An 82-year-old woman was given emergency admission because of severe anterior chest pain. We found an ascending aortic aneurysm 60mm in diameter. CT revealed acute aortic dissection with an ascending aorta. Emergeny operation was performed under a diagnosis of type-A acute aortic dissection with ascending aortic aneurysm. Operative findings showed thrombus in the dissection and a dilated ascending aorta without intimal tears. Operative findings differed from those of a classical dissection and were compatible with a diagnosis of aortic intramural hematoma (IMH). We performed hemi-arch replacement for the ascending aortic aneurysm under deep hypothermic cardiac arrest and she was discharged without any complications. IMH in the presence of coexisting ascending aortic aneurysm is extremely rare and we therefore reported the surgical repair of this rare case.

A 77-year-old man with an abnormal shadow on chest x-ray film, was found to have Kommerell's diverticulum associated with a right aortic arch 2 years previously. During the period of follow-up, the Kommerell's diverticulum was expanded to 5.3 cm in diameter. CT revealed a right aortic arch with mirror-image branching and Kommerell's diverticulum. To eliminate the risk of rupture, the Kommerell's diverticulum was excluded by deployment of a handmade fenestrated stent-graft using the brachial wire traction technique via the right femoral artery and left brachial artery. At 30-months of follow-up the patient is doing well, with no signs of endoleak or migration. Endovascular repair of Kommerell's diverticulum with a right aortic arch is feasible, safe and effective. This is a rare case of a right aortic arch with Kommerell's diverticulum and without left aberrant subclavian artery.

We report a case of successful graft replacement of the total aortic arch using selective cerebral perfusion for recurrent distal aortic arch aneurysm (DAAA). A 72-year-old man who had a history of patch aortoplasty for saccular DAAA was admitted to our hospital. Computed tomography and digital subtraction angiography showed recurrent saccular DAAA and coronary angiography revealed 90% stenosis of the first diagonal branch, resulting in a diagnosis of recurrent DAAA with coronary artery stenosis. A graft replacement of the total aortic arch with the aid of selective cerebral perfusion and coronary artery bypass grafting to the first diagonal branch was carried out. Postoperatively, he had no cerebral complications. One year after the operation, he had an operation for an abdominal aortic aneurysm. The patient is now leading a normal life.

The retroperitoneal approach for abdominal aortic aneurysm (AAA) has been used to reduce the risk of postoperative ileus and respiratory failure. This technique is usually used in patients with non-ruptured infrarenal AAA because it has been considered to be more time consuming to approach the aorta than the normal transabdominal approach. However, we may not have sufficient information if the aneurysm is confined to the infrarenal abdominal aorta in a ruptured case. In such a situation, the retroperitoneal approach might be better than the transabdominal approach because an aortic clamp can easily be applied to the suprarenal aorta. We report three cases of ruptured AAA treated successfully by the retroperitoneal approach.