The current worldwide trend in the treatment of peripheral arterial disease (PAD) is towards an increase in endovascular procedures either in the aorto-iliac area or in the infrainguinal district. However, the role of the open repair with a femoro-popliteal bypass is still debated and in our opinion there still a room for traditional surgery in the presence of complex lesions involving the superficial femoral artery and the popliteal and tibial vessels. In this field, vein bypass provides better results than prosthetic grafts, but in selected cases and not only in the absence of a suitable vein, new modified grafts may be used with satisfactory results. The choice between the two options, open and endovascular, that in some cases can be associated in hybrid procedures, depends on several factors. Only if we are able to take into account all the different preoperative issues, we could choose the right procedure in the right patient.

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Restenosis is the major drawback in patients undergoing tibial angioplasty. In contrast to earlier observations, tibial patency was shown to impact on clinical outcomes in current randomized trials and is thus attributed more importance. Accordingly, intentions to reduce tibial restenosis have been intensified. Both drug-eluting balloons (DEB) and drug-eluting stents (DES) were shown to reduce tibial restenosis when compared with its plain counterparts. However, both endovascular technologies have its limitations for tibial arterial application. While DEB technology may not address elastic recoil, a pathophysiological mechanism frequently observed in tibial arteries and a significant contributor to restenosis, currently available DES do not fully address tibial arterial lesion morphology. Purpose of the present manuscript is to outline the problem and the incidence of tibial arterial restenosis, its importance on clinical outcomes and to provide an overview on technical developments aimed at its prevention.

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Objective: To evaluate the incidence of wound complications after the retroperitoneal approach for abdominal aortic aneurysm (AAA) repair, and to ascertain the cause of abdominal bulge (AB).Subjects and Methods: Forty-three patients with AAA repair via the retroperitoneal space were retrospectively investigated. Wound complications and their incidence were studied by chart review. The thickness of the abdominal wall muscle was measured by follow-up computed tomography films. Compound muscle action potentials (CMAPs) of the abdominal rectus muscle were examined for three bulge patients and three non-bulge patients.Results: Wound hypoesthesia (30%), wound numbness (21%), AB (7%), and wound pain (2%) were found in these patients. The thickness of the abdominal wall muscle was reduced in the incision side. CMAP of abdominal rectus muscle in the incision side disappeared only in AB patients.Conclusions: (1) Wound hypoesthesia and numbness displayed a high incidence. (2) Atrophy of the abdominal wall muscle in the incision side was found in these patients. (3) The cause of AB is considered to be muscle atrophy induced by denervation injury of an 11th intercostal nerve. (4) To avoid an eleventh intercostal nerve injury must be deemed the most effective method for preventing AB.

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Objectives: To elucidate the differences in subcutaneous ultrasound findings between dependent edema (DE) and secondary lower extremity lymphedema (LE).Materials and Methods: Twenty legs in 10 patients with DE and 54 legs in 35 patients with LE, who first visited our clinic between April 2009 and December 2012, were studied retrospectively. Subcutaneous echogenicity and echo-free space (EFS) were assessed at 8 points on the thigh and leg using an 8–12 MHz ultrasound transducer.Results: In DE, echogenicity was increased most in the lower leg, without a difference between the medial and lateral side. The EFS was most remarkable in the lower leg, and the lateral side was more severe. In the early stages of LE, echogenicity was similarly increased in the medial thigh and in the leg, while remarkable EFS was observed only in the lower leg. As clinical severity progressed, echogenicity increased in all parts of the lower extremity. EFS also increased in all parts of the leg, but the lower leg was still the most severe.Conclusion: Echogenicity seemed to progress differently in DE and LE, but EFS progressed similarly and according to gravity. The current ultrasound findings may have added some diagnostic value in differentiating these conditions.

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Objective: To evaluate the long-term outcomes of surgical treatment for popliteal artery entrapment syndrome (PAES).Materials and Methods: This study was undertaken from a retrospective review of case notes of patients treated for PAES between August 1974 and July 2013. We examined patients’ characteristics and surgical procedures, and evaluated long-term outcomes including clinical symptoms and graft or native artery patency.Results: Twenty-nine limbs (24 patients, mean age: 32 years) underwent surgery. Popliteal arteries were occluded (n = 18) stenosed (n = 7) and normal (n = 4). Twenty-five limbs required both revasularization (interposition [n = 24] and bypass surgery [n = 1]) and myotomy. Four limbs were treated solely with myotomy. During the long-term follow-up period, three limbs required reoperation. The overall primary graft and native popliteal artery patency rates at one and 5 years were 96.3% and 91.9%, respectively.Conclusion: The treatment of PAES with myotomy and selective revascularization achieves good short- and long-term outcomes. The use of an interposition vein graft reconstruction is associated with minimal morbidity and good long-term patency.

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Introduction: We retrospectively analyzed outcomes of patients who had undergone endovascular aneurysm repair (EVAR) for abdominal aortic aneurysm (AAA) more than 3 years previously in a single institution. We compared outcomes between patients who underwent EVAR within and outside of the devices’ instructions for use (IFU) and examined mid-term morphological changes in AAA.Methods: A total of 275 patients who underwent EVAR for AAA were selected. IFU parameters included aneurysmal neck length, angulation and presence of massive atheroma. Patients were divided into 2 groups: the Within IFU group (W-IFU: n = 193) and the Outside of IFU group (O-IFU: n = 82).Results: Patients in the O-IFU group were older and had a larger AAA diameter. Other comorbid factors were similar between the 2 groups. There was no difference in overall survival rates and reintervention rates between the 2 groups. The most common cause for reintervention was AAA enlargement 3 years after EVAR. Irrespective of the IFU, mid-term morphological changes, including neck angulation, neck diameter, sac re-expansion, and Palmaz stent displacement, were found.Conclusion: Outcomes of EVAR were considered acceptable in the O-IFU group. Careful follow-up is necessary considering the morphological changes in AAAs after EVAR.

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Background: Chronic diabetic foot ulcer has a high rate of healing failure. Beraprost sodium, oral form of prostaglandin I₂ analogue, maybe used for increasing wound healing.Objective: To compare the healing rate of chronic diabetic foot ulcer between Beraprost sodium and control groups.Design: A single blind randomized trial.Materials and Methods: Fifty non-healed chronic diabetic foot ulcer patients were randomized to be the study and control groups. Beraprost sodium was prescribed in the study group according to protocol.Results: At 6th week follow up, median wound healing rate in the study group was significantly higher than in the control group with the rate of 88.1% and 33.3%, respectively. Complete wound healing in the study group was also significantly higher than in the control group (48%:8%). In the study group, 9 patients (37.5%) could be administered with recommended dose. Side effects were headache in 14 patients (58.3%) and palpitation in one patient (4.2%). One patient was discontinued for severe headache.Conclusions: The use of Beraprost sodium in chronic diabetic foot ulcer patients significantly increases the wound healing rate. Headache was the common side effect.

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Objectives: This study was evaluating the outcomes of endovascular aneurysm repair (EVAR) using the endowedge technique (EnT) and/or snorkel technique (SnT) for abdominal aortic aneurysms (AAAs).Materials and Methods: The patients treated with EnT and/or SnT were retrospectively reviewed between January 2010 and June 2013. All patients underwent EVAR under general anesthesia. Bilateral femoral arterial access was obtained through bilateral femoral cut-down to place the stent graft mainbody, and brachial arterial access was obtained percutaneously to perform the EnT and/or SnT.Results: Three patients were treated with unilateral EnT, 1 with unilateral SnT, two with bilateral SnT, and two with combined EnT/SnT. A total of 12 renal arteries was attempted to preserve, and could be successfully performed by these techniques in 11 renal arteries. After complete deployment of the endograft, intraoperative angiography showed no type Ia EL. During the median follow-up of 11 months (range: 2–22 months), no deaths nor aneurysm enlargement occurred, and all treated renal arteries were patent without further intervention.Conclusions: Our findings suggest that the management of AAAs by EVAR with EnT and/or SnT could achieve an adequate proximal seal, and preserve renal artery perfusion in patients with unfavorable neck anatomy.

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Introduction: Klippel-Trenaunay syndrome is composed of port-wine stain, limb hypertrophy and varicose veins.Methods: The two patients with Klippel-Trenaunay syndrome treated by endovenous radiofrequency thermal ablation and ultrasound-guided foam sclerotherapy of the abnormal veins was conducted.Results: Radiofrequency thermal ablation resulted in successful occlusion of the incompetent anterior accessory great saphenous vein. Moreover, ultrasound-guided foam sclerotherapy showed complete occlusion of the residual veins. At 6 month follow-up, both patients markedly decreased leg symptoms including pain, cramping, limb swelling, and bulging of veins.Conclusion: Radiofrequency thermal ablation combined with foam sclerotherapy is a minimally invasive procedure alternative to the standard invasive surgery and can be the option for saphenous ablation in Klippel-Trenaunay syndrome patients.

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A 4-year male was referred to our hospital for high fever. Incidentally, abnormally high blood pressure was detected. A thorough examination revealed severe stenosis at the origin of two left renal arteries and elevation of plasma renin activity as well as aldosterone level. Some lesions of previous asymptomatic brain bleeding were also revealed. Instead of using prosthetic materials, we transected renal arteries and directly anastomosed them to abdominal aorta, expecting subsequent growth of native vessels. The postoperative course was uneventful. The plasma renin activity and aldosterone level as well as the dose of antihypertensive drug decreased significantly after the operation.

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We successfully treated small saccular abdominal aortic aneurysms involving the renal artery origin with direct sagittal suture closure under supra-celiac or supra-superior mesenteric artery cross clamping after renal artery reconstruction in two cases. This technique might be a useful option for localized saccular aortic aneurysms in selected cases.

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Isolated spontaneous dissection of the celiac artery (DCA) is extremely rare and its therapeutic strategy is still not established. We report two cases of DCA, in which 58-year-old and 43-year-old male patients with right hypogastralgia and back pain, respectively, were diagnosed by enhanced computed tomography and treated conservatively with antihypertensive agents. They were doing well under circumspect medical management without recurrence of symptoms or progression of dissection after 3.5 years and 3 months, respectively, after detection of DCA. Conservative treatment with blood pressure control and careful surveillance is considered to be applicable in most cases of DCA.

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A 74-year-old woman underwent replacement of the ascending aorta for acute type A aortic dissection. The patient suffered from bacteremia postoperatively and repeated computed tomography showed an increasing diameter of pseudoaneurysms at the site of the proximal anastomosis due to graft infection. Re-mechanical Bentall operation and arch replacement were therefore performed using a composite graft of a rifampicin-bonded gelatin-sealed 24-mm woven Dacron graft and a mechanical valve. The postoperative course was uneventful. We report the successful in situ reconstruction using the above-mentioned Dacron graft and describe the preparation of the rifampicin solution using a surfactant.

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Secondary deep vein thrombosis associated with iliac lymph node metastasis of an unknown primary tumor has not been previously reported. The patient was a 57-year-old male with persistent right leg edema. Computed tomography demonstrated a mass surrounding the right external iliac vessels, and deep vein thrombosis in the right external iliac and femoral veins. Physical, laboratory, and imaging examinations did not reveal any further tumor. The patient was diagnosed with deep vein thrombosis associated with right iliac lymph node metastasis of an unknown primary tumor. Complete resection of the tumor along with the involved vessels and vascular reconstruction was performed.

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We report two cases of graft migration during open stent grafting, detected by transesophageal echocardiography (TEE). The incidence was 3.7% in our series. The length of landing zone was reduced from 45 mm to 25 mm in case 1 and from 50 mm to 22 mm in case 2 before chest closure. Aneurysmal protrusion on the greater curvature with thin mural thrombus were findings common in both cases. Although additional intervention was not done based on the TEE findings of no endoleak and thrombus formation in the aneurysm, and postoperative course was uneventful, meticulous imaging check-up was needed.

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Minimally invasive treatment of cardiovascular disease might decrease the risk of morbidity and mortality for high-risk patients. We describe a patient with concomitant large thoracic and abdominal aortic aneurysms, atrial septal defect (ASD) with heart failure and colon cancer with bleeding. We applied minimally invasive, transcatheter closure of the ASD and a hybrid approach to treat two aortic aneurysms, followed by colectomy. The postoperative course was uneventful with no complications. Minimal invasive treatment for cardiovascular diseases allowed safe and early treatment of malignancy in an elderly, high-risk patient.

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Here, we describe a case of an 83-year-old man treated with percutaneous IIA coil embolization for an enlarging remnant IIA aneurysm. CT scans revealed a contained rupture and persistent flow in the right IIA with the enlargement. We selected percutaneous embolization via the deep iliac circumflex artery, that was communicating with the superior gluteal artery and the IIA. Coil embolization of the arteries supplying the IIA aneurysm was successfully performed with 12 embolization coils placed in the IIA and its branches. The absence of blood flow and shrinkage of the aneurysm were confirmed by CT three months after embolization.

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Patients with compression of the celiac axis by the median arcuate ligament may develop aneurysms in the pancreaticoduodenal arcades. We experienced two cases of ruptured pancreaticoduodenal artery aneurysm associated with this condition. Both patients presented with abdominal pain and shock, and abdominal contrast-enhanced computed tomography showed retroperitoneal hematoma and compression of the celiac axis by the median arcuate ligament. Both patients were successfully treated by coil embolization. Patients with celiac axis compression or stenosis may develop recurrent aneurysms unless revascularization of the celiac axis is performed. Long-term follow-up is required because aneurysms may develop after 10 years or longer.

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