In this study, we retrospectively reviewed 36 cases that required surgical treatment in the femoropopliteal regions (46 regions) because of the development of obstructions after stent placement in these patients. Of the 46, stents were placed in 37 involved regions (80.4%) that included the common femoral and popliteal arteries; such as the common femoral, entire length of superficial femoral, or popliteal arteries, and the anastomosis site created during femoropopliteal (prosthetic graft) bypass surgeries (Group A). In contrast, 9 involved regions (19.6%) did not include the common femoral or popliteal arteries; the stents were primarily localized in the superficial femoral artery (Group B). Symptoms of stent occlusion were more severe in the former group of patients, who subsequently required peripheral artery bypass surgery. These results indicate that placement of stents in the common femoral artery and popliteal arteries should be avoided. (*English translation of J Jpn Coll Angiol 2012; 52: 19-23)

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We reviewed the results of thromboembolectomy, which was performed for the treatment of chronic thromboembolic pulmonary hypertension (CTEPH), 1 year after the operation. We obtained hemodynamic and respiratory data of 60 patients from the 112 patients who were operated at our institute. The hemodynamic parameters such as mean pulmonary arterial pressure (PAP), pulmonary vascular resistance(PVR), and cardiac index (CI) were significantly improved after the operation, and this improvement of pulmonary hemodynamics persisted even a year after the operation. A significant improvement in gas exchange was observed immediately after the operation and a further elevation in the partial pressure of oxygen in arterial blood (PaO2) was observed 1 year after the operation. (*English Translation of J Jpn Coll Angiol 2012; 52: 53-58)

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Measurement of heart rate variability (HRV) is a non-invasive technique that can be used to investigate functioning of the autonomic nervous system, especially the balance between sympathetic and vagal activities. It is reported that dilatation of coronary microcirculation by augmentation of sympathetic nerve activity (SNA) caused by cold exposure was impaired in diabetes. The question of whether or not SNA in HRV could respond to coronary ischemia was evaluated by cold exposure in diabetic rats. It was found that diabetes with weight loss significantly increased SNA both in baseline and cold exposure, compared with control. A correspondence was also found with coronary ischemia. It can be concluded that measurement of HRV may provide useful information regarding the coronary risk of cold exposure in diabetes. (*English translation of J Jpn Coll Angiol 2012; 52: 295-301)

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Calcification of the internal carotid artery (ICA) hinders accurate evaluation of the stenosis by conventional ultrasonography due to acoustic shadow. We examined the relationship between acceleration time (AcT) and ICA origin stenosis. 137 samples (266 vessels) that enforced duplex ultrasonography in our hospital were targeted. The results have shown that there is a significant relationship between AcT and stenosis. AcT of more than 110 msec suggests that the stenosis is more than 60% by the North American Symptomatic Carotid Endarterectomy Trial (NASCET) method. AcT is thought to be useful for the diagnosis of ICA stenosis with calcification. (*English Translation of J Jpn Coll Angiol 2011; 51: 365-371)

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Objective: To assess the influence of diabetes mellitus (DM) and end-stage renal failure on hemodialysis (HD) on the healing time of tissue lesions and blood flow to the foot following a paramalleolar bypass in patients with critical limb ischemia (CLI).
Methods: Consecutive patients with CLI and tissue loss (24 limbs) were followed up retrospectively after paramalleolar bypass, and the healing time of tissue lesions, graft patency, limb salvage and survival rates were analyzed. The blood flow to the foot was assessed by skin perfusion pressure (SPP) pre- and postoperatively. The delta SPP was calculated as the difference between the SPP before and after bypass. The patients were divided into 3 groups: diabetic (DM, n = 9); diabetic and end-stage renal failure on hemodialysis (HD, n = 10); or neither (n = 5).
Results: A total of 15 dorsal and 9 plantar artery bypasses were performed. The median follow up was 7.3 months (range, 1–18 months). No patients required major amputations, and all tissue lesions healed. The mean duration to complete tissue healing of the DM, HD and neither groups was 2.2, 2.5 and 1.2 months, respectively, was and these were not statistically significant. A significant improvement in the delta SPP after paramalleolar bypass was observed in the neither group compared with both the DM and HD groups.
Conclusion: Blood flow to the foot was not sufficiently improved in CLI patients with DM and HD, despite paramalleolar bypass. This may be the cause of the prolonged tissue healing duration of CLI patients with DM and HD. (*English Translation of Jpn J Vasc Surg 2012; 21: 91-95)

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Objective: We here describe our experience with innovative uses of these devices.Patients and Methods: We reviewed treatment outcomes of 310 endovascular abdominal aortic repair (EVAR) and 83 thoracic endovascular aortic repair (TEVAR) cases performed between August 2007 and February 2012. We separately assessed results in elderly and high-risk patients who had a novel procedure. This group included 94 patients who underwent EVAR with IIA embolization, 10 patients who had EVAR and a renal artery chimney procedure for a short aortic neck, 20 patients who had two de-branching TEVAR or Chimney method for thoracic aortic aneurysms (TAA) and 3 patients who had debranching TEVAR for thoracic abdominal aortic aneurysms (TAAA).Results: Of the 393 patients given stent grafts (SGs), 3 (0.8%) died in the hospital, including 1 patient with pneumonia who underwent EVAR and IIA embolization and 1 patient with a cerebral infarction who had TEVAR. Four patients (4.3%) who were treated with EVAR with internal iliac artery (IIA) embolization presented with residual buttock claudication 6 months postoperatively, and 3 patients (3.2%) had onset of ischemic enteritis; however, in all 7 patients, the condition resolved without additional intervention. In the 10 patients who had EVAR and a renal artery chimney method, the landing zone (LZ) was ≤10 mm, but neither endoleak nor renal artery occlusion was observed perioperatively or during midterm follow-up. Of the 20 patients who had a 2-debranching TEVAR, including 9 in whom the chimney method was used with the LZ in zone 0, 1 (5%) had a residual endoleak. In 3 patients with TAAA, we used SGs to cover 4 abdominal branches and bypassed the visceral artery; the outcomes were good, with all patients being ambulatory at hospital discharge.Conclusion: Among innovative SGs treatments, the debranching procedure and the chimney method using catheterization and the coil-embolization technique provided good outcomes, as used in addition to surgical procedures. Aortic aneurysm treatment will become increasingly noninvasive with the continuing development of more innovative ways to use the SGs currently available in Japan. (*English Translation of Jpn J Vasc Surg 2012; 21: 165-173)

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Object: We assessed whether or not deep venous reflux (DVR) improved after short saphenous vein (SSV) stripping was performed in patients with SSV reflux and DVR.
Materials and Methods: Sixty-eight patients with SSV reflux who underwent SSV striping every Monday between 2008 and 2011 at Ryougoku Ashino Clinic were enrolled in this study. Forty-six of the 68 patients were selected for the analysis because they underwent duplex ultrasound examinations before and after the operation. The DVR was classified into four categories: type 0, no reflux; type I, reflux in popliteal vein; type II, reflux from popliteal vein to the middle of the superficial femoral vein (SFV) and type III, reflux from the popliteal vein to the SFV.
Results: There were 23, 13, 2 and 8 patients with type 0, I, II, III before operation, respectively. There were 33, 8, 1, 4 patients with type 0, I, II, III after operation, respectively. There were no changes in 29 patients, improvement in 15 and new DVR in three (type 0 to I).
Conclusion: SSV stripping is feasible in patients with DVR and the DVR might not be deteriorated even though that is performed.

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The prevalence and clinical characteristics of Japanese patients with Buerger disease (thromboangiitis obliterans: TAO) were analyzed based on the Ministry of Health, Labour and Welfare (MHLW) database in 2009. A total of 129 new patients and 3639 patients in follow-up were selected according to the clinical criteria of TAO. The current number of patients with TAO in Japan is estimated at about 4000. The clinical course is relatively favorable, and the rates of limb morbidity and mortality were not completely discouraging.

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Stanford type A and open false lumen are accepted predictors for in-hospital mortality in patients with acute aortic dissection (AAD). However, the association of renal dysfunction on admission with in-hospital mortality is not well known. The aim of this study was to investigate the prognostic value of renal dysfunction in patients with AAD. A total of 250 patients with type B AAD admitted to our institution between January 2003 and August 2011 were enrolled in this study. In multivariate logistic regression analysis, the significant predictors of in-hospital mortality were age (odds ratio [OR] 1.575, 95% confidence interval [CI] 1.078–2.864, p = 0.024), maximum aortic diameter measured by an initial computed tomography (CT) (OR 1.740, 95% CI 1.029–2.940, p = 0.039), decreased enhancement of kidney (OR 7.716, 95% CI 2.335–25.501, p = 0.001) and estimated glomerular filtration rate (eGFR) <60 ml/min/1.73m ² on admission (OR 2.782, 95% CI 1.062–7.283, p = 0.037). In conclusions the results identified a renal dysfunction on admission as the independent predictor of in-hospital mortality in type B AAD. Further investigations are needed to evaluate therapies and strategies for decreasing the deterioration of renal function to improve in-hospital mortality in patients with AAD.

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Purpose: The purpose of this study is to identify the risk factors affecting the high mortality rates associated with the treatment of ruptured abdominal aortic aneurysm (AAA).Methods: In this retrospective study, the subjects consisted of 105 patients who underwent repair of ruptured AAA at our institution from December 1984 to March 2012. We compared the patients of ruptured AAA in survival group with those in death group to evaluate the clinical factors in ruptured AAA mortality.Results: The operative and in-hospital mortality of ruptured AAA patients was 22.9% compared with 1.9% for that of non-ruptured AAA patients. The mean hemoglobin level was significantly lower in death group than in survival group. Intraoperative bleeding volume was significantly higher in death group than in survival group. Cox proportional hazard analysis showed that level 3 or 4 according to the Rutherford classification, preoperative hemoglobin level of less than 9.0 g/dl, intraoperative blood loss volume of more than 3000 ml, postoperative bowel ischemia and class 3 or 4 according to the Fitzgerald classification were significantly associated with high mortality.Conclusion: These findings showed that every effort to maintain preoperative hemodynamic stability reduce volumes of blood loss in operation, and to minimize postoperative deterioration of organ functions would be essential to improve patient survival.

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Objective: The purpose of this study was to review the experience of aneurysms in the upper limbs treated with surgery and assess the outcomes. Materials and Methods: This study retrospectively reviewed the medical records of five patients with upper extremity aneurysms treated with surgical resection at Tokyo Medical and Dental University Hospital between March 2000 and February 2012. These patients were treated with excision surgery either with or without reconstructive surgery.Results: Two of the five patients were males and three were females with a mean age of 52 years (age range: 25–72 years). We treated 2 brachial, 2 ulnar, and 1 radial aneurysms. All aneurysms were excised, and two patients had reconstructive surgery. Three patients had false aneurysms, which included an ulnar artery aneurysm diagnosed as angiolymphoid hyperplasia with eosinophilia. During follow-up period, all grafts were clinically patent, and no cases had recurrent lesions. No patients had ischemic symptoms or any other postoperative complications.Conclusion: Arterial aneurysms of the upper extremities are uncommon, and were most commonly caused by non-traumatic etiology in this series. These aneurysms were excised with or without reconstructive surgery, because of the fear of rupture and embolization. Revascularization can be performed selectively.

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Background: Fenestrated endovascular abdominal aneurysm repair (FEVAR) using branched arteries devices for visceral arteries is increasingly being used for the repair of juxtarenal aortic aneurysms (JAAs) in Europe, United States, Australia, New Zealand, and Asia. This study aimed to evaluate the technical feasibility and short-term results of FEVAR in treating JAAs in Japanese patients.Methods and Results: FEVAR with Cook fenestrated stent-graft (Cook Medical Inc., Bloomington, Indiana, USA) was performed for 5 patients at high risk for open repair of JAA. Seventeen visceral vessels were successfully accommodated with 12 fenestrations, and five visceral arteries with four scallops with a loss of renal artery. In one case, a type III endoleak occurred at a renal artery fenestration, and this had disappeared in the 1-month postoperative computed tomography (CT). The mean follow-up duration was 8 months. Iliac leg occlusion occurred in 1 case, which was treated with thrombectomy and additional leg device deployment. All patients had survived at the end of the follow-up period and continued their outpatient visits.Conclusions: Implantation of a Cook fenestrated stent-graft incorporating the visceral arteries is technically feasible in high-risk Japanese patients with JAA and may be a viable alternative to current methods.

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Behcet’s disease is an inflammatory disorder of unknown cause. It’s a systemic disorder that may affect any system in the body. Vascular system involvement occurs in 25%-30%. The case presented here elicits both venous and arterial complications of Behcet’s disease in the same patient. The patient presented to our emergency with signs and symptoms of ruptured tibioperoneal aneurysm that was treated both medically and surgically.

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A 32-year-old male patient was admitted to the hospital with a pulsing mass of the right palm. He was an electrical construction engineer who frequently used a screwdriver. Computed tomography (CT) examination revealed a 22- × 30-mm saccular aneurysm of the right ulnar artery. The ulnar artery aneurysm was resected, and we could perform direct anastomosis of the ulnar artery. The dilated true aneurysm was compatible with a traumatic origin. A postoperative enhanced CT examination showed smooth reconstruction of the palmar arch. An occupational true aneurysm of the ulnar artery could be treated by resection and direct anastomosis.

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The patient was an 82-year-old man who was found to have a juxtarenal abdominal aortic aneurysm accompanied by a circumaortic left renal vein (CLRV). During dissection of the proximal anastomosis site the CLRV was injured, but was successfully repaired. A graft implantation was performed below the renal arteries. The incidence of CLRV is thought to be rare, however it is found in 7% of cadavers donated for anatomy. CLRV may cause unexpected bleeding by inadvertent dissection of the abdominal aorta. To prevent unexpected bleeding, surgeons should always keep in mind this potential risk when performing surgery.

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We report a modified intercostal artery implantation using the tube of the aortic wall alternative to the Crawford inclusion and Carrel Patch techniques for thoracoabdominal aortic aneurysm repair. Intercostal and lumbar arteries were isolated within a full-thickness excised aortic cuff and tailored into a tube. An 8-mm limb was sewn to the proximal graft and the aortic cuff tube. The distal tube end was sewn to an 8-mm limb and a distal limb was connected to the distal graft. Computed tomography (CT) showed no pseudoaneurysms or aneurysmal expansion but did show patent intercostal arteries at the implantation site more than 5 years later.

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We reported simple partial root remodeling using a graft trimmed twin ”U” shape for extensive dissection into the right/non-coronary sinuses with acute type A aortic dissection with cardiac tamponade, acute myocardial infarction on the right coronary artery and aortic regurgitation. After total arch replacement with frozen elephant trunk technique for distal dissection, partial root remodeling on the non and right coronary sinuses was performed. Postoperative computed tomography (CT) showed well shaped Valsalva sinuses and aortic regurgitation completely disappeared. This technique might become an alternative procedure for aortic dissection severely involving Valsalva sinuses without dilatation on the aortic root.

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A 67-year-old woman admitted with severe hypertension, atrial fibrillation, and dyspnea was found to have hypertension and congestive heart failure due to stenosis of the descending aorta. Atypical aortic coarctation was diagnosed. Extra-anatomical bypass was performed from the ascending aorta to the terminal abdominal aorta and the pulmonary vein was isolated. The graft was arranged to pass through the left thoracic cavity from the pericardium via a transretroperitoneal approach to the terminal abdominal aorta. Direct contact was avoided between the graft and the abdominal organs, and the pressure gradient between the ascending aorta and the abdominal aorta was decreased.

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During endovascular aneurysm repair, interruption of the inferior mesenteric artery (IMA) or internal iliac arteries (IIAs) is thought to be associated with postoperative pelvic ischemic complications, including ischemic colitis. However, preserving the IIA does not guarantee protection against ischemic colitis. We herein report two cases of bilateral common iliac artery aneurysms, which were treated with bifurcated stent grafting with bilateral IIA embolization and simultaneous IMA stent placement to prevent colonic ischemia. This procedure might be effective for both preserving the IMA circulation and preventing ischemic colitis.

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