Objective: Penetrating atherosclerotic ulcer (PAU) of the aorta is defined as an atherosclerotic lesion with ulceration of the aortic intima and media and rupture of the internal elastic lamina. PAU induced aortic dissection, aortic rupture, and secular aortic aneurysm and typically occurs in elderly hypertensive patients with severe atherosclerosis. Although it has been reported that atherosclerosis similarly occurs in the abdominal aorta, its natural history and treatment are still unclear. This study investigated the clinical features, natural history, and treatment of PAU of the abdominal aorta.
Method:Between April 2006 and March 2009, 4 diagnoses of PAU in the abdominal aorta were made by computed tomography (CT) and magnetic resonance imaging (MRI). These 4 cases were analyzed along with 61 previously reported cases from the literature with diagnoses of PAU in the abdominal aorta, aortic rupture, and isolated abdominal aortic dissection over the past 15 years, giving a total of 65 cases.
Results:The patients were men with an average age of 63.5 years. All 4 had hypertension, and 2 had concomitant coronary artery disease. Two patients were asymptomatic, and the other 2 were symptomatic and transmural rupture had occurred. All diagnoses were made by CT and MRI. All 4 patients underwent open surgery with a knitted Dacron graft, with no postoperative deaths. In the literature, 53% of cases were symptomatic, including pain (40%, n = 26), shock (4.6%, n = 3), and lower limb embolism (9.2%, n = 6). The remaining 40% of cases were asymptomatic (n = 26). Six patients were treated medically, while 58 patients underwent surgery, with 2 postoperative deaths.
Conclusion:We suggest that surgical treatment (open surgery or endovascular stent grafting) should be performed to prevent an aortic catastrophe such as intramural hematoma, dissection, or rupture. (English translation of Jpn J Vasc Surg 2010; 19: 723-730.)

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Objectives: Early and mid-term results of stent graft (SG) treatment for thoracic aortic aneurysms (thoracic endovascular aneurysm repair: TEVAR) were retrospectively compared with open surgical treatment.
Methods: The records of 213 patients in whom single thoracic aortic aneurysm repairs had been performed in our department from January 2006 through August 31, 2009 were reviewed. Acute aortic dissection was excluded. Each case was reviewed for indications for TEVAR from an anatomical standpoint. Among 62 cases in which TEVAR was indicated, 30 (SG group) were treated by TEVAR and 32, by open surgery (OP group). Early and mid-term results were analyzed retrospectively in both groups.
Results: There were no operative deaths in either group. The SG group demonstrated significantly less operative bleeding, a shorter operative time, and shorter postoperative hospital stay compared with the OP group. There were 3 deaths in the SG group and 4 in the OP group, which occurred within an average of 656.4 days during the follow up period. The 3 year actuarial survival rate was 88.7% in the SG group and 87.1% in the OP group, and there were no significant differences between the groups.
Conclusion: Although early and mid-term results of TEVAR and open surgery were similar, TEVAR is generally less invasive and may be preferable for high-risk patients, compared with open surgical repair. (English Translation of Jpn J Vasc Surg 2010; 19: 51-56.)

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Background: Endovascular aneurysm repair has gained widespread acceptance, and there has been a significant increase in the number of aneurysms treated with stent grafts. However, the endovascular technique alone is often not appropriate for anatomically complex aneurysms involving the neck branches. We used the TAG stent for thoracic aortic aneurysms (TAA), and report our initial results.
Patients and Results: We deployed 80 TAG stents in 65 patients electively treated with TAA between June 2006 and June 2008. Thoracic endovascular aneurysm repair (TEVAR) was performed in 45 cases of descending aortic aneurysm with no morbidity or mortality. A combination of open surgery and TEVAR was performed in 11 out of 20 cases with aneurysms of the aortic arch. The prior total arch replacement and elephant trunk procedure was performed in 3 cases with dilated ascending aorta, total debranching from ascending aorta with sternotomy in 5, and carotid-carotid artery crossover bypass in 3 cases. Meanwhile, TEVAR with coverage of the left subclavian artery was performed in the remaining 9 distal arch cases. In 3 cases with extremely short necks, a 0.018” guide wire was inserted percutaneously in a retrograde manner through the common carotid artery (CCA) into the ascending aorta to place the stent graft in close proximity to the CCA (wire protection). In 1 of these 3 cases, the TAG stent was deployed through the CCA, and the 0.018” guide wire was used to deliver a balloon-expandable stent in order to restore the patency of the CCA. In arch and distal arch aneurysm cases, perioperative mortality and the incidence of stroke were both 5.0%; dissection of the ascending aorta was seen in one case (5.0%).
Conclusion: As treatment for descending aortic aneurysms, TEVAR can replace conventional open repair. However, TEVAR for arch aneurysms has some problems, and further improvement is necessary. (English Translation of Jpn J Vasc Surg 2010; 19: 547-555.)

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Objective: We evaluated the outcomes of bypass surgery for revascularization in cases of critical limb ischemia with the distal anastomotic site at or below the ankle; we focused on the differences in outcomes between 2 groups having different proximal anastomotic sites.
Patients and Methods: Out of 270 cases diagnosed with critical limb ischemia from January 2003 to October 2009, bypass surgeries with the distal anastomotic site at or below the ankle were performed on the limbs of 69 patients (75 limbs). These cases were classified on the basis of the proximal anastomotic sites: group F (n = 50) where the common femoral artery was the proximal anastomotic site and group P (n = 25) where the below-knee popliteal artery was the site.
Results: The 5-year cumulative primary/secondary patency rates were 69.3%/81.8% for group F and 68.7%/84.9% for group P. The 5-year cumulative limb salvage rate was 97.9% in group F and 80.3% in group P.
Conclusion: Among the cases reviewed, results were comparable between cases with the proximal anastomotic site at the below-knee popliteal artery and those with the site at the common femoral artery.

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Purpose: To examine the relationship between the incidence of later cardiovascular events after abdominal aortic aneurysm (AAA) surgery and postoperative lipid levels.
Methods: Atherosclerotic risk factors including postoperative serum lipid levels were examined in 116 patients aged 70 or less undergoing an elective AAA surgery. Later cardiovascular events after AAA surgery occurred in 21 patients, including cerebral infarction (n = 4), catheter intervention or surgery for coronary artery disease (CAD) (n = 10) and other vascular disease.
Results: Postoperative cholesterol levels during the average follow-up period of 55.6 ± 44.3 (months) were 49.0 ± 15.7 (mg/dL) for high-density lipoprotein cholesterol (HDL-C), 97.9 ± 31.2 (mg/dL) for low-density lipoprotein cholesterol (LDL-C), which were both significantly improved compared to preoperative values (p <0.001). Cox hazard analysis indicated that preexistent CAD significantly increased in the risk for later cardiovascular events (hazard ratio 5.67; 95%CI 1.92-16.8; p = 0.002) and lowered postoperative LDL-C/HDL-C ratio <1.5 decreased in the risk after AAA surgery (hazard ratio 0.10; 95%CI 0.01-0.83; p = 0.033). Patients with postoperative LDL-C/HDL-C ratio <1.5 (n = 22) had a significantly better cardiovascular event-free rate than those with that ratio >=1.5 (n = 94) (p = 0.014).
Conclusion: Lowered postoperative LDL-C/HDL-C ratio <1.5 can decrease in the risk for later cardiovascular events after AAA surgery. These results may support the rationale for postoperative aggressive lipid-modifying therapy.

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Three of four (75%) vein biopsy samples from four patients (all male, mean onset: age 33.0, mean biopsy: age 59.7) of chronic phase phlebitis migrans showed positive periodontal bacteria DNA under the PCR (polymerase chain reaction) method.Of the 24 cases of Buerger disease (22 males, 2 females, mean onset: age 31.9, mean examination: age 62.6) that were investigated in our vascular laboratory, 65% of the patients suffered from moderate to severe varicose veins. Eight cases had a history of phlebitis migrans and three had an active ulcer or uncontrollable erosion in the foot. The rate of incidence was significantly higher than that of the well-matched control group. Other findings included one instance of deep vein thrombosis, and one instance of deep vein reflux.We could suggest that some intractable ulcer or erosion cases of Buerger disease may be complicated by superficial vein incompetence or other deep vein insufficiency. We also we need to check Buerger disease patients with duplex for vein reflux and other insufficiencies. Treatment of the varicose veins (including elastic stockings) was effective for all of the patients. (English Translation of Jpn J Phlebology 2011; 22: 25-31.)

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Purpose: Efficient and secure collection of CD34+ cells are crucial for the angiogenic therapies. We have developed autologous peripheral blood-mononuclear cell (MNC) transplantation induced by erythropoietin (rhEPO) for critical ischemic limbs.
Methods: Seven patients, including five with arteriosclerosis obliterans, one with Buerger's disease and one with progressive systemic sclerosis, underwent ten cell therapies. The first administration of rhEPO was performed two weeks before apheresis, and the second administration and blood donation were performed one week before apheresis to activate bone marrow. MNCs including CD34+ cells, isolated from peripheral blood by apheresis, were immediately injected intramuscularly into ischemic limbs.
Results: The number of peripheral blood-CD34 + cells had significantly increased from 1.32 ± 0.83/microL, before the rhEPO induction, to 1.86 ± 0.94/microL, before the apheresis. The number of transplanted MNCs ranged between 0.5 × 10⁹ and 16.5 × 10⁹, and that of CD34+ cells, between 0.1 × 10⁶ and 12.7 × 10⁶, accounting for 0.02%-0.1% of MNCs. There were no serious complications. Finger ulcers with Buerger's disease were significantly improved one month after the transplantations, but the same or other ulcer(s) appeared 2-6 months later. Three patients had an improvement in rest pain, and one patient extended maximum pain-free walking distance.
Conclusions: Erythropoietin-induced autologous peripheral blood-MNC transplantation is a useful and safe alternative for ischemic limbs.

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Three cases with lesions in the right aortic arch (RAA) are presented. For two patients, whose RAA contained a retroesophageal segment, the primary treatment was total arch replacement (TAR) for acute type A dissection or severe arch angulation with thoracic endovascular aneurysm repair (TEVAR) as second-stage surgery. The third patient, who had RAA with mirror image branching, underwent supra-aortic bypass followed by TEVAR. There was no operative mortality, but the condition of two patients who underwent TAR was complicated by bilateral recurrent nerve palsy, which can be critical. The combination of TEVAR and supra-aortic bypass might thus be preferable for patients with RAA.

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Although the Angio-Seal arterial closure device is widely used for preventing bleeding and facilitating early ambulation after arterial puncture, it is also associated with unique complications, such as stenosis, occlusion, or peripheral embolism. We report the first case of a foot ulcer that developed 70 days after an Angio-Seal application. The collagen sponge component accidently positioned itself in the arterial lumen and was not absorbed. A foreign body reaction was observed microscopically. In patients with arteriosclerosis, the Angio-Seal device should be used carefully; post procedural monitoring is necessary after implantation.

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The optimal surgical management of patients with concomitant abdominal aortic aneurysm (AAA) and gastrointestinal malignancy remains controversial. A 79 year-old man who presented with hematemesis was found to have advanced gastric cancer concomitant with infrarenal AAA. The patient underwent simultaneous endovascular aneurysm repair (EVAR) and distal gastrectomy. The postoperative course was uneventful. The present case illustrates the clinical utility of EVAR for the high-risk patient with concomitant AAA and gastrointestinal malignancy.

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Purpose: To share our hybrid endovascular experiences using chimney or sandwich stent grafts for acute aortic arch pathologies.
Methods: Hybrid procedures for a distal aortic arch aneurysm and an ascending anastomotic aortic aneurysm rupture were reported. Right to left common carotid and left axillar artery bypasses were located. Covered stents were inserted into the inominate artery, with the flow-proximal end located in the ascending (standard chimney) or the descending aortic stent graft (retrograde sandwich).
Results: Both cases had no signs of brain ischemia. Aneurysms are decreasing in size.
Conclusion: Chimney and sandwich techniques were technically feasible in the complex and acute situations.

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Iatrogenic acute aortic dissection during percutaneous coronary intervention is an extremely rare, but critical complication. Localized aortic dissections have been treated by sealing the entry with a coronary stent. Extensive dissections may require a surgical intervention. We present a case of type A extensive aortic dissection occurring during angioplasty of the left circumflex artery for acute myocardial infarction. This iatrogenic aortic dissection required emergent surgical repair with supracoronary replacement of the ascending aorta.

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Aneurysms of the intrathoracic subclavian artery are extremely rare. A 74 year-old man was referred to our hospital with an abnormal chest X-ray film. Contrast computed tomography revealed an intrathoracic left subclavian artery aneurysm. Via left 4th posterolateral thoracotomy, the aneurysm was exposed under systemic deep hypothermia and circulatory arrest. The distal arch was replaced with a 26 mm single-branched graft and the left subclavian artery was reconstructed with a 10 mm graft.

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A persistent left superior vena cava (PLSVC) is the most common thoracic venous anomaly, and we should be aware of its existence. We encountered a case of significant left arm swelling due to recurrent left subclavian venous stenosis in a hemodialysis patient with a PLSVC. Endovascular stent placement was performed safely and effectively for the stenosis employing the pull-through technique, in which a guidewire was passed from the left internal jugular vein to the access vein. On the following day, left arm swelling had improved. 3 months after stent placement the left arm swelling has not recurred.

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A 50 year-old man with no significant medical history was admitted for dyspnea and left femoral swelling. Contrast-enhanced computed tomography revealed pulmonary thromboembolism (PTE) and a thrombus in the inferior vena cava (IVC). The thrombus extended from the proximal IVC to the left popliteal vein. Therefore, we decided that an IVC filter insertion was difficult to indicate. Urgent IVC and peripheral vein thrombectomy was performed under cardiopulmonary bypass. On postoperative day 1, venous ultrasonography showed residual deep vein thrombosis in the left external iliac-femoral vein and the popliteal vein. The IVC filter insertion was performed to prevent the recurrence of PTE.

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A 71 year old man was diagnosed to have enlargement of abdominal aortic aneurysm due to type 2 endoleak two years after endovascular aneurysm repair (EVAR). 3D-CT demonstrated a type 2 endoleak that originated from the superior mesenteric artery that fed the inferior mesenteric artery and the right iliolumbar artery that flowed into the 4th lumbar artery. Transarterial embolization was performed by means of N-butyl-2-cyanoacrylate (NBCA). After the treatment, he suffered ischemic colitis that extended from the sigmoid colon to the descending colon. Conservative treatment was mainly performed, and clinical improvement was observed over time. He was discharged after 73 postoperative days.

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We report a case of a patient with late-onset primary lymphangiectasia whose persistent diarrhoea was successfully managed with octreotide. A 63 year-old man visited our clinic with a complaint of worsening general edema. Gastrointestinal endoscopy revealed typical whitish jejunal villi, which suggested primary intestinal lymphangiectasia. Despite a diet, supplemented with medium-chain triglycerides; antiplasmin therapy; oral corticosteroids; and surgery, including pericardial window and lymphaticovenous anastomoses; his symptoms, including watery diarrhoea, showed no improvement. After administration of octreotide, his persistent diarrhoea resolved within a couple of days. Octreotide was continued for 2 months. Thereafter, his diarrhoea has not recurred for 6 months.

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Hepaticartery pseudoaneurysms are a rare complication of chronic pancreatitis. However, giant pseudoaneurysms (80 mm) and complicated biliary obstructions are extremely rare. This article reports a 75 year-old man with chronic pancreatitis that presented as upper abdominal pain and obstructive jaundice. Computed tomography revealed a hepatic artery pseudoaneurysm measuring 80 × 72 × 70 mm. We performed aneurysm resection and common hepatic artery bypass, using a great saphenous vein graft in the patient. The postoperative course was uneventful, and he was discharged on the 10th postoperative day. However, on the 135th postoperative day, he died of massive hemorrhage into the peritoneal cavity.

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We report a patient with inflammatory abdominal aortic aneurysm who underwent endovascular aneurysm repair, despite his having an allergy to iodinated contrast medium and anatomy unsuitable for the procedure. Intravascular ultrasound-guided and CO₂-assisted aortic stent graft placement was performed, and the procedures resulted in the successful exclusion of the aneurysm with regression of the mantle sign and resolution of hydronephrosis.

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Wereport a rare case of ruptured intercostal arteriovenous fistula in a patient with neurofibromatosis type 1. The patient presented with severe back pain. Angiography revealed ruptured intercostal arteriovenous fistulas. Successful coil embolization to occlude the fistulas and the aneurysm resulted in successful recovery of the patient.

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