Background: A board of accreditation for cardiovascular surgery was established 2 years ago in Japan. However, this board is mainly focused on cardiac surgery. Vascular diseases have been increasing with the increase of elderly people and diabetic patients in recent years, but are not a major concern in the present criteria of the cardiovascular board of accreditation. Therefore, it is necessary to organize an exclusive board of accreditation for vascular surgery in order to achieve a standard and quality of treatment for vascular diseases. We retrospectively reviewed the medical records of vascular cases admitted in our hospital in the last 10 years. We analyzed their background and their treatments was performed. Based on the results of this study, we make a proposal for an exclusive board of accreditation for vascular surgery. Methods: The vascular patients, admitted in our department were divided into two groups; the early period from 1996 to 2000, and the late period from 2001 to 2005. The number of patients with their complications, characteristics of their diseases, and their treatments including surgery were analyzed and compared in both periods. Results: The numbers of the vascular patients and vascular operations have increased. Operations for the thoracic aorta and vascular reconstruction for the arterial occlusive disease have been more frequently performed in the later period. The number of patients complicated with diabetes mellitus or regular hemodialysis also has increased, especially in patients suffering from arterial occlusive diseases. Catheter intervention for the aortoiliac occlusive disease was applied more frequently in the later period, and the vasculogenic treatment with bone marrow injection started also in the late period. Conclusion: The board of vascular surgery needs to include the experiences of, 1) the management of the cardiopulmonary bypass for the operation of the thoracic aorta, 2) vascular reconstruction of the tibial arteries, 3) treatment of the high-risk patients with diabetes mellitus and regular hemodialysis, and 4) new techniques such as catheter intervention and vasculogenic therapy. The relationship with the present board of cardiovascular surgery needs to be determined through further discussion.
Popliteal aneurysms constitute about 80% of peripheral aneurysms and tend to be bilateral, concomitant with other aneurysms. The typical type was true aneurysm caused by non-specific degeneration, and more than half of the patients were symptomatic. There is no established operative indication. We operated on 20 limbs in 18 patients. The mean age was 52 years old, ranging from 12-78 years old and with 3 patients younger than 30 years old. Men were 14 patients, and the left:right distribution was equal, except for 2 bilateral aneurysms. Aortic aneurysms were found in 2 patients simultaneously, one of who had ipsilateral femoral artery aneurysm. The mean aneurysmal diameter was 4.3 cm (1.6-5.5 cm). Only two patients were asymptomatic. These were bilateral aneurysms, which were diagnosed by contrast enhanced computed tomography performed due to contralateral symptomatic aneurysm. The other 18 cases were symptomatic. The popliteal artery was occluded even 1.6 cm in diameter, and one patient required below-knee amputation because of foot necrosis due to embolism for several months. Because even small aneurysms cause acute arterial occlusion, aneurysmectomy and autogenous vein graft replacement should be performed soon after popliteal aneurysm was diagnosed.
Background: To evaluate initial technical results and long-term patency after treatment of iliac artery occlusions with percutaneous angioplasty and stent deployment. Methods: Between July 1997 and April 2006, 218 iliac endovascular procedures were performed on 171 patients. The chronic total occlusions of iliac artery were seen in 61 lesions on 60 patients, mean age 70 years. Fifty one patients were men, 9 were women. The occlusion was approached from the ipsilateral and/or contralateral common femoral artery with an angled-tip hydrophilic guide wire (0.035 inch). Angioplasty performed using an appropriately sized balloon and recanalized vessel were treated with a Palmaz stent, Easy Wallstent, Luminex stent and Smart stent. The follow up period ranged from 2 months to 67 months (mean 25 months). All patients underwent assessment of patency by duplex ultrasound and clinical assessment, including measurement of ankle/brachial index (ABI). Results: Initial technical success was achieved in 49 of 61 lesions (80%). The lengths of occlusion varied from 1.0 cm to 18 cm (mean 8.6 cm), lesion were located in common iliac arteries (19). External iliac arteries (16) and in combinations of both (26). Distribution and lesion length stratified by TASC classification were TASC-B (19), TASC-C (15), TASC-D (27). The mean number of stents deployed in iliac lesions was 2.5±1.5. The cumulative 1, 3 and 5 year primary patency rates were 89%, 74% and 59%. The secondary 1, 3 and 5 year secondary patency rate were 100%, 92% and 92%. Two complications were observed: one subacute occlusion of the stented segments a day after the procedure and one case of cerebral embolic episode during a procedure that recovered without any damage. One distal embolization was seen in our series. In 7 cases reintervention was performed with angioplasty in the stent or deployment of a new stent. Iliac restenosis with unsuccessful secondary angioplasty mandated vascular surgery in 2 of 48 cases, femorofemoral cross-over bypass in one case and aortobifemoral bypass in one case. Conclusion: Endovascular treatment of iliac occlusion can be performed with reliable long-term patency and could have a place as an alternative therapeutic option to major transabdominal bypass surgery.
We describe our experience with a 79-year-old man who had a ruptured inflammatory abdominal aortic aneurysm with an aortocaval fistula. The patient had low back pain, abdominal pain, and anorexia. Four days later, thoracic discomfort developed. He consulted a physician and was found to have electrocardiographic abnormalities, renal failure, and a pulsating abdominal mass. He was therefore transferred to our hospital. An aortocaval fistula caused by rupture of an abdominal aortic aneurysm was diagnosed, and surgery was performed. An inflammatory abdominal aneurysm was diagnosed on the basis of intraoperative findings. Hemodynamics were maintained with the use of an autologous blood recovery system. A good surgical field was obtained, and the fistula was closed. After surgery, symptoms promptly resolved, and the patient was discharged from the hospital in good condition. Inflammatory abdominal aortic aneurysms are rarely associated with aortocaval fistulas. We report this case, along with a review of the literature.
Background: The number of patients who have concomitant abdominal aortic aneurysm (AAA) and gastrointestinal malignancy has recently been increasing. However the best operative strategy for these patients remains controversial. Methods: A 58-year-old man underwent radical operation with colostomy and ileal conduit formation for rectal cancer 2 years previously. He had already been diagnosed as having AAA at that time because the aneurysm recently enlarged to approximately 60 mm in diameter, he received operation for AAA. Although he had mild obesity and double stoma on both sides of the abdomen, we selected a left retroperitoneal approach, and the replacement of aneurysm was successfully performed. Results: The postoperative course was uneventful, and he was discharged 8 days after the operation. Conclusion: We should select the best operative strategy, including endovascular stent graft, depending on the condition of each patient suffering both AAA and gastrointestinal malignancy.
A 71-year-old man who had previously undergone a low anterior resection for rectal cancer, was admitted for surgery because of a dilated abdominal aortic aneurysm. An abdominal CT scan revealed a pararenal abdominal aortic aneurysm, with a maximum diameter of 53 mm. An abdominal aortic angiogram suggested occlusion of both the internal mesenteric artery and the internal iliac artery. A coronary artery angiogram suggested coronary triple vessel disease in combination with an old myocardial infarction. After prior coronary artery bypass grafting, abdominal aortic graft replacement with reconstruction of bilateral renal artery was performed. Because the patient developed severe ischemic colitis a day after the operation, urgent left hemicolectomy and colostomy were thus performed. He was discharged in good condition 127 days after Y-graft replacement. Patients who have previously undergone colorectal surgery are considered to be at high risk for developing colon ischemia postoperatively. We therefore suggest that careful perioperative treatment is required to prevent the development of colon ischemia in these patients.
We report a case of non-ruptured popliteal aneurysms with a bleb on the right leg. A 75-year-old man was admitted with coldness and leg pain at rest. At the time of admission, emergency angiography found a right popliteal aneurysm and total arterial occlusion due to a thrombus, which extended below the knee with some collateral circulation. We started anticoagulation therapy and on the 4th hospital day we performed dissection of the popliteal aneurysm with thrombectomy, providing relief of the vasocclusion. The size of the aneurysm measured 25 mm × 40 mm with a bleb on the wall of the aneurysm. Pathologic examination of the bleb revealed an abnormal arterial structure consisting only of the tunica media. On the 4th postoperative day, a peroneal aneurysm was found by ultrasound examination. On the 13th post operative day, rupture of the peroneal aneurysm was found on emergency angiography and a covered stent was inserted. A third aneurysm was found at this time at the post tibial region, which was not treated as it did not show any tendency to increase. This weakness of blebs hold a high risk of rupture and we should resect the aneurysm as soon as a bleb is diagnosed on the aneurysm.
An 82-year-old man underwent abdominal aortic aneurysm repair with a prosthetic graft four years previously. He presented with pain and swelling of the left thigh in a generally debilitated condition. Computed tomography scan revealed left distal anastomotic false aneurysm and bacterial culture was positive for methicillin-resistant Staphylococcus aureus (MRSA). We performed debridement of the abscess and irrigation by an electrolyzed strong acid solution. Twelve months later, the abscess cavity reexpanded in the retroperitoneal space occupied by the prosthetic graft. We then transferred the pedicle rectus abdomis muscle flap to the abscess cavity. After this treatment, he has had no active inflammatory signs and no abscess formation for 12 months.