Objectives: Abdominal aorto-enteric fistula (AEF) has many problems to be resolved such as bleeding and infection, and a treatment strategy has not been established. We have experienced successful treatment of several AEF cases and we report our treatment strategy. Methods: The important points as a treatment strategy of AEF are 1) rapid control of bleeding, 2) fistula treatment, and 3) infection control. First, bleeding is controlled with an endovascular aneurysm repair (EVAR), and after confirmation of no endoleaks, intestinal tract repair and omentopexy are performed by laparotomy. The stent graft is not removed due to the priority of minimal invasion. The most suitable antibiotics are selected from the results of intraoperative culture and administered for a sufficiently long period. Results: We experienced five cases of AEF from 2016 to 2020. Three cases were primary AEF (abdominal aortic aneurysm-duodenal fistula) and two cases were secondary AEF. Of the two cases, one was after EVAR (abdominal aortic aneurysm-duodenal fistula) and one was after traditional open repair (pseudoaneurysm of proximal anastomosis-small intestinal fistula). Bleeding was controlled by immediate EVAR except for one patient with a history of EVAR. After that, intestinal repair by laparotomy was performed in all cases. Omentopexy was performed in four cases and remaining one case was used mesentery because the omentum was absent due to total gastrectomy. As for antibiotics, penicillins or cephalosporins were administered intravenously for about 4 weeks and transferred to oral administration. Although one patient died of postoperative pneumonia, four patients were discharged from the hospital. An average of 17.8 months (2.1 to 53.8 months) has passed after surgery, and there are no signs of infection due to AEF. Conclusion: A treatment strategy for AEF focusing on rapid bleeding control, fistula treatment, and infection control has good results.

A 67-year-old man whose medical history included diabetes, hypertension, and sleep apnea syndrome had undergone endovascular aortic repair (EVAR) using an Excluder device for abdominal aortic aneurysm and right common iliac arterial aneurysm. After discharge, there were no ischemic symptoms in the lower limbs, and the course was good. Seven months after EVAR, he suffered from coronavirus disease 2019 (COVID-19) and was hospitalized on the third day of COVID-19 onset. On the 14th day of illness, his respiratory condition deteriorated, and noninvasive positive pressure ventilation therapy was started. On the 28th day of illness, he noticed a feeling of coldness in both lower limbs. On the 33rd day of illness, sudden severe pain from the lower back to the lower limbs and weakness appeared. Contrast-enhanced computed tomography showed thrombotic occlusion of the abdominal endograft and the left renal artery and bilateral external iliac arteries to the inguinal ligament level in the periphery. Thereafter, an urgent axillobifemoral arterial bypass was performed. The postoperative course was uneventful. We report an acute thrombotic occlusion of the abdominal endograft caused by COVID-19.

Patients with coronavirus disease (COVID-19) are at increased risk of thrombosis. A 70-year-old man with hypertension was hospitalized with fever, shortness of breath, and hypoxia. He had tested positive for COVID-19 9 days prior and exhibited a significantly elevated D-dimer level (28.2 µg/mL). One day after admission, new-onset acute right lower-extremity pain was reported. On examination, he had profound mild weakness in the right leg and absent pulses below the right femoral artery. Computed tomography angiography revealed a focal aortic thrombus at the level of the inferior mesenteric artery; a thrombus in the left anterior tibial vein; and acute occlusion of the right iliac artery, distal right profunda femoris artery, and popliteal artery. Electrocardiography revealed a normal sinus rhythm. Clinically, he had Trans-Atlantic Inter-Society Consensus II Stage IIb acute limb ischemia. The patient underwent emergent thrombectomy, and an acute thrombus was removed. Palpable pulses were restored in the right foot. The patient was maintained on therapeutic intravenous heparin and transitioned to direct oral anticoagulants. He has not experienced any recurrent ischemic limb events, but the aortic thrombus has not disappeared.

We report a case of acute arterial occlusion due to dissection of the brachial artery, which is rare in canine bites, including some bibliographical considerations. The case was an 86-year-old woman. The left upper limb was bitten by apet dog and injured. The chief complaint was swelling of the upper left limb and numbness. Radial artery pulsation could not be detected, and vascular damage was suspected. No obvious wounds were found on the skin. Contrast-enhanced CT showed localized occlusion of the brachial artery. The site of color change in the brachial artery was resected and autologous vein graft replacement was performed. Arterial dissection was found in the resected specimen. Anticoagulant therapy was used for 1 year after the operation, and antiplatelet preparations were taken thereafter for 8 years after the operation.

We herein report a case of a giant superior mesenteric artery (SMA) aneurysm. A 65-year-old woman was admitted to our hospital because of a pulsatile upper abdominal mass. She was diagnosed of a giant aneurysm of the SMA (maximum diameter of 70 mm) by enhanced computed tomography (CT). In the preoperative angiography, the right hepatic artery was branched from the aneurysm, and two branches from the distal part of the aneurysm provided blood inflow to the small bowel and colon respectively. Aneurysmectomy with reconstruction of the SMA branches was performed. The SMA trunk was anastomosed to the right hepatic artery. Two branches of the SMA aneurysm were anastomosed to the abdominal aorta with the saphenous vein grafts individually interposed. The postoperative course was uneventful, and no abdominal complications occurred.