Three cases of aortic arch aneurysm complicated by aberrant right subclavian artery (ARSA) are reported. Two patients underwent emergent operations with diagnosis of a Stanford type A acute dissection and a ruptured distal arch aneurysm. The third patient underwent an elective operation under a diagnosis of distal arch aneurysm and right subclavian artery aneurysm. In all cases, deep hypothermic circulatory arrest with retrograde cerebral perfusion through median sternotomy was applied. The first patient with acute aortic dissection underwent total arch replacement and elephant trunk installation into the descending aorta. No ARSA was recognized. The other 2 patients underwent distal arch replacement with reconstruction of bilateral subclavian arteries. The in-situ reconstruction of the ARSA was performed in one patient and bypass grafting from the ascending aorta was done in the other patient. There were 2 hospital deaths. The postoperative angiogram of the first patient showed that the ARSA was occluded. One other patient needed a tracheostomy because of pulmonary complications and he died of asphyxia. The last patient died of esophageal perforation secondary to pressure necrosis.

Between 1988 and 1991, 231 patients underwent surgical repair for abdominal aortic aneurysm. Among them 132 patients underwent isolated Y graft replacement electively. They were divided into two groups, according to the operative procedure; transperitoneal approach (n=51) and retroperitoneal approach (n=81), and the surgical results were compared retrospectively. There was no significant difference in operative time, amount of operative bleeding, operative transfusion, total transfusion, autotransfusion, duration of intubation, total use of analgesia or length of postoperative stay in the two groups. The amount of fluid drained from the nasogastric tube was significantly greater in the transperitoneal group. The initiation of drinking and eating were both significantly prolonged in the transperitoneal group. The transperitoneal approach is indicated for cases with thoracic or thoracoabdominal aneurysm which may be operated on in the future, cases of bilateral common iliac aneurysms and cases with heart disease. Otherwise it is preferable to select the retroperitoneal approach as the first choice for elective surgical treatment of abdominal aortic aneurysm, because the retroperitoneal approach is superior in terms of the recovery of gastro-intestinal movement.

Two cases of ruptured abdominal aortic aneurysm (AAA) treated with retroperitoneal approach are presented. Case 1 was a 73-year-old man with an infrarenal AAA of 44mm in diameter, and case 2 was a 73-year-old man with a 54mm pseudoaneurysm after graft replacement for AAA. Both patients had a history of previous laparotomy and their aneurysms had ruptured into only the right retroperitoneal space. A left retroperitoneal approach permitted wide and rapid exposure of the aorta with minimal damage to the intestines and respiratory function. Their postoperative courses were uneventful.

Infectious arterial aneurysm in a rare condition with a high mortality because of rapid aneurysmal growth and subsequent rupture. We encountered 3 cases of arterial aneurysm due to Salmonella infection. We evaluated there 3 cases and an additional 14 cases reported in the Japanese literature. Eleven patients with Salmonella infection had bacteremia. The incidence of bacteremia in patients with Salmonella infection was more frequent than that in patients with other bacillary infections. The location of the aneurysm was the abdominal aorta in 14. Rupture or impending rupture of the aneurysm was identified in 12. Fifteen patients underwent operation including in situ reconstruction in 9 and extra-anatomic bypass in 6. Among 15 patients who underwent an operation, 14 survived. These data suggest that accurate preoperative diagnosis, long-term antibiotic therapy, and immediate surgical intervention are essential for effective treatment of arterial aneurysm due to Salmonella infection.

A 73-year-old man who had undergone Y-grafting suffered from septicemia. A culture of arterial blood yielded Bacteroides fragilis. Computed tomography showed abscess and gas around the prosthetic graft. Under a diagnosis of a prosthetic graft infection caused by Bacteroides fragilis, removal of the infected graft, extra-anatomic bypass and omental grafting were performed 13 days after the first operation. After intensive treatment, he recovered and was discharged on the 45th day postoperatively.

A 71-year-old woman who had Takayasu's disease underwent Y-grafting, bypass grafting between the abdominal aorta and left renal artery with 8mm ePTFE graft and right nephrectomy for infrarenal abdominal aortic aneurysm and renovascular hypertension (RVH). Four years after the first operation, the bypass graft became occluded and hypertension was exacerbated. Magnetic resonance angiography revealed that the left renal artery was supplied by the collateral arteries. We performed replacement of the thoracoabdominal aorta and reconstruction of the left renal artery using the saphenous vein. Postoperatively serum creatinine level decreased and hypertension was controllable. She was discharged from the hospital and has been well for three years.

A 52-year-old man who had liver cirrhosis sufferred ruptured thoraco-abdominal aortic aneurysm. This patient was classified as having Child's class B liver cirrhosis preoperatively. The thoracoabdominal aorta was successfully replaced with reconstruction of the renal arteries, superior mesenteric artery, celiac artery, and 10th intercostal artery. Omentopexy was added. As persistent ascites continued postoperatively, peritoneovenous shunting was performed on the 29th postoperative day. Ascites disappeared and 20 days later the patient was discharged from hospital and has been well for two years.

A 59-year-old man presented with severe abdominal pain. CT scan showed a type A aortic dissection and pericardial effusion. As cardiac tamponade was present, emergency total arch replacement was performed. Because of his symptom, we added an exploratory laparotomy, which revealed intestinal necrosis. Therefore, necrotic intestine 4.5m in length was resected. After intensive care, he began oral feeding on the 25th day and was discharged on the 76th day postoperatively.

The elephant trunk procedure is used to close the false lumen of the distal aorta in the surgical treatment for aortic dissection. We examined the state of the false lumen thrombus and measured the diameter of the aortic dissection, using postoperative digital subtraction angiography and computed tomographic scanning. We performed the elephant trunk procedure in 24 cases in the period, between January 1995 to December 1999. Total aortic arch replacement was performed in Stanford type A dissection, and descending aorta replacement was performed in Stanford type B dissection. In all patients, thrombotic closure around the elephant trunk graft was confirmed. Thromboexclusion of the false lumen of the descending aorta was observed in 18 cases (75.0%). The secondary operation may be unnecessary, because there was a tendency towards reduction of the diameter of dissecting aorta. These data revealed that this procedure was effective. In 6 cases (25.0%), residual dissection was recognized in the thoracoabdominal aorta, but there was no case of expansion requiring further operation. Nevertheless, careful follow-up is necessary, because aneurysms could expand in the future.