左腋窩両大腿動脈バイパス術後の胸腹部大動脈人工血管置換術

Thoracoabdominal Aneurysm in a Patient with an Axillo-bifemoral Bypass

腋窩大腿動脈バイパス術後の胸腹部大動脈瘤人工血管置換術はきわめてまれであり，開胸操作や補助循環に工夫が必要となる．われわれは左腋窩両大腿動脈バイパス術後患者の解離性胸腹部大動脈瘤に対して，腋窩大腿動脈バイパスを送血路とした超低体温完全体外循環下に胸腹部人工血管置換術を施行したので報告する．

We report an extremely rare case of thoracoabdominal replacement after left axillo-bifemoral artery bypass surgery. The patient was a 33-year-old man who had undergone left axillo-bifemoral artery bypass surgery after total arch replacement due to lower extremity ischemia by stenosis of the elephant trunk graft 10 years previously. He was admitted to the emergency department with back pain. Computed tomography （CT） revealed an acute aortic re-dissection and a thoracoabdominal aneurysm. Due to gradual increase of the size of aneurysm, thoracoabdominal replacement was performed. The fourth intercostal thoracotomy with stony extension was performed without cutting the axillofemoral bypass graft. A separate graft was attached to each of the axillofemoral artery bypass grafts to use perfusion sites after transecting the axillo-femoral bypass. Since lower extremity blood flow improved after reconstruction, the axillofemoral artery was transected. The postoperative course was uneventful. Thoracoabdominal replacement after left axillofemoral artery bypass surgery requires some ingenuity in thoracotomy and on extracorporeal circulation.