We report a rare case of a 73-year-old man with abdominal and thoracic aortic aneurysms complicated with Buerger's disease. He complained of abdominal pain, nausea and an abdominal pulsatile mass. Computed tomography and angiography revealed an abdominal aortic aneurysm (58mm in diameter) and a thoracic aortic aneurysm (47mm in diameter). Y graft replacement was performed for abdominal aortic aneurysm. The size of the thoracic aortic aneurysm increased from 47mm to 60mm in 3 years, and hoarseness appeared. We then performed graft replacement of the thoracic aorta. In cases of Buerger's disease, we have to consider perfusion of the extremities when we need extracorporeal circulation, and we must shorten ischemic interval.

From November 1976 to December 1991, we performed extra anatomic bypass procedures (EAB) in 100 cases with aortoiliac occlusive disease. The operative procedures included 26 axillo-femoral bypasses (Ax-F), 27 femoro-femoral bypasses (F-F) and 47 aorto-femoro-femoral bypasses (Ao-F-F). The average age was 75.8 years in Ax-F and 73.8 years in F-F. These were significantly higher than that of Ao-F-F (70.8 years). In addition, the rate of limb salvage in Ax-F was 85%, and this group had more critical cases than the other two groups. The cumulative primary patency rate and survival rate at 5 years were 64.4%, 20.8% (Ax-F), 65.9%, 51.1% (F-F) and 96.5%, 70.4% (Ao-F-F) respectively. The late results of Ao-F-F were comparable to direct aorto-femoral bypass procedures performed in our institution during the same period. On the contrary, the results of Ax-F and F-F were discouraging. We suggest that EAB should be selected for high risk, limb salvage cases and in particular, Ax-F and F-F should be limited to patients with nonphysical acting. We are opposed to appealing for an extended indications of EAB and it should not be regarded simply as a low-risk substitute for aorto-femoral bypass.

Vascular trauma of the upper extremities is rare. We have successfully treated a case of laceration of the right subclavian artery induced by chest injury. A 45-year-old man with blunt trauma was admitted and angiography revealed laceration of the right subclavian artery. The injured area was exposed by a median sternal approach. The right common carotid-subclavian artery bypass was successfully performed with autogenous vein graft in less than three hours from admission. He recovered without any neurological deficit or functional disability and returned to his former occupation.

We report two cases of an abdominal aortic aneurysm, one with congestive heart failure, and the other with a dissecting aortic aneurysm (type IIIb), who underwent an aorto-bifemoral bypass operation under a temporary external axillofemoral bypass. In one patient (Case 1, a 74-year-old male), who had an abdominal aortic aneurysm with congestive heart failure due to aortic valve insufficiency and stenosis, perioperative transesophageal echocardiography demonstrated that, with a temporary external axillofemoral bypass, the regurgitant doppler signal was unchanged during the cross-clamping period of the abdominal aorta. In the other patient (Case 2, a 71-year-old male), who had a dissecting thoracoabdominal aortic aneurysm with the lower abdominal aorta having a true aneurysm formation, the transesophageal echocardiography demonstrated that, with a temporary external axillofemoral bypass, the false lumen of the dissecting thoracic aneurysm had no change in size during the cross-clamping period of the abdominal aorta. Thus, a temporary external axillofemoral bypass might avoid any unfavorable hemodynamic effect during and after the abdominal aortic clamping in patients suffering from an abdominal aortic aneurysm with cardiovascular complications.