We report a case of successfully treated mesenteric ischemia following emergency endovascular aortic repair (EVAR) for ruptured abdominal aortic aneurysm (r-AAA). A 79-year-old man, who had received hemodialysis for 5 years for diabetic nephropathy, presented with sudden onset abdominal pain. Contrast-enhanced computed tomography revealed an rAAA with a 60-mm diameter in the infrarenal abdominal aorta. Emergency EVAR was performed. After completion of stent graft placement, intraoperative angiogram revealed serious imaging delay of the superior mesenteric artery. An emergency saphenous vein bypass was performed from the right external iliac artery to the ileocolic artery. The postoperative course was uneventful, and there has been no evidence of endoleak or enlargement of aneurysm diameter during the follow-up period of 2 years.

When performing surgery of the thoracic aorta, several supporting methods must be easily available to facilitate various grafting procedures which are selected as the most suitable method for each case. We report on a practical cardiopulmonary bypass (CPB) circuit which can be used in the surgical treatment of any thoracic aortic disease: aortic dissection, true aneurysm involving the aortic arch, descending aortic aneurysm or thoraco-abdominal aortic aneurysm. The circuit design is based on a percutaneous cardiopulmonary support system. We added some modifications to the system for managing CPB simply. The improved bypass circuit was applied in operations on 26 patients and yielded excellent clinical results. The advantages of the circuit are listed as follows: 1) If massive bleeding occurs during closed-circuit CPB, the blood can be sucked into a built-in hard shell reservoir on the venous side of the bypass, and can immediately be returned back into the bypass circuit. 2) Using clamping forceps it is possible to easily switch between closed-circuit CPB and conventional CPB using gravitational venous return. 3) Selective cerebral or other organ perfusion can be done by a built-in roller pump distal to the oxygenator. The perfusion line using the roller pump diverges from the main line using the centrifugal pump kept in a spinning state. If the hypothermic method is used, the lower body is perfused via a femoral arterial cannulation by the centrifugal pump, and the upper body by the roller pump with right subclavian arterial cannulation. When the cardiac rhythm changes to ventricular fibrillation in cooling the patient, the flow ratio of the lower body to the upper body must be 1:1, since retrograde perfusion from the femoral artery may cause cerebral infarction due to embolism of dislodged debris or thrombi from the aneurysm.

Non-occlusive mesenteric ischemia (NOMI) is a rare but often fatal event following cardiac surgery. Early diagnosis of NOMI is difficult because the related abdominal symptoms are not very specific. From April 1999 to September 2003, 1,040 patients underwent cardiac surgery, among whom 5 patients who underwent angiography were given a diagnosis of NOMI. A catheter was used for immediate intra-arterial infusion of 500μg prostaglandin E1 into the superior mesenteric artery over a period of 30min. Prior to angiography, all patients had cutis marmorata and elevated serum lactate levels. Three patients showed peritoneal signs and therefore underwent laparotomy. Of the 5 patients, 4 survived. In conclusion, if mesenteric ischemia is suspected, selective angiography must be performed as soon as possible for diagnosis and treatment. Additionally, the presence of other findings such as cutis marmorata and elevated serum lactate levels proved to be useful in the early diagnosis of NOMI.

The use of axillofemoral bypass grafts (AxFG) has became a widely accepted treatment for high-risk patients with aortoiliac occlusive disease. On the other hand, AxFG has been associated with a variety of complications in the upper extremity. A symptom of upper extremity thromboembolism after AxFG occlusion is reported as axillofemoral bypass graft stump syndrome (AxFSS). We report the case of a 55-year-old man with repeated AxFSS after an AxFG occlusion. He underwent brachial artery exploration and embolectomy. Angiograms showed an embolus floating in the axillary artery, which originated from the occluded graft stump. The stump was obliterated with a metallic stent introduced through the same arteriotomy made for the embolectomy. The endovascular treatment of AxFSS is minimally invasive and is an effective modality in this condition.

An 83-year-old woman with unstable angina pectoris underwent percutaneous coronary intervention (PCI) of the left circumflex artery, and her condition improved. However, on the eighth day after PCI, she went into a stated shock, and echocardiogram confirmed a large amount of pericardial effusion. Pericardiocentesis was immediately performed, and bloody pericardial effusion was drained. Cardiac rupture was suspected, although the cause was unknown. Emergency sternotomy was performed, and blow out type cardiac rupture in the center of a thumb-sized infarction was found at the area of the obtuse marginal branch. The ruptured left ventricular wall was successfully closed with 2 mattress sutures because the infarcted area was relatively small. Postoperative course was good, and she was discharged on the 25th postoperative day. In this case, the cause of cardiac rupture was thought to be a small branch of the left circumflex artery, which was occluded during PCI. This is one of the rare but important mechanisms of cardiac tamponade after PCI.