Congenital factor V deficiency is an uncommon bleeding disorder that necessitates hemostatic correction before surgery. We herein describe a patient with severe factor V deficiency who underwent successful off-pump coronary artery bypass grafting with a transfusion of fresh-frozen plasma.

We describe a rare complication and treatment progression that occurred in a 64-year-old man with an aortic abdominal aneurysm AAA that had been treated by endovascular aneurysm repair EVAR. He had undergone EVAR to treat an infra-renal type AAA 21 months previously and returned to the emergency department with back pain. Contrast-enhanced computed tomography CT revealed acute type B aortic dissection, so he was admitted and conservative medical management was started. Acute stomachache and limb pain appeared on hospital day 7, which prevented him from moving his lower limbs. The main body of the stent graft had collapsed, blocking blood flow, and contrast was not found in arteries from the collapsed stent graft portion to the knee level on emergency contrast CT images of the leg. His legs were revascularized by an extra-anatomical right axial-bilateral external iliac bypass. His symptoms disappeared and reperfusion injury was avoided. The collapsed stent graft had retained its original shape at 11 and 18 days after surgery. Furthermore, follow-up CT 4.5 years later showed that the stent graft retained its original form.

We report a case of a 55-year-old male with type B-chronic aortic dissection. Patient presented with intermittent claudication due to limb malperfusion resulting from expansion of a patent false lumen during walking regardless of normal range ankle-brachial index (ABI) at rest. Preoperative stress vascular ultrasonography was an effective modality for proper diagnosis. We should be concerned of reversible ischemia due to the dissection fl ap in patients with type B aortic dissection. Fenestration of the aorta can be a choice of treatment in such patients. The patient has been doing well with no ischemia for 3.5 years after the operation. Key words: chronic aortic dissection, aortic fenestration, limb malperfusion Case ReportA 55-year-old man with a history of type B aortic dissection suffered 1.5 years ago, presented with intermittent claudication was referred to our hospital. The ABI of this patient at rest in the supine position was within the normal range. Right ankle-brachial index (ABI) was 1.07, left one was 1.05. However, the ABI worsened after walking exercise (Fig. 1a). Right ABI turned down to 0.55, left ABI turned down to 0.57.Intermittent claudication started at distance of approximately 50 meters.Computed tomography revealed that the false lumen was patent and that a dissection fl ap extended to the terminal aorta. The true lumen was compressed by the false lumen and was narrowed.Mobile fl ap was detected near the terminal aorta by vascular ultrasonography, and blood fl ow to the bilateral limb was maintained without decrease in the ABI. However, a stress vascular ultrasonography performed after a 6-min walking exercise revealed that the subtotal occlusion of the true lumen in the terminal aorta caused by the expansion of a patent false lumen (Fig. 2). Furthermore, blood fl ow to the bilateral limb was reduced with simultaneous decrease in bilateral ABI.We performed surgical resection of the fl ap in the terminal aorta under laparotomy. During the procedure, the dissection fl ap was found extended to 15 mm in the proximal position to the terminal aorta bifurcation. The distal edge was blind with a mural thrombus, though a small re-entry was present (Fig. 3). After fenestration, aortotomy was closed with 4-0 Prolene sutures reinforced with a 10-mm-width felt strip.His symptom resolved following the operation. Achievement of functional recovery by this surgical treatment was confi rmed by a stress ABI (Fig.1b) and stress vascular ultrasonography performed after a 6-min walking exercise. Thermography after a walking test showed increased blood fl ow in the lower extremities, compared to the fl ow before the test. Enhanced computed tomography revealed

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