Two types of skin incision, pararectal and transverse, in the retroperitoneal approach to aorto-iliac region were compared. For the last 3 years, 34 abdominal aortic aneurysms, excluding ruptured cases, and 43 cases of aorto-iliac occlusive disease were all operated on by a retroperitoneal approach in our hospital. Of these, 36 patients underwent pararectal incision (P group) and 41 patients transverse incision (T group). An Octopus^® retractor yielded a wide operative field in all cases. The mean interval from the start of the operation to the aortic cross clamp were almost equal in the two groups (89.7 and 91.1 minutes). The mean amount of intraoperative bleeding was significantly smaller in the T group (749ml) than in the P group (1, 096ml). The mean interval after surgery to beginning peroral alimentation, weaning from analgesics and discharge from the hospital were all significantly shorter in the T group (1.6, 3.3 and 10.8 days) than the P group (2.8, 4.8 and 15.8 days). Transverse incision for a retroperitoneal approach to the aorto-iliac region is preferable for an early recovery and short hospital stay.

From November 1976 to December 1991, we performed extra anatomic bypass procedures (EAB) in 100 cases with aortoiliac occlusive disease. The operative procedures included 26 axillo-femoral bypasses (Ax-F), 27 femoro-femoral bypasses (F-F) and 47 aorto-femoro-femoral bypasses (Ao-F-F). The average age was 75.8 years in Ax-F and 73.8 years in F-F. These were significantly higher than that of Ao-F-F (70.8 years). In addition, the rate of limb salvage in Ax-F was 85%, and this group had more critical cases than the other two groups. The cumulative primary patency rate and survival rate at 5 years were 64.4%, 20.8% (Ax-F), 65.9%, 51.1% (F-F) and 96.5%, 70.4% (Ao-F-F) respectively. The late results of Ao-F-F were comparable to direct aorto-femoral bypass procedures performed in our institution during the same period. On the contrary, the results of Ax-F and F-F were discouraging. We suggest that EAB should be selected for high risk, limb salvage cases and in particular, Ax-F and F-F should be limited to patients with nonphysical acting. We are opposed to appealing for an extended indications of EAB and it should not be regarded simply as a low-risk substitute for aorto-femoral bypass.

Vascular trauma of the upper extremities is rare. We have successfully treated a case of laceration of the right subclavian artery induced by chest injury. A 45-year-old man with blunt trauma was admitted and angiography revealed laceration of the right subclavian artery. The injured area was exposed by a median sternal approach. The right common carotid-subclavian artery bypass was successfully performed with autogenous vein graft in less than three hours from admission. He recovered without any neurological deficit or functional disability and returned to his former occupation.

Superior mesenteric artery (SMA) aneurysms (SMAAs) are rare and account for approximately 7% of all visceral artery aneurysms. If the anatomical complexity permits and the patency of organ perfusion is allowed, then an endovascular approach is the first choice for minimally invasive procedures. We report the case of a 92-year-old female with a giant SMAA and challenging anatomy, including a short proximal sealing zone from the origin of the SMA and a short distal sealing zone from the hepatic artery bifurcation. In view of her advanced age, she was treated endovascularly with covered stents. Reintervention was required to correct a postoperative endoleak; however, a favorable outcome was achieved with endovascular therapy.