Successful Endovascular Treatment of Ureteroarterial Fistula and Anastomotic Pseudoaneurysms / 日本心臓血管外科学会雑誌

A 79-year-old man who had undergone aneurysmectomy and graft replacement for an abdominal aortic aneurysm developed abdominal distension and massive hematuria. A computed tomography (CT) scan revealed the presence of anastomotic pseudoaneurysms and an ureteroarterial fistula between the ureter and iliac artery (distal anastomotic pseudoaneurysm). On admission, the patient's vital signs were stable. The patient was considered a high-risk case for open surgery because of his renal dysfunction which required dialysis, chronic heart failure and hostile abdomen. We initially recommended open surgery because of possible graft infection, however, the patient refused to undergo the high-risk open surgery. We performed emergency surgery for the ureteroarterial fistula via coverage with off-label use of the stent-graft leg. Intraoperative angiography revealed that there was no leakage. After 1 month, we confirmed that the inflammatory laboratory data was normalized, subsequently, we performed endovascular re-intervention for the proximal aortic anastomotic pseudoaneurysm. The endoleak was finally repaired after off-label use of the stent-graft (aortic cuff exclusion) twice within 2 months. The patient did not develop any operation-related adverse events for 4 months, but subsequently he died of pneumonia that developed from a common cold. Thus, we successfully performed endovascular treatment for a high-risk patient with an ureteroarterial fistula and pseudoaneurysms, without any surgery-related infection.

Surgical Treatment for Thoracoabdominal Aneurysm with Severely Calcified Aorta / 日本心臓血管外科学会雑誌

We report a 59-year-old chronic hemodialysis patient with a thoracoabdominal aortic aneurysm, in whom the entire aortic wall and visceral branches were severely calcified. Using a staged operation approach, the celiac trunk and superior mesenteric artery were first bypassed with a composite graft made from a saphenous vein Y-graft and ePTFE. Next, we inserted a custom-made stent-graft, however, there was poor attachment at both the proximal and distal ends due to the severely calcified aortic wall. As a result, we used additional two stent-grafts. His postoperative course was good, and the CT scan performed one year after operation showed no endoleak.