Almost all patients with lymphedema in Japan, are treated as outpatients. The treatment should be carried out under corporation of both special hospitals for cancer-treatment and lymphedema-treatment. The treatment of lymphedema consists of basic guidelines of everyday life, manual lymph drainage (self manual massage) and elastic stockings/sleeves. However, the treatment should not be performed uniformly in all patients, and be carried out based on scientific evidence, depending on the individual pathophysiology and life environment.

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Purpose: To evaluate immediate and mid term results of juxtarenal aneurysm repair with an endovascular graft that incorporated the visceral aortic segment with graft material. Materials and Methods: A prospective analysis of patients undergoing implantation of an endovascular device with extension into the renal arteries was conducted. All patients were deemed unacceptable candidates for open surgical repair and had challenging proximal neck anatomy (length ≤ 10 mm, or ≤ 15 mm with a compromising morphology). Fenestrations were customized to accommodate aortic branch anatomy based upon computed tomography (CT) data. Selective visceral ostia were incorporated into the repair using balloon expandable stents following endograft deployment. All patients were evaluated with CT, duplex ultrasound, and abdominal radiograph at discharge, 1, 6, and 12 months and yearly thereafter. Results: A total of 139 patients were treated, with 362 visceral vessels incorporated into the repairs. The most common design involved both renal arteries and the superior mesenteric artery (SMA) (60%). All but one prostheses were implanted successfully without the acute loss of any visceral arteries. The mean follow-up was 21 months (range 0–55 months). Two patients died within 30 days of device implantation. Although pre-discharge images demonstrated 4 type I endoleaks and 3 type III endoleaks, type I endoleak or type III endoleak were not detected in this study population at 30-days follow-up. The aneurysm sac decreased more than 5 mm in 54% of patients at 6 months, in 80% of patients at 12 months, in 79% patients at 24 months. Eighteen patients had elevation of serum creatinine (>30% from baseline), with 5 requiring hemodialysis. Of the 362 vessels incorporated, 11 late renal artery stenoses, 8 renal occlusions, and single SMA stenosis were detected. Conclusion: The placement of endovascular prostheses with graft material incorporating the visceral arteries is technically feasible. The incidence of endoleaks is relatively low. Acceptable intermediate-term outcomes have been achieved in the treatment of juxtarenal aortic aneurysms, although it remains critical to follow the status of stented visceral vessels because of possibility of visceral artery stenoses.

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The onset of Stanford A aortic dissection, which remains a serious disease with a low survival rate, is relatively rare during the follow-up period after open heart surgery. Herein, we report onset factors such as the ascending aorta diameter at the time of surgery and hypertension, and the early outcomes of patients who underwent surgery for Stanford A aortic dissection that developed during the follow-up period following open heart surgery. Subjects were five patients who underwent surgery at our hospital between January 1992 and December 2005 for aortic dissection that developed during the follow-up period following open heart surgery. Initial surgery comprised aortic valve replacement (n = 2), coronary artery bypass surgery (n = 2), and Bentall procedure (n = 1), and the mean time to the onset of aortic dissection was 7.7 years. Surgery for aortic dissection consisted of ascending aortic replacement (n = 4) and arch replacement (n = 1). In addition, coronary revascularization was simultaneously performed for patients who underwent coronary artery bypass surgery as initial surgery. No early mortality was observed and one patient died of pneumonia during the follow-up period.
The most serious risk factor in the onset of aortic dissection following open heart surgery is the ascending aorta diameter, which must be closely monitored during postoperative follow-up if thinning or weakness of the aorta is observed at the time of initial surgery. Simultaneous ascending aortic replacement should be actively performed during initial surgery if the aorta diameter measures ≥ 40 mm at the time of surgery and the aforementioned risk factors are observed, and reoperation must be actively considered if the diameter expands to ≥ 50 mm during postoperative follow-up.

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Background: We used gadolinium-enhanced three-dimensional magnetic resonance angiography (MRA) as a screening tool for patients with clinical lower extremity arterial occlusive disease. When critical lesions were identified by MRA, digital subtraction angiography (DSA) was performed to determine the choice of therapy: percutaneous transluminal angioplasty, bypass surgery, amputation, or no treatment. Although MRA images are similar to those of DSA, we felt them wee some differences existed. This study compares the two. Methods: Between July 2004 and November 2005, 12 patients had their lower extremities evaluated by both MRA and DSA. Lesions identified by 3D-MRA were classified into 5 types: signal defect, stenosis, diminished signal, slit lesion, or complex lesion. These areas were categorized as occlusion, severe stenosis, mild stenosis, or no lesion on DSA. Results: MRA identified 105 lesions. Twenty-eight areas with a signal defect on MRA were associated with 23 areas of occlusion (82.1%), 4 areas of severe stenosis (14.3%), 1 area of mild stenosis (3.6%), and no areas of no lesion (0%) on DSA; 11 areas of stenosis were associated with no occlusion (0%), 4 areas of severe stenosis (36.4%), 5 areas of mild stenosis (45.5%), and 2 areas of no lesion (18.2%); 34 areas of diminished signal were associated with 1 area of occlusion (2.9%), 12 areas of severe stenosis (35.3%), 9 areas of mild stenosis (26.5%), and 12 areas of no lesion (35.3%); 24 slit lesions were associated with no areas of occlusion (0%), 2 areas of severe stenosis (8.3%), 15 areas of mild stenosis (62.5%), and 7 areas of no lesion (29.2%); 8 complex lesions were associated with no areas of occlusion (0%), 7 areas of severe stenosis (87.5%), no areas of mild stenosis (0%), and 1 area of no lesion (12.5%). Conclusion: Although MRA images are similar to DSA images, tey are not identical. Criteria and indications for each should be developed and used to complement each other.

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Background: Lymphedema is the result of impaired lymphatic drainage from the affected organ. This abnormality can be primary or secondary. Different nonoperative and operative approaches have been introduced to treat chronic lymphedema. In this study, we describe a new surgical technique and compare its results with other more commonplace methods. Materials and methods: We included 296 patients given a diagnosis of chronic lower extremity lymphedema who had not responded to nonoperative management for at least 6 months. They were collected during 15 years between March 1987 and March 2002. Doppler ultrasonography of the deep venous system to confirm its patency was routinely performed in all. Then, they underwent surgery and were followed for at least 1 year postoperatively. Results: All patients were operated by our new technique which is a modified form of Miller’s or Homan’s. The outcome was excellent and 89.2% of patients had no complications. A 10.8% total complication rate was achieved, the most common of all was wound seroma. Conclusion: According to the difficulties with treatment of chronic lymphedema and variety of surgical options, our method achieved excellent health and could be the standard operative procedure to treat the intractable forms of disease.

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Abdominal aortic aneurism (AAA) rupture is a disastrous condition with high mortality. This study was conducted to evaluate the factors influencing the operative outcomes. Two retrospective studies were performed. First, the proportion and outcome of AAA rupture among cases admitted to the emergency room of Saiseikai Fukuoka General Hospital, were reviewed from November 2003 to December 2005. Second, prognostic factors were compared between the survivors and deaths from AAA rupture during a 12-year period (1994 to 2005). From November 2003 to December 2005, 7327 cases were transferred to the emergency room of our hospital. Six cases of AAA rupture were included among 275 cases of cardio-pulmonary arrest on arrival (CPAOA). One of six cases was transfered to the operating room but died before aneurysmal repair. There were no survivors among the cases of CPAOA. From 1994 to 2005, 43 cases underwent surgery for ruptured AAA. Thirty cases (70%) survived and 13 (30%) died in our hospital. Preoperative cardio-pulmonary resuscitation, preoperative shock, suprarenal aortic clamp, massive blood loss were significantly associated with mortality. These factors reflected the seriousness of preoperative hypotension and the amount of retroperitoneal hematoma. Mortality as a function of time from onset of aortic rupture to hospital admission was 5/9 (56%) within 1 hour, 6/10 (60%) for 1 to 3 hours, 2/11 (18%) for 3 to 10 hours, 0/13 (0%) for more than 10 hours. Cases with a longer interval from onset of aortic rupture, seemed to be survivors with a stable condition. The incision-clamp times of the mortality cases were shorter than those of the survivors. Quick aortic clamping is essential for surgery for cases with severe hypotension. Mortality of ruptured AAA was significantly associated with preoperative circulatory insufficiency. Evaluation of the in-hospital emergency system and operative technique for aortic rupture should include admission-operation time, incision-clamp time, aortic clamping time in cases of preoperative shock as well as hospital mortality.

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Background: In the surgery of the thoracoabdominal aortic aneurysm, retrograde perfusion from the femoral artery has risks of proximal embolization of peripheral atheroma and thrombus, or of malperfusion to the abdominal organs and segmental arteries of the spinal cord in patients with dissection. To avoid these risks, we performed a “segmental retrograde replacement of the thoracoabdominal aneurysm without the retrograde perfusion from the femoral artery”. Methods: Between July 2005 and February 2007, consecutive 7 patients were enrolled in this retrospective study. The average age was 62 years (4 men, 3 women). The aneurysms were true in 1, chronic dissection in 5, and infective pseudoaneurysm with sepsis in 1 patient. Crawford classification type I was seen in 1, type II in 4 and type III in 2 patients. Adamkiewicz arteries were preoperatively confirmed on multidetector row CT in all patients. Procedure: The infrarenal abdominal aorta was cross clamped and a composite tube graft with multiple side branches was anastomosed to the distal abdominal aorta or the iliac arteries without cardiopulmonary bypass. When the ischemic duration of the lower body reached 60 to 90 minutes, partial cardiopulmonary bypass to the lower body (main pump) was initiated through a side branch of the main graft (venous drainage from the right atrium with a long cannula inserted from the femoral vein). Then, the descending aorta was clamped above the celiac artery and the upper abdominal aneurysm was opened. The abdominal organs (8F cannulae) and the opened lumbar (L1, 2) arteries (2–2.5 mm cannulae) were selectively perfused with a second pump (450–600 ml/min). The selectively perfused abdominal branches and lumbar arteries were interposed with side branches of the main graft, and the perfusion was changed from a main graft in order. The proximal aorta was then clamped, and the descending thoracic aorta was opened. The intercostal arteries (T8–T12) were selectively perfused (10–20 ml/min/1 artery). The proximal anastomosis of the main graft was accomplished with discontinuation of the cardiopulmonary bypass. The graft interposition to the intercostals arteries, including the Adamkiewicz artery, were completed while continuing the selective perfusion. Results: There was 1 hospital death caused by respiratory failure in a patient with infective pseudoaneurysm with sepsis (postoperative 45th days). No patient showed spinal cord dysfunction, nor organ dysfunction caused by embolism of atheroma, thrombus or bacterial mass, or by malperfusion in patients with dissection. Conclusion: This surgical procedure provides an excellent protection of the abdominal organs and spinal cord, and will contribute to the improvement of the results of thoracoabdominal aortic surgery.

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We reported three cases of popliteal artery aneurysm (PAA) with limb ischemia. Case 1: A 75-year-old man was referred complaining of severe left leg pain. Amputation of the left leg was performed because there was no indication for revascularization. Thrombotic PAA was recognized at the time of operation. Case 2: A 75-year-old man noted an asymptomatic left popliteal tumor. Though ultrasound echography showed a PAA (2.7 cm in diameter), the patient refused surgical intervention. Afterward, he was referred to our hospital for intermittent claudication. Left popliteal- tibial artery bypass was performed because the popliteal artery was thrombotic and the PAA was occluded. Case 3: A 29-year-old man was admitted with severe right leg pain. He had not been treated for his popliteal tumor because it was asymptomatic. Magnetic resonance imagimg confirmed a right PAA and angiography showed occlusion of the popliteal artery. Right popliteal-peroneal artery bypass was performed. PAA is the most common peripheral arterial aneurysm. Limb threatening ischemia is caused by acute aneurysm thrombosis or embolization. To avoid limb amputation, prompt surgical therapy is needed for small PAA with intramural thrombus.

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A 47-year-old woman with Behçt’s disease was admitted to our hospital for treatment of a thoracoabdominal aortic aneurysm. Computed tomography of the abdominal aorta showed a saccular aneurysm with a curvilinear, enhanced, thickened wall and mural thrombosis at the level of the superior mesenteric artery. We performed tube graft replacement of the thoracoabdominal aorta with all visceral vessel bypasses. The patient had an uneventful postoperative course and was discharged 4 weeks after her operation. She was followed up for 44 months and remains in good clinical condition without anastomotic aneurysm, graft occlusion or aneurysm at another site.

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Aortocaval fistula (ACF) is a rare complication of abdominal aortic aneurysm (AAA) involving fewer than 1% of all AAAs. ACF through a contained ruptured aortic aneurysm is an extremely uncommon complication following ruptured abdominal aortic aneurysm. ACF may cause severe hemodynamic disturbance due to a left-to-right shunt. We report here a case of ACF secondary to a contained ruptured abdominal aortic aneurysm, in a 65-year-old woman, which to our knowledge has not been reported in the literature before. Its diagnosis and treatment are presented in this article.

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Spontaneous rupture of the thoracic aorta without any apparent aortic pathology is extremely rare. It is a life-threatening condition and almost always requires surgical treatment. We report successful conservative therapy for spontaneous rupture of the aortic arch in an 89-year-old man. The patient presented to a local hospital with severe chest pain and loss of consciousness for a few minutes. An enhanced chest computed tomography showed massive mediastinal hematoma without any specific aortic disease such as aortic dissection or aneurysm. He was transferred to our hospital for possible surgical repair. He was then given a diagnosis of spontaneous rupture of the aortic arch. He was asymptomatic and hemodynamically stable. We decided to treat him conservatively, considering his surgical risk factors such as advanced age, history of ischemic heart disease and severely calcified aortic arch. The blood pressure was strictly controlled according to a standard therapeutic protocol for Stanford type B acute aortic dissection. He was discharged on day 29 and has been followed up showing no recurrence in the past 2 years. Basically we should treat such condition with lifesaving surgery, however, there is an option of non-surgical treatment for selected patients.

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