Treatment of patients suffering peripheral arterial disease (PAD) has changed significantly over the last decades. Endovascular therapy now accounts for 25-40% of vascular interventions in Europe and, in addition, medical therapy and life style changes have proven beneficial to the PAD patient. Traditionally, open vascular surgery has been provided by the vascular surgeon, endovascular treatment by the radiologist and medical treatment by the internist or angiologist. However, patients and politicians are demanding increased service and if all treatment options for the vascular patient can be offered by the same physician in the same department, not only will demands be fulfilled, but the quality of treatment may improve as well. In most European countries the vascular surgeon decides on the indication for either open surgery or endovascular treatment. Preventive medications to avoid complications to atherosclerosis are simple to prescribe and adjust in the majority of patients and are often provided within the vascular department. The future vascular specialist will be a physician with a basic vascular training, including vascular medicine, open as well as endovascular surgery. This article describes this development, which is happening at different paces throughout most of Europe.

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The author has classified the ideal way vascular surgery should develop, into 3 stages, expressing an opinion on the direction of future advances of vascular surgery while considering the situations in which vascular surgeons are currently placed and the path along which they should progress. The first stage is the current situation in which vascular surgeons are currently placed, the second stage is the one in which vascular surgery becomes separated and independent from cardiovascular surgery specialist system, and the third stage is the one in which the vascular specialist system is newly instituted. The current situation is yet to reach the stage at which vascular surgeons can establish a vascular surgery specialist system independent of the cardiovascular surgery specialist system. Senior vascular surgeons must directly face this current situation, and to begin to establish a vascular surgery specialist system by themselves in order to fulfill their responsibility. The intravascular treatments currently carried out according to their own independent criteria by cardiac surgeons, vascular surgeons, radiologists, cardiologists or neurosurgeons have to be integrated through close cooperation, and for the establishment of a new vascular specialist system, all knowledge and know-how have to be put to use with vascular surgeons playing the central role. We hope for the advent of an age when vascular surgeons having many years of experience with the vascular diseases that have rapidly increased with the aging of society may actively play their role in and contribute to the advancement of medicine.

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Background: Rupture of thoracic aortic aneurysm is a lethal condition and its surgical outcome has been poor with high mortality and morbidity rates. This study was undertaken to assess retrospectively our surgical results for ruptured thoracic aortic aneurysms. Methods: This study includes 27 patients who underwent emergency operation for ruptured thoracic aortic aneurysm from 2001 to 2005 at our institution. Patients with acute aortic dissection and impending rupture of thoracic aortic aneurysm were excluded. The types of aneurysm were true in 20, false aneurysm in 2, and chronic aortic dissection in 5 patients (chronic type A dissection in 1, and chronic type B dissection in 4). The operative procedures were total arch replacement in 12, graft replacement of descending aorta in 9, hemiarch replacement in 1, graft replacement of thoracoabdominal aorta in 4, aortic root + hemiarch replacement in 1 patient. Results: There were 7 hospital deaths (25.9%), and the causes of death were low cardiac output in 2, cerebral infarction in 2, sepsis in 2, and lungs bleeding in 1 patient. Postoperative respiratory disorder was found in 5 (18.5%), and cerebral infarction in 8 (29.6%) patients. Predictive risk factor for hospital death was surgery through a left lateral thoracotomy. The risk factor for cerebral infarction was age more than 80 years. Postoperative survival rate at 3 years was 71.4% by the Kaplan-Meier method. Conclusion: The operative mortality of ruptured thoracic aortic aneurysm was still not unsatisfactory high. Prompt and adequate operative intervention without delay is required for the improvement of surgical outcome.

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Background: Early postoperative feeding is recommended recently even after abdominal surgery. We tried early postoperative feeding after elective abdominal aortic surgery with a transperitoneal or retroperitoneal approach. Methods: A semisolid diet was given to 108 patients 2 or 3 days after elective abdominal aortic aneurysm surgery. A transperitoneal approach was used for 90 patients and a retroperitoneal approach was used for 18 patients. There was no significant difference between the two patient groups in terms of age, gender, operation time, bleeding, or postoperative period to semisolid diet intake (2.5±0.5 day after transperitoneal approach and 2.4±0.5 day after retroperitoneal approach). The amount of diet intake was recorded at each meal and the postoperative diet intake pattern was classified into good diet intake and poor diet intake types retrospectively. Results: Fifty patients after transperitonal operation (56%) and 13 patients after retroperitoneal operation (72%) were classified as good diet intake type (NS). A half amount of diet intake was possible 3.4±2.4 postoperative day after the transperitoneal approach and 2.8±0.8 postoperative day after retroperitoneal approach (NS). Vomiting was observed in 6 patients after transperitoneal (7%) and none after retroperitoneal operation (NS). Nasogastric tube insertion was not necessary in every patient. After transperitoneal operation, there was no significant difference in age, gender, postoperative semisolid diet intake day, operation time, bleeding and preoperative risk factors between patients with good and poor diet intake. Conclusion: Early postoperative diet intake was possible even after transperitoneal abdominal aortic aneurysm operation. No specific factors were observed related to poor diet intake in patients who underwent abdominal aortic aneurysm operation with transperitoneal approach.

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Between January 1976 and May 2005, the long-term results of 522 patients with aortoiliac lesions due to arteriosclerosis obliterans who underwent 319 aorto-femoral bypasses (group A), 88 femoro-femoral crossover bypasses (group B), 44 axillo-bilateral femoral bypasses (group C), and 71 endovascular procedures (group D) were examined. An endovascular procedure was selected for the short segmental stenotic lesions and a bypass for occluded lesions. If the patients were in generally good condition, an anatomical bypass was performed. If they were in poor general condition, an extranatomical bypass (femoro-femoral crossover bypass or axillo-femoral bypass) was performed. The primary patency rates were 91% and 86% at 5 and 10 years in group A, 73% and 73% in group B, 44% and 44% in group C, 83% at 5 years in group D. The survival rates were 83% and 62% at 5 and 10 years in group A, 59% and 30% in group B, 44% and 0% in group C, 79% at 5 years in group D. In conclusion, TASC II will be presented in 2007. The indications for endovascular procedure will be increase in the future, but we consider that the operative method which we chose as indicated by the prognosis and therapeutic results is appropriate at present.

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Concomitant coronary artery disease (CAD) and peripheral vascular disease (PVD) are frequently seen. We evaluated the incidence of CAD in patients admitted for the treatment of PVD and the results. Between April 1996 and December 2004, 297 cases underwent abdominal aortic aneurysm (AAA) repair and 164 cases underwent peripheral vascular surgery for arteriosclerosis obliterans (ASO). Since 2001, consecutive 220 cases (AAA: 124, ASO: 96) underwent routine preoperative coronary angiography. Of these, 27 cases (12.3%, AAA: 16, ASO: 11) had episodes of CAD and 71 cases (36.8%, AAA: 40, ASO: 31) had significant coronary stenosis. Of 71 cases, only six cases (8.5%, AAA: 4, ASO: 2) were symptomatic. Coronary angiography revealed 35 cases of one-vessel disease (18.1%, AAA: 20, ASO: 15), 24 of two-vessel disease (12.4%, AAA: 12, ASO: 12), 8 of three-vessel disease (4.1%, AAA: 6, ASO: 2), and 4 left main trunk plus three-vessel disease (2.1%, AAA: 2, ASO: 2). Of 56 cases (12.1%, AAA: 32, ASO: 24) requiring coronary artery bypass grafting (CABG, on pump: 14, off pump: 42), 39 cases (Group C) underwent CABG prior to peripheral vascular surgery, 10 cases (Group P ) underwent peripheral vascular surgery prior to CABG and 7 cases (Group S) underwent CABG and peripheral vascular surgery simultaneously. In Group C, there were 1 operative death due to the rupture of AAA at 4 days after urgent off pump CABG, 2 hospital deaths due to infection and 1 late death. In Group P, there was no death nor cardiac event. In Group S, there was no death but there were 2 cases of mediastinitis and 1 of retroperitoneal hematoma. Because of the high incidence of asymptomatic CAD in patients of PVD, coronary angiography is necessary to evaluate the severity of coronary artery and manage CAD properly before the treatment of PVD. Staged CABG followed by PVD treatment is preferable unless the diameter of AAA exceeds 60 mm or leg ischemia is severe.

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We encountered two cases of refractory leg ulcers due to venous stasis dermatitis, which was cured completely by ligation of veins including greater and lesser saphenous veins, varicose branches and incompetent perforator veins under local anesthesia. Venous ligation therapy, improving dermal circulation, could be one of the advantageous treatments for persistent stasis ulcer, what is often derived from primary varicose veins.

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We report an extremely rare case of fistula between a splenic artery aneurysm and stomach without massive bleeding. A 67-year-old man was admitted with upper abdominal pain. Gastrofiberscopy revealed a large mass near the cardia and computed tomography scan showed a contained ruptured splenic artery aneuysm which communicated with the stomach. Based on these findings we diagnosed a fistula between a splenic artery aneurysm and stomach which did not present massive bleeding. Symptoms of fever and anemia suggested infection of the aneurysm, therefore urgent operation was performed. The operative technique was splenectomy, total gastrectomy and drainage around aneurysmal wall. The postoperative course was uneventful and the patient improved with no complication.

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