Background: Flow patterns inside a cuffed anastomosis are influenced by subject-specific 3D geometry. We attempted to evaluate the hemodynamic advantages of femoro-popliteal bypass using a pre-designed cuffed graft by image based computational fluid dynamics (CFD). Methods: 3D geometry was investigated by 3D digital subtraction angiography (3D DSA) and cine-angiography. Local rheological factors at the distal anastomosis were calculated by CFD analysis. The obtained data were compared to the results of calculation in a virtual model of classical end-to-side anastomosis for this case. Results: The distal anastomotic cuff eliminated the low shear stress area which would be observed at the heel of anastomosis created in a conventional end-to-side fashion. Cine-angiography of real cases suggested the beneficially changed flow pattern may enhance the clearance of blood from the anastomosis. Conclusion: Clinical CFD analysis based on 3D DSA demonstrates case-specific local flow dynamics. Image based CFD may add further information on patency estimation.

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The objective of the present study was to survey lower limb amputations in Iwate prefecture (1.4 million inhabitants) performed due to peripheral arterial diseases. We mailed questionnaire annually to 72 institutions that perform general surgery, orthopedic surgery, plastic surgery, cardiovascular, or vascular, surgery from 2002 to 2004. The categories included age, gender, co-morbidities, diagnoses, symptoms, complications and outcome. Sufficient data were received from 88.6% of all hospitals. Between 2001 and 2003, 155 patients, 118 men and 37 women, underwent 161 lower limb amputations. The mean age of the patients was 73.0 years old (range 41-96), the clinical diagnosis was arteriosclerosis obliterans (ASO) in 83.2% of the cases. There were 99 above-knee amputations (AKA, 61.5%), 22 below-knee amputations (BKA, 13.7%) and 40 foot or toe amputations (minor, 24.8%) were performed. The annual incidence of amputations per 100,000 population was 3.7. As age increased, the amputation incidence, especially of AKA patients rose steeply. Sixty-five patients (46.8%) were diabetic, 47 patients (33.8%) had hypertension, and 47 (33.8%) were smokers. Of the patients undergoing amputation, 98.6% had gangrene or ulcer, 42.1% complained of pain of rest, 24.8% had infection at the time of their operation. Postoperative systemic complications included pneumonia (5.2%), cardiac (3.9%), gastrointestinal (3.9%), cerebrovascular (1.3%) symptoms and sepsis (1.3%). Complications of AKA and BKA patients occurred in 20.4% and 18.2%, respectively, and in 2.5% of minor amputations. Wound complications developed in 20 limbs (12.4%) and required 8 revisions (5.2%). Perioperative 30-day mortality rates for AKA, BKA, and minor amputations were 7.5%, 4.5%, and 0%, respectively. Overall postoperative hospital mortality rate was 21.9%, being significantly worse for BKA (36.3%) than minor amputations (10.0%). Patients who had developed systemic complications or contralateral limb ischemia had a significantly higher postoperative mortality rate. Patients undergoing lower extremity amputations, especially major amputations had many underlying co-morbidities, and hence post-operative mortality rates were very high. These data suggest that early detection and preventive risk factor management for critical limb ischemia are essential.

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Autogenous vein bypass grafting for arteriosclerosis obliterans in 246 limbs of 215 cases in the past decade (group R) were compared with those on 256 limbs of 212 cases in the previous decade (group P). There was a significant increase in concomitance of diabetes mellitus, chronic hemodialysis, critical limb ischemia, and paramalleolar bypass in group R than group P. The majority of graft failures, which were mainly caused by poor quality of veins and regional intimal hyperplasia, occurred within 2 years postoperatively in both groups. The 5-year cumulative secondary patency rates were 90.3% in group P and 94.8% in group R, and the 10-year secondary patency rate were 85.6% in group P and 92.6% in group R, respectively. The changes of clinical backgrounds such as an increase of co-morbidity, critical limb ischemia and paramalleolar bypass did not affect the graft patency.

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We perfused the kidneys with cold Ringer's solution during pararenal abdominal aortic aneurysm (AAA) surgery requiring suprarenal aortic cross-clamping, aiming to protect renal function. From January 2001 to October 2005, 15 patients, excluding patients on hemodialysis, underwent pararenal AAA surgery that required some form of suprarenal aortic cross-clamping and perfusion with cold Ringer's solution. The average patient age was 72±6 years, and all were men. Maximum AAA diameter was 54±8 mm. A transperitoneal approach was selected for all. Of 11 who underwent bilateral suprarenal aortic cross-clamping, both renal arteries were perfused with cold Ringer's solution in 7, and one artery in 4. In the 4 patients undergoing unilateral suprarenal aortic cross-clamping, the affected renal artery was perfused in all. Two patients had aneurysms that required renal artery reconstruction. Duration of renal exclusion was 46±23 min. Although delayed bleeding necessitated repeat laparotomy in 1 patient, no hospital deaths occurred and no patient needed to begin hemodialysis. Mean postoperative blood urea nitrogen (BUN) and serum creatinine (CRE) were 20.6±7.2 mg/dl and 1.43±0.80 mg/dl respectively, both significantly higher than preoperative levels (P=0.046 and 0.02, respectively). However, BUN and CRE soon returned to preoperative serum concentrations. BUN and CRE did not differ significantly between patients with prolonged renal ischemia (≥45 min) and those with briefer ischemia at any time. Duration of renal ischemia and postoperative percent change in BUN and CRE were unrelated except in patients with renal ischemia exceeding 60 min. Thus, perfusion with cold Ringer's solution proved safe and effective, in protecting renal function.

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We report 2 surgical cases of mycotic abdominal aortic aneurysm (MAAA). One combined with psoas abscess and vertebritis caused by Salmonella underwent axillo-bifemoral bypass with curettage of abscess lesions of the vertebral body followed by autologous bone transplantation. The other caused by Streptococcus pneumoniae which was thought to be in an early stage of the disease underwent resection of the aneurysm and in situ prosthetic graft replacement, and omentopexy around the graft. Their postoperative courses were good and no recurrence of infection was seen in either patient. MAAA is rare but has high mortality and it requires surgical treatment. Resection of the aneurysm, in situ reconstruction, and omentopexy is desirable but when infection is severe, extra-anatomical reconstruction should be considered as a surgical option.

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A volleyball player who complained of right upper extremity ischemia caused by embolism from the injured thrombotic posterior circumflex humeral artery (PCHA) is presented. The patient was a 28-year-old man who suffered from ischemic symptoms in the right hand and fingers. Plethysmography showed flat waves in all the right fingers, and arteriography revealed thrombotic occlusion of the PCHA at its origin, and re-visualization of its peripheral branches through a collateral network. Based on these findings, a diagnosis of thrombotic occlusion of the PCHA resulted from chronic injury caused by repeated powerful motion like throwing movement of the right upper extremity, and distal embolism from the PCHA was established. To prevent recurrence, ligation of the root of the PCHA was successfully performed. If athletes complain of upper extremity ischemia, urgent angiography should be performed for early diagnosis and proper treatment to prevent further progression of the ischemia.

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A 79-year-old man had a ruptured atherosclerotic aneurysm of the left circumflex femoral artery or deep femoral artery. The left superficial femoral artery was occluded. If aneurysmectomy and suture closure were to be performed, the left deep femoral artery might be stenotic. So we performed artificial patch plasty after aneurysmectomy to maintain the collateral blood source of the left lower limb. Five years after the initial operation, he was re-admitted for pseudoaneurysm in the left groin area. After resection of the aneurysm, graft interposition was successfully performed. Aneurysms of the medial circumflex femoral artery are very rare. They are mainly caused by osteotome injury and retractor trauma during hip surgery.

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We operated on a 84 year-old man with a gastroduodenal artery aneurysm of 4.5 cm. Since catheter-based treatment was contraindicated due to his severe allergic reaction to iodine, surgery was the only way to treat the aneurysm. This kind of aneurysm may blow out even with a diameter of less than 1 cm and therefore aggressive treatment must be considered.

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We report a rare case of a 49-year-old woman with Buerger's disease who underwent revascularization of the upper limb used autologous basilic vein graft. She complained of coldness, dullness, and arm claudication of her left forearm, and she felt inconvenience in her everyday life. Axillo-brachial bypass using an autologous vein graft was performed. When there is an artery which we can rebuild for superior limb Buerger's disease, we think that we should consider revascularization.

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We report a case of vascular Behçet's disease in a 26-year-old man complicated by peripheral aneurysms in 4 locations over 8 years. The patient was given a diagnosis with Behçet's disease at age 18, at which time he underwent ligation for a right anterior tibial artery aneurysm. At age 19, he underwent aneurysmorrhaphy for a right posterior tibial artery aneurysm and aneurysmectomy with end-to-end anastomosis for a left radial artery aneurysm. The postoperative course was uneventful. There was no relapse. In September 2005, he felt a pulsating mass on the dorsal aspect of his right knee joint. A popliteal artery aneurysm was diagnosed by echography. A computed tomography scan revealed a saccular aneurysm with a maximum transverse diameter of 5 cm. Aneurysmectomy and replacement were performed by end-to-end anastomosis using a great saphenous vein graft. The patient made good progress following surgery without any complications. Behçet's disease was in remission before surgery and pathological results after showed no significant inflammatory findings.

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