We report a case of arteriovenous fistula (AVF) secondary to spontaneous rupture of the right common iliac aneurysm into the right common iliac vein. In February 2003, an 81-year-old woman was admitted with dyspnea. Diuretics and digitalis were given under a provisional diagnosis of primary heart failure. Afterwards the heart failure turned out to be high output failure due to AVF. In June the patient complained of swelling of her right leg and was referred to our department. Ultrasonography to determine deep vein thrombosis of the right femoral vein revealed a dilatation of the left femoral vein, but there was no thrombosis. A pulse Doppler detected an arterial blood flow signal during early systolic pulse in the right femoral vein, confirming the suspicion of an AVF in abdominal cavity near this location. A pulsatile mass associated with bruit and thrill was palpable in the lower abdomen. Digital subtraction angiography showed a 50mm aneurysm of the right common iliac artery. Rapid visualization of the inferior vena cava and retrograde opacification of the right iliac vein indicated the presence of an AVF between the common iliac artery and vein. Operation was done by laparotomy on June 24, 2003. An occlusive balloon catheter was inserted from the right femoral vein and the balloon was dilated to patch the fistula before opening the aneurysm. After clamping the proximal and distal arteries the aneurysm was opened. By this maneuver there was no bleeding from the fistula. The AVF was closed from inside the aneurysm by 3 interrupted 4-0 monofilament sutures. The aneurysm was replaced with a prosthetic graft (Hemashield 8mm). The postoperative course was uneventful. The lower limb edema subsided and heart failure improved.

We describe a novel method for repeat median sternotomy. We have successfully used ‘finger’ lifting resternotomy technique and achieved zero major cardiovascular injury/catastrophic hemorrhage events at reoperation. After general anesthesia, all patients were placed in the supine position and two external defibrillator pads were placed on the chest wall. We perform a median skin and subcutaneous incision along the previous sternotomy incision extending 3 cm distal to the sternum. The sternal wires that had been used for the previous closure were left in place but untied. Using a long electric cautery, right thoracotomy was performed under the right costal arch approach. Then, the operator could approximate the sternal wires in the retro-sternal space. At the same time, the operator could confirm the retro-sternal adhesion status which by touching with a finger. Resternotomy was performed using an oscillating saw pointed toward the operator's finger, which allowed safe re-median sternotomy from the lower to the upper part of the sternum. This technique of finger-lifting resternotomy has been employed in 50 cardiovascular reoperations and resulted in 0 incident of major cardiac injury or catastrophic hemorrhage. The finger-lifting resternotomy technique is safe and simple in reoperation procedures and yield excellent early outcomes.