm initially misinterpreted. A 70 year-old man visited the outpatient with complaints of right crural swelling. He was diagnosed femoral hematoma with CT scan. After several days, he revisited our emergency room because of worsening right crural swelling and difficulty in walking. He was admitted with a diagnosis of crural phlegmon. On the next day of admission, he was diagnosed ruptured right popliteal artery aneurysm and large crural hematoma with a contrast-enhanced CT scan. An emergency operation was performed through the posterior approach with thigh tourniquet. After the resection of the popliteal and crural hematoma, his right popliteal artery was reconstructed with ePTFE graft replacement. We could not identify the wall of ruptured popliteal artery aneurysm. The post operative course was uneventful. The patient was doing well at his 1-year follow-up evaluation. We considered that the final diagnosis was popliteal artery pseudoaneurysm caused by idiopathic popliteal artery rupture.

It is difficult to control infection and achieve revascularization for inguinal infection complicated with femoral artery infection. A 72-year-old man, who had undergone an operation of left femoro-popliteal bypass using a great saphenous vein graft, was transferred to our hospital emergently 17 days after a puncture to the left inguinal region for endovascular repair of right lower extremity at another hospital. Computed tomography revealed a pseudoaneurysm at the proximal anastomosis and we performed patch plasty for perforation with vein graft. Staphylococcus aureus (MSSA) was detected in a culture from the hematoma. Bleeding at the anastomosis due to infection occurred postoperatively, and we interposed a vein graft newly harvested in the proximal anastomosis and performed tensor fasciae latae myocutaneous flap coverage at the same time. But the infection did not improve, therefore, we finally performed debridement of the femoral artery, obturator bypass, and myocutaneous flap re-coverage. The postoperative course was good, and the patient was discharged. We performed debridement of the femoral artery and obturator bypass for inguinal infection complicated with femoral artery infection after lower extremity artery bypass, and succeeded in revascularization and controlling infection.

True brachial artery aneurysm after long-standing arteriovenous fistula for hemodialysis are rare. We herein report a surgical case of true brachial artery aneurysm associated with vascular access. The patient was a 49-year-old man, who had been on dialysis for 35 years due to chronic renal insufficiency. His left antecubital arterio-venous fistula (AVF) became occluded after 20 years of use. A right antecubital AVF was created and the blood vessels of the left upper extremity had not been punctured in the 15 years since then. He visited a clinic due to numbness of his left hand. Cyanosis of the left hand and a pulsatile brachial mass were pointed out. Enhanced CT showed the left brachial artery was generally dilated and a giant aneurysm with dense intramural thrombus developed after the branching of the deep brachial artery. The numbness and cyanosis were suspected to be symptoms of embolization from the intramural thrombus. Aneurysmectomy and graft replacement with a reversed saphenous vein were performed. Pathological examination showed a true aneurysm.

We report a case of stent graft occlusion, severe lower extremity ischemia, and ruptured abdominal aortic aneurysm due to type B acute aortic dissection 3 years after endovascular aneurysm repair. He admitted our hospital because of abrupt back pain and dysesthesia of bilateral lower limb. Contrast-enhanced computed tomography (CT) scan showed type B acute aortic dissection and occlusion of the stent graft due to dynamic compression by the false lumen. Emergent right axillo-bifemoral bypass operation was done for his critical limb ischemia. Immediately after the successful operation, he fell into shock vital and dissecting abdominal aortic aneurysm rupture was revealed by CT scan. We performed the stump occlusion of the infrarenal abdominal aorta and the bilateral common iliac arteries by abdominal midline incision. Postoperative myonephropathicmetabolic syndrome due to the left ischemia resulted in amputation of his left lower leg for lifesaving. While EVAR cases are increasing, various its complications come to be reported. We consider that this case report might be cautious about the indication of EVAR for the younger generation.

We report a case of acute limb ischemia (ALI) in a patient with popliteal arterial variants. The patient was a 77-year-old woman who was referred to our hospital due to left lower limb pain persisting for 4 days. Contrast-enhanced computed tomography (CT) scans revealed an obstruction suggestive of an embolism in the distal peroneal artery, with patency being observed below the posterior tibial artery at the ankle level due to collateral circulation. Based on a diagnosis of ALI: Grade 1, the patient was hospitalized for conservative therapy; however, ischemic symptoms in the patient’s left limb rapidly worsened after admission, and rest pain and cyanosis were observed. A re-review of the initial contrast-enhanced CT images revealed defects in the unaffected side of the posterior tibial artery and hypoplasia in the anterior tibial artery. The peroneal artery was thought to have flowed directly into the plantar artery, causing the anomaly of popliteal artery. Thereafter, a thrombectomy was performed for the peroneal artery. A dark red fresh thrombus was removed successfully and improvement in blood flow was observed. The possibility of angiodysplasia should be considered, and making an accurate diagnosis and an appropriate decision among treatment options was considered important.

We encountered a woman in her 70s who developed wrapping sac enlargement and rupture 14 years after vascular graft replacement for an abdominal aortic aneurysm (AAA). She underwent replacement of an AAA with a straight knitted Dacron graft (12 mm) at 62 years of age and replacement of the ascending aorta owing to Stanford type A acute aortic dissection at 74 years of age. She was transferred to our hospital with a sudden onset of back pain and lumbago. Contrast enhanced computed tomography (CT) revealed the presence of contrast medium between the graft wall and aneurysm sac. Selective angiogram of the bilateral internal iliac and 5th lumbar arteries did not show inflow vessels. The wrapping aneurysm sac rapidly enlarged. An early open repair was scheduled; however, she developed shock suddenly on the 7th hospital day. CT revealed a huge hematoma in the retroperitoneal space. An emergency laparotomy was performed for a ruptured AAA. The aneurysm sac was opened and contained fresh thrombus. The rupture site was recognized in the upper and left side parts of the aneurysm sac. The proximal and distal anastomotic sites were intact. There was pulsatile bleeding from an orifice thought to be a lumbar artery in the lower and left side parts of the aneurysm sac. The orifice was then suture-ligated with 4/0 polypropylene to achieve hemostasis, and the sac was closed. We speculated that resembling type II endoleak was caused by temporary coagulopathy during the perioperative period of Stanford type A acute aortic dissection and the formation of longitudinal vascular network induced by reperfusion of the occluded intercostal artery due to false lumen retrograde blood flow. Resembling type II endoleak can occur even after vascular graft replacement for an AAA irrespective of the time after surgery.