Objective: We report the early and long-term results of hybrid endovascular repair of a thoracoabdominal aortic aneurysm (TAAA), perioperative disseminated intravascular coagulation (DIC), and hemorrhagic complications associated with postoperative DIC. Methods: We evaluated 15 patients (10 males and 5 females; median age 74.6 years) who underwent hybrid endovascular repair for TAAA and chronic thoracoabdominal aortic dissection between January 2011 and September 2022. Postoperative complications, survival, incidence of DIC, and risk factors for hemorrhagic complications associated with postoperative DIC were evaluated. DIC was diagnosed using the scoring system established by the Japanese Association for Acute Medicine. Results: Only one patient (6.7%) died within 30 days of treatment due to cerebral hemorrhage. The 5-year survival rate was 64.6% and aneurysm-related deaths were not detected. The 5-year rate of freedom from aneurysm-related complications is 70%. Preoperative DIC occurred in five patients (33%), while postoperative DIC increased in 11 patients (73%), and hemorrhagic complications were detected in 3 patients (20%). A univariate analysis identified preoperative FDP value, thrombus volume, and stent-graft treatment length as risk factors for bleeding complications. Conclusion: Hybrid endovascular repair for TAAA may be a good option for high-risk patients who are ill suited to conventional open repair. Postoperative DIC and hemorrhagic complications associated with extensive stent grafting occur with relatively high frequency and can be fatal. Therefore, risk assessments and appropriate therapeutic interventions for perioperative DIC are necessary.

A 73-year-old man was referred to our hospital after a CT scan of the gastroenterology department of another hospital revealed a 35 mm aneurysm in the left femoral deep artery. The patient underwent a common femoral artery-to-deep femoral artery bypass using the great saphenous vein. On the fifth postoperative day, contrast-enhanced CT confirmed the patency of the graft, but also revealed lymphatic leakage. Due to wound dehiscence caused by the leakage, lymphatic ligation was performed. The wound healed, and the patient was discharged on postoperative day 30. There are no clear criteria for surgical intervention in deep femoral artery aneurysms, but many reports recommend early treatment. Although aneurysm ligation alone is considered safe, we opted for revascularization because the deep femoral artery can serve as an important collateral vessel. Given the risk of graft infection, we chose the great saphenous vein for the bypass. Although the patient experienced postoperative lymphatic leakage, no graft infection was observed. We report a case of a deep femoral artery aneurysm treated with revascularization using the great saphenous vein.

Aorto-duodenal fistula after abdominal aortic replacement is a rare but fatal complication. In principle, surgical treatment is necessary. However, standard method of treatment has not yet been established. In cases in which the duodenum has formed a fistula due to contact with the prosthetic graft, leaving the duodenum in the anatomic pathway is considered a high risk of recurrence. Therefore, it is important not only to repair the duodenum and but also to avoid contact with the prosthetic graft to prevent recurrence. We report two cases who developed secondary aorto-duodenal fistula after artificial vessel replacement for abdominal aortic aneurysm, who underwent abdominal aortic re-replacement, partial duodenal resection, and duodenal jejunal anastomosis with posterior jejunal colon path reconstruction. The first case was treated with omental flap transposition at the same time, and in the other case omental flap could not be used because of the lack of enough tissue. However, both cases had a good clinical course without recurrence of infection. This method of altering the route of intestinal reconstruction does not allow the artificial vessel to come into direct contact with the duodenum and may be effective in preventing recurrent infection.

A 47-year-old man was presented with back pain. The thoracoabdominal contrast CT scan showed a dissection from the origin of the left subclavian artery to the left common iliac artery. In addition, the dissection extended to the superior mesenteric artery (SMA) and the left renal artery. However, these blood flows were maintained, and no abnormalities were observed in the intra-abdominal organs. Stanford B acute aortic dissection was diagnosed, and conservative treatment was planned. On day 7 of admission, paralytic ileus due to the SMA ischemia was suspected through the X-ray and contrast CT scan. On day 10, his renal function deteriorated sharply. The contrast CT scan showed a progressive shrinkage of the true lumen and enlargement of the false lumen from the descending thoracic aorta to the abdominal aorta, ischemia of the ascending colon wall, and the left kidney infarction. On day 13 thoracic endovascular aortic repair (TEVAR) was conducted at the proximal part of the descending thoracic aorta. On postoperative day (POD) 3, the contrast CT scan showed an improvement in the blood flow of the colon and the left kidney. Though there were fever and infection treated by antibiotics, his postoperative course was generally good and he was discharged on POD 39.

Acute superior mesenteric artery (SMA) ischemia is a life-threatening condition with a high mortality rate, and endovascular therapy is one of its treatment options. The Indigo Aspiration System (Penumbra Inc., Alameda, CA, USA) received approval for reimbursement as a peripheral thrombus aspiration device in September 2023. The patient, a 77-year-old man, presented with acute abdominal pain and was transferred to our hospital following a diagnosis of acute SMA ischemia confirmed by CT scan. Due to signs of peritoneal irritation, we planned an exploratory laparotomy after revascularization via aspiration thrombectomy. An 8 Fr. guide catheter was introduced into the SMA, and angiography revealed an occlusion at the bifurcation of the middle colic artery and the second jejunal artery. Revascularization was successfully achieved. Laparotomy was then performed to assess intestinal viability, revealing necrosis on a portion of the small intestine’s serosal surface. Partial resection of the small intestine was carried out, but the ileal end, ileum, and ascending colon were preserved. A post-operative contrast-enhanced CT scan showed good patency of the SMA, and the patient was discharged on post-operative day 14. The Indigo Aspiration System proved effective for treating acute SMA occlusion.