A 71-year-old man was admitted complaining of abdominal pain. Contrast enhanced CT scan showed bilateral inflammatory common iliac artery aneurysms and encasement of bilateral ureters with perianeurysmal fibrosis. Drip infusion pyelography (DIP) showed bilateral hydronephrosis. After insertion of ureteral stents, Y-graft replacement and bilateral ureterolysis were performed successfully in spite of adhesion of the ureters to the aneurysmal wall. Postoperative DIP showed good passage in ureters and improvement of hydronephrosis. We would like to emphasize the usefulness of preoperative ureteral stenting for identification and mobilization of ureters.

The“elephant trunk”operation, first described by Borst and associates, is a multistage operation for diffuse aneurysmal disease. We report a 59-year-old man complaining of hoarseness, who had a diffuse aneurysm extending from the ascending aorta to the upper abdominal aorta with occlusive disease in the neck branches. His aorta was replaced in two stages using the“elephant trunk”operation. The first stage operation, replacement of the ascending aorta and transverse aortic arch, was performed through a median sternotomy under selective cerebral perfusion. The second stage operation, replacement of the descending thoracic and upper abdominal aorta, was performed under F-F bypass. He had occlusive disease on bilateral carotid arteries with a history of brain infarction, had lost his left lower limb because of arteriosclerosis, and had undergone replacement of the infrarenal abdominal aorta because of an aneurysm. Despite a complicated preoperative general condition, the postoperative course was uneventful. The“elephant trunk” operation facilitates staged operation for diffuse aneurysmal disease as presented here, and thereby improves opeative result by reducing surgical stress.

We report 18 cases of thoracoabdominal aortic aneurysm repair. Most causes of the thoracoabdominal aortic aneurysm were atherosclerotic lesions (56%) or inflammatory changes (39%), such as Takayasu's aortitis and Behçet's disease. The Crawford procedure was performed in 13 patients, patch aortoplasty in 3, the Hardy procedure in 1 and extra-anatomic bypass in 1. As an adjunct, temporary bypass was employed in 8 patients and F-F bypass in 7 patients. Visceral arteries were perfused selectively during aortic cross-clamp. A total of 39% of all patients required emergency surgery for rupture, and among inflammatory aneurysms 86% of them ruptured. The early mortality rate was 0% in non-ruptured thoracoabdominal aneurysms, 42.9% in ruptured and 16.7% overall. There were 3 severe post-operative complications including one each of paraplegia, non-occlusive intestinal ischemia and rupture. All of them turned resulted in in-hospital death and the in-hospital mortality rate was 33.3%. There was no late death among atherosclerotic thoracoabdominal aortic aneurysms. However both Behçet's disease cases required re-operation for rupture at the anastomotic site in the late postoperative period and one patient died. One Marfan's syndrome patient also died 3 years postoperatively. We conclude that the Crawford procedure with F-F bypass is an effective and safe approach to thoracoabdominal aortic aneurysm repair and yields good clinical results.

Nine patients with type IIIb dissecting aortic aneurysm underwent graft replacement of the thoracic and abdominal aorta between 1988 and 1992. The spiral opening method was used to expose the thoracic and abdominal aorta. Temporal bypass was employed in 2 patients and F-F bypass in 7 patients. Visceral arteries were perfused selectively during aortic cross-clamp. The entire descending thoracic aorta and abdominal aorta was reconstructed in 6 patients and the proximal descending thoracic aorta to renal arteries in 3 patients. The Crawford graft inclusion technique was used in all cases. Three patients required emergency surgery for rupture in one and impending rupture in 2. Operative deaths occurred in 2 patients (22.2%). Morbidity included renal failure (2), bleeding requiring reoperation (2), arrythmia (1), paraplegia (1), paraparesis (1), respiratory failure (1) and ileus (1). In the past two years, we operated on 5 cases of type IIIb dissecting aneurysms and there was neither operative death nor paraplegia.