PMC6501254_01
Preoperative enhanced computed tomography indicates an infected aortic aneurysm at the thoracoabdominal level. (a) Small aneurysm with intra-aortic air (arrow), the superior mesenteric artery (star), and renal artery in the axial view. (b) Obstructed distal abdominal aorta and common iliac arteries (arrows) with calcification in the coronal view. (c) Suspected aortoduodenal fistula (arrowhead) in the sagittal view.
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A 35 mm thoracoabdominal aneurysm with intra-aneurysmal gas was seen on enhanced computed tomography (Figure 1), consistent with an infected thoracoabdominal aneurysm accompanied by Leriche syndrome. When we reached the aorta through careful retroperitoneal approach, we could not reserve the left inferior epigastric artery, running obliquely around the incision area (Figure 1).
Diagram of the surgical procedure. (a) Aneurysm, aortoduodenal fistula (arrow), and a 4-branched graft are shown. Oblique lines show the infectious area. Wavy lines are resected areas of the duodenum and jejunum. (b) Aortic repair and left leg revascularization are shown. The aortoduodenal fistula was subsequently resected. (c) Enterostomy was attached to the jejunum as the first stage of intestinal reconstruction. (d) The duodenojejunostomy was performed as the second stage of intestinal reconstruction.
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Tokyo, Japan) (Figure 2(a)). The SMA and right renal artery were reconstructed using the right graft branch, and the left renal artery was reconstructed with the left graft branch (Figures 2(b) and 3(a)). After the vessel reconstruction, a horizontal segment of the duodenum containing a 5 mm fistula was resected (Figures 2(a) and 2(b)). And the intestinal fistula was made for feeding (Figure 2(c)). Vancomycin and meropenem were administered for 1 month, and a duodenojejunostomy, as the second stage, was performed on day 30 after the inflammation subsided (Figure 2(d)).
Postoperative three-dimensional reconstructed computed tomography scan shows the graft of the thoracoabdominal aorta and the additional femorofemoral bypass graft. (a) The superior mesenteric artery and right renal artery (black arrow) and the left renal artery (white arrow) were reconstructed with three of four leg grafts. (b) The left common femoral artery was bypassed with the remaining left leg graft (black arrowhead). The right common femoral artery was also bypassed with an 8 mm graft (white arrowhead).
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Ltd., Tokyo, Japan) attached to the side of the leg graft branch (Figure 3(b)).