Our strategy for treatment of thoracic aortic aneurysms with severely stenotic or occluded cerebral vessels is as follows. 1) The status of cerebral vessels and brain is assessed in detail by a team of neurologists and neurosurgeons, 2) cerebral surgical treatment is performed prior to aortic arch surgery, and 3) reconstruction of the total arch is performed using the arch-first technique through a median sternotomy. We successfully performed artificial graft replacement of the total aortic arch in two patients with old cerebral infarcts and severely stenotic cerebral vessels. In both cases, the operation was performed through median sternotomy under circulatory arrest by feeding the blood to the ascending aorta and draining it from the right atrium. Cerebral protection during reconstruction of the aortic arch was provided by profound hypothermia and retrograde cerebral perfusion (RCP). Prior to the incision of the aneurysm, cerebral branches were dissected to avoid escape of debris into cerebral vessels. The graft replacement was completed in 4 steps: 1) anastomosis of each of the 3 arch vessels, 2) distal anastomosis of another graft for the elephant trunk procedure, 3) anastomosis of the arch graft and the graft for the elephant trunk, and 4) proximal anastomosis. Just after cerebral branches were anastomosed to the 3 branches of the graft, the blood was supplied to the brain through the side branch of the graft instead of RCP. No signs of neurological deficit occurred postoperatively. The above protocol provided protection of high-risk patients with old cerebral infarcts from possible postoperative brain damage.

An 81-year-old man who had a saccular abdominal aortic aneurysm (AAA) with a narrow terminal aorta underwent endovascular aortic aneurysm repair (EVAR) with the Medtronic Endurant^® stent graft system. After 4 days, computed tomography (CT) showed stenosis of the stent graft left limb, which was pressed flat against the right limb at the narrow terminal aorta. We performed re-intervention to dilate the narrow terminal aorta and bilateral limbs with kissing stenting using Express Vascular LD^® (Boston Scientific). After operation his ankle brachial pressure index rose from 0.88 to 0.99 and there was no evidence of stenotic limbs at CT image. We need to be careful about the stenotic limb after EVAR with Medtronic Endurant stentgraft system for AAA with a narrow terminal aorta.

A case of non-anastomotic aneurysms of a knitted Dacron graft is reported. The patient, a 35-year-old female, had had a bypass operation with a Cooley double velour knitted Dacron graft 11 years previously for stenosis of the descending thoracic aorta caused by aortitis syndrome, was admitted complaining of a painful pulsating tumor of the left hypochondral region. We diagnosed multiple aneurysms of Dacron graft with computerized tomography and aortography. The dilated Dacron graft was resected and replaced by a woven polyester graft. The resected specimen showed longitudinal ruptures macroscopically and a decrease of the number of Dacron fibers at the dilated portion was detected microscopically. The nonuniformity of the diameter of Dacron fibers and cracks in the fibers were observed with a scanning electron microscope. Thus, for patients implanted with a knitted Dacron graft, periodical careful follow-up is required for early detection of aneurysmal changes of the graft.

We developed a new double-lumen balloon catheter for retrograde cerebral perfusion (RCP) via jugular vein cannulation. Between November 1996 and September 2000, 34 of 73 patients treated with surgical procedures for thoracic aortic aneurysms underwent RCP using the new catheter during circulatory arrest under deep hypothermia. Nine patients underwent a median sternotomy, and 25 underwent a left thoracotomy. In all cases, the new catheter installation under fluoroscopy was easy, and it took about 15min. The mean RCP time, pressure, and flow rate were 26.8min, 20.0mmHg, and 202.6ml/min, respectively. Our procedure using the new catheter was safe and easy in RCP during circulatory arrest in aortic arch replacement regardless of surgical approaches such as a left thoracotomy or median sternotomy.

An 89-year-old man complained of pulsatile masses in his right groin. Computed tomography (CT) scans revealed an aneurysm of the right deep femoral artery. He was admitted to our hospital with a diagnosis of deep femoral artery aneurysm (DFAA). The clinical frailty scale score was 6 (moderately frail), and he also suffered chronic obstructive pulmonary disease (COPD). Considering his complicated frail and impaired pulmonary function, conventional graft replacement and aneurysmectomy were thought to be quite a high risk. Thus, we selected endovascular treatment. It was not possible to secure a sufficient proximal landing zone for measurement, we did not select a stent-graft treatment. Therefore, we performed hybrid therapy with proximal neck ligation and distal outflow coil embolization. The postoperative course was uneventful, and CT disclosed complete occlusion of the aneurysm.