Purpose: The purpose of this study is to evaluate early and late results of femoro-crural bypass using polytetrafluoroethylene (PTFE)-vein composite grafts or PTFE grafts with distal vein cuffs for arteriosclerosis obliterans (ASO) and to compare those with the results of autogenous vein bypass. Methods: The clinical records of 58 patients who underwent femoro-crural bypass for ASO from December 1998 to December 2005 were retrospectively reviewed. The backgrounds and the results of 28 PTFE-vein composite grafts or PTFE grafts with distal vein cuffs (PTFE-vein) and 30 autogenous vein bypass (AV), including morbidity, mortality, graft patency, limb salvage rate and survival rate, were compared. Results: Average age of patients (76 y.o. vs. 72 y.o.) and the rate of redo operation (32% vs. 7%) were higher and the complication rate of hypertension (71% vs. 93%) was lower in PTFE-vein group. The cumulative primary, secondary patency and limb salvage rate of PTFE-vein were 67%, 74% and 81% at 1 year and those of AV were 83%, 90% and 100% at 2 years, respectively. AV was superior to PTFE-vein in both primary and secondary patency. There was no significant difference in survival rates. Conclusion: AV should be selected as the first choice for femoro-crural bypass, while PTFE-vein can be an alternative procedure for patients with critical limb ischemia whose autogenous vein is not available or not sufficient.

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Background: We evaluated the collateral blood flow to the gluteal muscles using near infrared spectroscopy (NIRS) during operation for abdominal aortic aneurysm (AAA). Methods: Fifty-seven patients who had a graft implant for AAA were divided into two groups on the basis of their first peripherals anastomotic position: common iliac artery (group C) and external iliac artery (group E). A pair of NIRS probes (NIRO-300, Hamamatsu Photonics K.K., Hamamatsu, Japan) were attached on both gluteal regions, and oxygenated hemoglobin (oxyHb), deoxygenated Hb (deoxyHb), and tissue oxygenation index (TOI) were continuously monitored during operation. Recovery time (RT), TOI change ratio in 2 min after the first side declamping of the graft leg (ΔTOI2), the TOI return ratio (TOI of every 5 min after the first declamping of the graft leg-TOI during aortic cross clamping)/(TOI before aortic cross clamping-TOI during aortic cross clamping), and the TOI return ratio at the end of operation were calculated. Results: In the first declamping side, some patients showed difficulty to decide RT, and in the other patients recovery time (RT) was not significantly different between group C and E. ΔTOI2 was 0.12±0.08%/sec in group C and 0.014±0.03%/sec in group E (p=0.0004) and TOI return ratio at 20 min was 1.02±0.18 in group C and 0.75±0.26 in group E (p=0.0005). Though the TOI response of group E was slower and lower, TOI return ratio at the end of operation rose up 0.90±0.14. The collateral blood flow from deep femoral artery (DFA) to the gluteal muscles was detected in all patients of group E. On the contralateral side, collateral blood flow from the contralateral internal iliac artery (IIA) at the first declamping was detected in some patients. RT could not be calculated. ΔTOI2 was 0.009±0.017%/sec in group C and -0.001±0.009%/sec in group E (p=0.097), and the TOI return ratio at 20 min was 0.26±0.36 in group C and 0.11±0.25 in group E (p=0.254). These parameters showed no significant difference between group C and E. Only one patient among two groups showed postoperative ischemic complication, that is buttock claudication, and he had showed the lowest TOI return ratio (0.48) at the end of operation. Conclusion: When one side of IIA is sacrificed, the collateral blood flow to the gluteal muscles is thought to come from ipsilateral DFA, contralateral IIA, and contralateral DFA, and our study showed that the ipsilateral DFA is the most important collateral vessel. NIRS is useful for monitoring pelvic blood flow during AAA operation.

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The aim of this study was to evaluate our results of treatment for acute type IIIb aortic dissection associated with malperfusion of abdominal organs, and to consider the therapeutic strategies.
Between December 1997 and August 2005, 123 patients with acute type IIIb aortic dissection were treated at our hospital. Of those, 11 patients (8.9%) required emergency treatment for malperfusion of abdominal organ. In our hospital, the indication of emergency treatment for acute type IIIb aortic dissection was any symptom of acute abdomen plus insufficiency of visceral arterial circulation on computed tomography or angiography.
All of the 11 patients (100%) had cul-de-sac of a false lumen, 8 (72.7%) had at least one symptom of acute abdomen, and 3 (27.3%) had metabolic acidosis before surgical treatment. In 7 patients of the “true lumen stenosis type,” 5 patients who were treated with open stent grafting are alive. The other two patients, who were treated with transluminally placed endovascular stent grafting (TPEG) or with superior mesenteric artery (SMA) bypass, died. Of the 2 “visceral arterial dissection type” patient, one was treated with transluminal stenting of the celiac artery and the other was treated with resection of the intestine and ileocolic artery bypass, and both are alive. Two “mixed type” patients who were treated with open stent grafting died. The mortality rate of this series was 36.4%.
In conclusion, to improve the prognosis of acute type IIIb aortic dissection associated with malperfusion of abdominal organ, it is important that we obtain early diagnosis of organ ischemia caused by cul-de-sac of a false lumen and choose the correct treatment based on understanding of the mechanism of organ ischemia.

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We report two cases of Stanford type B aortic dissection with occlusion of the infrarenal abdominal aorta. Case 1) A 69-year-old woman complained of back pain and was referred to our hospital. Computed tomography (CT) showed Stanford type B aortic dissection and conservative therapy was started. During the course of her treatment, pain in both lower extremities appeared at rest and CT showed occlusion of the infrarenal abdominal aorta. Right axillo-bifemoral bypass was performed and her postoperative course was uneventful. Case 2) An 82-year-old man complained of sudden back pain, lumbago and paralysis of both lower extremities and was transported to our hospital by ambulance. CT showed Stanford type B aortic dissection and occlusion of the infrarenal abdominal aorta. Emergency right axillobifemoral bypass was performed, but he died 3 days after the operation because of myonephropathic metabolic syndrome (MNMS). Axillo-bifemoral bypass is a useful therapy for occlusion of the abdominal aorta, but special attention is needed for the acute onset of MNMS after the operation.

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We encountered a case of splenic artery aneurysm, which was treated by laparoscopic aneurysmorrhaphy and splenectomy. A 66-year-old woman was admitted due to an asymptomatic aneurysm in the splenic hilum, which was found serendipitously by magnetic resonance imaging. After an attempt at transcatheter coil embolization failed, laparoscopic ligation of splenic artery accompanied with splenectomy was performed. The patient's postoperative course was uneventful. Laparoscopic treatment of splenic artery aneurysm is safe and effective.

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A 73-year-old man suffered sudden and severe pain in the toes of both feet while walking. A general practitioner treated him with an antiplatelet agent but his symptoms became progressively worse and he was referred to our department. On admission, the patient had cyanosis of both toes with pain at rest. Anti-platelet agents and vasodilators, given intravenously or orally, proved ineffective in alleviating the symptoms. Computed tomography showed signs of “shaggy aorta” in the infrarenal abdominal aorta. Thus, we made a diagnosis of blue toe syndrome caused by a shaggy aorta and performed a vascular-prosthesis replacement. After this operation, his symptoms improved gradually and the cyanosis of his toes also resolved. There were no complications and the operation was effective.

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We report combined endovascular and surgical approach for thoracoabdominal aortic aneurysm (TAAA) in 4 high-risk patients. This approach was planned to avoid excessive adverse effects by a thoracotomy or usage of extracorporeal circulation. In all cases, visceral vessels were reconstructed prior to endovascular stent-graft repair. We underwent both procedures as a single stage operation in early two cases. The results were non-satisfactory because of a fatal complication or paraparesis. On the contrary, two patients who experienced 2-stage treatment suffered no complications. In conclusion, 2-stage combined endovascular and surgical approach may be a safer and more effective alternative to TAAA in high-risk patients.

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A 37-year-old female driver who had not been wearing a seatbelt was admitted to the orthopedic department with a diagnosis of compression fracture of the L-2 vertebral body after a motor vehicle crash. Angiography showed slight infrarenal aortic dilatation above the inferior mesenteric artery (IMA) and stenosis due to disruption of the intima below IMA. We diagnosed of blunt traumatic abdominal aortic injury with circumferencial disruption of the intima. The patient suffered cholangitis due to common bile duct stricture secondary to the blunt abdominal trauma. After alleviation of jaundice we performed infrarenal abdominal aortic replacement by knitted Dacron tube graft sucessfully. She was discharged on postoperative day 34 in a stable condition.

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