A 42-year-old man presented with right leg pain during exercise. Physical examination revealed a diminished pulse. MDCT (multidetector-row computed tomography) demonstrated occlusion of the right popliteal artery due to malposition of the medial head of the gastrocnemius muscle. Popliteal artery entrapment syndrome (Delaney type II) was diagnosed, and a popliteo popliteal bypass was performed using the autogenous great saphenous vein. The postoperative course was without complications, and the ankle-brachial pressure index (ABPI) improved from 0.70 to 1.00. MDCT was useful in characterizing this variation in that it revealed the precise anatomical relation of the muscle, bone, and artery, leading to appropriate treatment.

View full abstract

An 82-year-old woman had had bypass surgery for arteriosclerosis obliterans in both legs. We performed a stent graft implantation for an impending rupture of an aneurysm of the descending thoracic aorta complicated with a small abdominal aneurysm. An abdominal thromboembolic aneurysm occurred after the thoracic stent graft implantation due to the detachment of the mural thrombus of the abdominal aneurysm, and therefore we performed an emergency abdominal aorta replacement and thrombectomy in the leg grafts. The leg motor function had been maintained until immediately before the emergency surgery, but a vesicorectal disorder and paraparesis from level 11 of the thoracic spinal cord downward occurred after the emergency surgery. After performing both hyperbaric oxygen (HBO) and physical therapy, the vesicorectal disorder disappeared, and the patient was discharged after she became ambulatory. We believe that paraparesis occurred in this case because of a possible collateral circulation of the lumbar artery to the spinal cord following the thoracic stent graft implantation.

View full abstract

We report the surgical treatment of an 81-year-old man with abdominal aortic aneurysm with horseshoe kidney. Preoperative 3 dimensional-computed tomography angiography (3D-CTA) revealed normal right and left major renal arteries and one accessory renal artery supplying blood to the right lower pole and renal isthmus, and no arterial branches between the isthmus and the aneurysm. Contrast-enhanced CT revealed the left and right ureters coursing along on either side of the isthmus and the aorta. We made a midline incision to obtain transperitoneal exposure of the isthmus and the aneurysm. The isthmus could be easily dissected from the aneurysm and the aneurysm was successfully treated with a prosthetic graft, without resection of the isthmus or the accessory renal artery. Postoperatively, the patient showed no evidence of renal dysfunction and was discharged after an uneventful course in the hospital. When considering exposure to the aneurysm and reconstruction of the renal arteries, it is very important to identify the number and location of the renal arteries, evaluate the isthmus and determine the position of ureters by preoperative 3D-CTA and contrast-enhanced CT, and if necessary, intravenous pyelogram.

View full abstract

A 73-year-old man had undergone endovascular aneurysm repair with a handmade stent graft at age 69. Follow-up computed tomography at one year showed type I endoleak and three years later, the maximum aneurysm diameter had increased to 70 mm. Because the patient had severe respiratory dysfunction, the endovascular method was chosen for further management. A Zenith device was used to reduce the risk of migration and enhance the vessel attachment. The patient was discharged in good general condition, without evidence of endoleak.

View full abstract

Paraplegia after open repair of infrarenal abdominal aortic aneurysm (AAA) is uncommon. We encountered a case of ruptured AAA associated with postoperative paraplegia. A 60-year-old man suffered right lower abdominal pain and lumbago. Abdominal computed tomography scan revealed an infrarenal AAA and hematoma in the retroperitoneal space. During preparations for operation, his blood pressure suddenly decreased 40 mmHg. Emergency operation was performed as soon as possible. Postoperatively, he developed paraplegia. He was treated with continuous infusion of naloxone hydrochloride, steroid pulse therapy and early rehabilitation. He was subsequently given an ambulation discharged. In this case, low blood pressure during preoperative workup and operation might have caused serious ischemia of the spinal cord.

View full abstract

A patient with intractable chyloperitoneum was successfully treated with octreotide, a somatostatin analogue. The patient was a 65-year-old man. A persistent chyloperitoneum developed as a complication after an abdominal aorta to bilateral femoral artery bypass with a bilateral femoro-popliteal bypass due to obstructive atherosclerosis. Dietary therapy with a fat-free diet had been continued for 11 days but the lymphorrhea did not diminish. A surgical ligation of a lymph channel around the abdominal aorta was performed via a re-laparotomy on the 12th postoperative day and fasting therapy under intravenous hyperalimentation was induced, however, the lymphorrhea persisted. Finally, octreotide was administered on the 15th postoperative day. The lymphorrhea decreased dramatically thereafter and the chyloperitoneum disappeared after 11 days of the octreotide treatment. Octreotide is therefore considered to be an effective therapy for chyloperitoneum and its early administration should shorten the therapeutic period.

View full abstract

Spontaneous dissection of the superior mesenteric artery is a rare condition especially when not associated with the aortic dissection. We describe a 57-year-old man with isolated dissection of the superior mesenteric artery. Enhanced CT (computed tomography) scan revealed the isolated dissection of the superior mesenteric artery beginning 0.5 cm from its origin, with thrombosis in the false lumen. Because the true lumen did not show significant stenosis, we followed him without any invasive treatment. The next morning, he had complete symptomatic relief. On the second day after admission, we decided on cessation of fasting because there was no expansion of the false lumen on the enhanced CT scan. Aspirin was prescribed due to the slight stenosis of the true lumen. The false lumen disappeared on enhanced CT three months after his initial presentation. We did not administer any anticoagulant agents. Anticoagulation or antiplatelet drug should be considered according to the severity of the stenosis of the true lumen. Indications for surgery appear to be an aneursymal formation or the development of ischemic colitis under any suitable medication.

View full abstract

We developed the new clip for gelatin-resorcin-formalin (GRF) glue (Ki-clip) and reinforcement of the suture line using a felt strip in the surgical treatment of acute aortic dissection. Between February, 2005 and January, 2006, 6 patients underwent surgical treatment for Stanford A type acute aortic dissection. Their mean age was 75.2 ± 6.0 year. Two patients underwent ascending aorta replacement, and 4 patients underwent total arch replacement. The shape of the Ki-clip resembles two overlapping combs at the tip. This characteristic makes it possible to stitch felt strips for reinforcement of the aorta through the combs, while clamping the adventitia and intima. In addition, after suturing the vascular graft, we tightened the outside felt to decompress the false lumen. The average operation time was 323.0 ± 43.0 min, the average operative bleeding was 750.0 ± 596.5 cc, and the average blood transfusion during operation was 7.8 ± 5.9 units (MAP), 7.0 ± 3.9 units (FFP), 8.3 ± 4.1 units (PC). There was no re-do surgery for hemostasis. The new clip for GRF glue and tightening the outside felt to decompress the false lumen was easy to use and was effective for hemostasis in the surgical treatment of acute aortic dissection.

View full abstract