An 89-year-old man with a past history of paroxysmal atrial fibrillation was urgently admitted to our hospital because of sudden-onset pain in the left forearm. The pulse of the left brachial artery had disappeared. Angiography demonstrated left brachial artery occlusion due to a thrombus. The day after an emergency thrombectomy, abdominal pain occurred after eating. Enhanced computed tomography and aortography revealed that the superior mesenteric artery (SMA) was occluded with collateral circulation from the inferior mesenteric artery (IMA). Under a diagnosis of angina abdominalis, the bypass procedure, using a saphenous vein graft (SVG) from the abdominal aorta to the SMA, was carried out under the support of cardiopulmonary bypass. To maintain antegrade alignment of the SVG, the SVG was anastomosed proximally to the infrarenal abdominal aorta. Severe atherosclerotic changes were observed in the main trunk of the SMA. However, no intestinal necrosis occurred because of the well-developed collateral flow from the IMA. The mechanism of angina abdominalis is probably due to thromboembolism in the SMA which had preexisting stenotic organic lesions.

We report a case of an infected aortic pseudoaneurysm caused by delayed sternal osteomyelitis. A 79-year-old man underwent combined surgery comprising aortic valve replacement (AVR), coronary artery bypass grafting (CABG) and permanent pacemaker implantation at our department due to aortic insufficiency (third degree), coronary sclerosis, and sick sinus syndrome (type 1). The subject was discharged home on postoperative day (POD) 27. Sternal osteomyelitis developed on POD 50, and the subject was re-hospitalized. However, on day 6 of readmission, auscultation revealed a new systolic murmur (Levin IV/VI) in the second right intercostal space sternal border and transthoracic echocardiography showed abnormal blood flow from the base of the aorta to the left front. Contrast-enhanced computed tomography (CT) revealed an infected pseudoaneurysm of the ascending aorta that was not detected by CT at readmission. An infected aortic pseudoaneurysm caused by delayed sternal osteomyelitis was diagnosed. On day 8 of readmission, the pseudoaneurysm was excised and the ascending aorta was replaced. Intraoperative findings revealed that the aortic pseudoaneurysm had formed from the site of the ascending aorta anastomosis at the time of performing AVR and that part of the aneurysm had perforated into the right ventricular outflow tract. In the present case, the new cardiac murmur identified on auscultation and consequently performing echocardiography at the bedside led to the definitive diagnosis.