During the past 19.5 years, we performed open repairs of 666 non-ruptured abdominal aortic aneurysms (AAA) and iliac artery aneurysms regardless of the patient's age, previous abdominal surgery, or comorbidities. To evaluate our strategies, we reviewed octogenarians and patients with previous laparotomy, dividing them into several groups. (1) Octogenarians were divided into the EO-group (extremely-old patients, 85 years old or older : n=56) and the O-group (octogenarians, younger than 85 years old : n=113). (2) All cases operated by transabdominal approach (n=661) were divided into the A-group (with previous laparotomy : n=164) and the B-group (without laparotomy : n=497). (3) A-group was also divided into subgroups according to the kind of previous surgery : M-group (stomach or gall bladder surgery : n=120), C-group (colorectal surgery : n=20), Ao-group (aortic surgery : n=16), and S-group (colonic or urinary stoma constructing surgery : n=6). We introduced our clinical pathway in January 2000 and non-heparin technique in November 2000 for all AAA repairs. Non-heparin technique was revised in January 2003, excluding AAA with occlusive disease after several thrombotic complications. A comparison between EO-group and O-group proved that there was a significant difference only in aneurysmal diameter and frequency of renal impairment. Mean operation time (201±56 min vs 210±52 min), intraoperative blood loss (442±338 ml vs 430±242 ml), postoperative length of stay (9.4±5.0 days vs 8.2±2.8 days), and hospital mortality (0% vs 0.9%) were the same in both groups. Analyses of the consequences of previous laparotomy showed that A-group needed significantly longer exposure time (74±27 min vs 63±23 min : p=0.00001) and operation time (218±55 min vs 204±53 min : p=0.004) than B-group, but intraoperative blood loss (453±370 ml vs 449±274 ml) and transfusion rates (6.7% vs 8.5%) were the same in both groups. Because the data of M-group and C-group were similar to each other as well as those of Ao-group and S-group, we compared the perioperative data between M+C-group and Ao+S-group. Concerning exposure time, M+C-group required 6 min more than B-group and Ao+S-group 37 min more than M+C-group. The operation time of M+C group was 8 min longer than B-group and that of Ao+S-group was 45 min longer than M+C-group. Although there were significant differences in intraoperative blood loss (396±247 ml vs 820±701 ml : p=0.009) and transfusion rates (4.2% vs 22.7% : p=0.001) between M+C-group and Ao+S-group, postoperative length of stay (8.1±2.2 days vs 10.2±7.5 days) was almost the same, and the majority of patients (97.2% and 100% of respective groups) were discharged. Our experiences with clinical pathway and non-heparin technique suggest that open repair of AAA should not be refrained only for extremely old-aged patients or patients with previous laparotomies.

We present herein the case of a 45-year-old man with a coronary artery aneurysm (diameter 19 mm) in the proximal part of the left anterior descending branch associated with eosinophilic granulomatosis with polyangiitis (EGPA). As coronary angiography showed #6 : 100% and #12-2 : 90%, and Tc-99 m myocardial scintigraphy showed exertional ischemia in the anterior septum, revascularization was considered to be indicated. Prednisolone and mepolizumab were administered preoperatively to suppress the activity of vasculitis due to eosinophilia, and surgery was performed when the eosinophil count normalized. The patient underwent off-pump coronary artery bypass grafting (LITA-LAD, SVG-OM2). The patient was discharged, and the postoperative course was uneventful. In coronary artery bypass grafting for EGPA, eosinophils may infiltrate the internal thoracic artery and result in vasculitis, which may affect the patency rate. Perioperative management of vasculitis may thus be important.