A 32-year-old man with severe back pain and cold, pulseless bilateral lower extremities was admitted. Enhanced CT scan revealed acute type A aortic dissection and the true lumen was severely compressed or occluded at the level of the abdominal aorta. Emergency simultaneous graft replacement of the ascending aorta and aortic arch was performed under deep hypothermic circulatory arrest, antegrade selective cerebral perfusion in addition to the elephant trunk technique. Although distal anastomosis was constructed only to the true lumen, leg ischemia persisted. Therefore, a new modified procedure applying a branched graft used for antegrade systemic perfusion as inflow and conventional axillo-bifemoral bypass graft was anastomosed to restore adequate circulation to the lower extremities. In the treatment of acute type A aortic dissection complicated with leg ischemia, the modified technique we employed is a simple and feasible method for leg revascularization in cases in which malperfusion to the leg persists in spite of complete of aortic repair.

Tracheo-innominate fistula (TIF) is an uncommon life-threatening complication of tracheostomy. We report a 36 year-old man with post-tracheostomy TIF which was successfully repaired. After temporary control of bleeding, he was transported to our hospital by an ambulance helicopter. Emergency surgery was performed. The tracheal fistula was closed by direct suture and it was covered by sternocleidomastoid muscle flap. After sufficient irrigation, ascending aorta-innominate artery bypass was performed using 8 mm Dacron graft through a right pleural cavity. The postoperative course was uneventful. The patient was discharged from our hospital after 30 days of operation. He has been in good condition for 3 years after surgery. Reconstruction of the innominate artery with vascular prosthesis is feasible even is cases of TIF. However, preventive measures are extremely important to avoid long-term complications such as graft infection or recurrence of TIF.

A 62-year-old man underwent replacement of the ascending aorta for a Stanford type A acute aortic dissection. The proximal stump was reinforced with using internal and external PTFE felt strips, fibrin glue and cellulose fibers. However, hemolytic anemia and hematuria occurred postoperatively. ECG-gated reconstruction CT demonstrated that the hemolytic anemia was induced by collision of red blood cells on the inverted felt strip of the proximal anastomosis. The patient underwent a reparative procedure 1 week subsequent to the initial operation. During reoperation, half of the inner felt strip used for proximal stump fixation was found to be turned up and protruding into the inner lumen. An incision was made in the synthetic graft and the inverting felt material was removed as much as possible, and then a bovine pericardial patch was used as a means of covering the internal felt strip. Here, we report a rare case of hemolytic anemia at the site of an inverted inner PTFE felt strip used for reinforcement of proximal anastomosis. We found that an ECG-gated reconstruction CT is particularly useful in diagnosing this complication around a beating heart.

A 74-year-old woman had undergone right axillo-bifemoral bypass for infrarenal aortic stenosis due to aortitis syndrome in another hospital. She was admitted as an emergency case to our hospital with a ruptured thoracoabdominal aortic aneurysm, and an emergency operation was performed. We used arterial cannulation to the artificial vascular graft implanted for axillo-bifemoral bypass and first cooled the body temperature to below 25°C, then dissected the aorta. In the case of ruptured descending and thoracoabdominal aortic aneurysm, profound hypothermia is a valuable adjunct for unexpected blowout rupture during the preparation of the aneurysm and spinal cord and visceral protection.

Ruptured abdominal aortic aneurysm (AAA) associated with horseshoe kidney is an extremely rare condition. A 76-year-old man with lung cancer treated by radiotherapy was transfered to our hospital for emergency surgery of a ruptured AAA. Preoperative abdominal CT revealed an AAA 70 mm in diameter, massive hematoma in the retroperitoneal space and horseshoe kidney with a huge renal cyst. Because the patient was in serious condition, we performed emergency operation immediately after arrival at our hospital. The AAA was replaced by a straight prosthtic graft without division of the renal isthmus, however one aberrant renal artery was sacrificed. The postoperative course was uneventful with no evidence of renal dysfunction. In cases of ruptured AAA in a state of shock, emergency operation is first priority. Even though we could do only minimal preoperative examinations, the surgery of the ruptured AAA with horseshoe kidney can be performed safely, if an accurate perioperative judgement for the treatment of abberant artery and renal isthmus is made.