Patients and Methods: Between 2003 and 2006, 399 patients visited our Wound Care Center and 205 (51.4%) of them had ischemic foot ulcers, of whom 44 underwent vascular surgeries. Their average age was 71.4–year–old, 30 (68.2%) of them had diabetes mellitus, and 18 (40.9%) of them had chronic renal failure on hemodialysis. Their vascular surgeries counted of endoarterectomy of the common femoral artery in 1, above–knee femoro–popliteal bypass in 12, below–knee femoro–popliteal bypass in 12, and tibio–peroneal bypass in 19. In addition, five patients underwent suprainguinal bypass surgeries and 9 patients underwent percutaneous peripheral interventions to increase inflow. The local blood flow of their ischemic limbs was assessed by skin perfusion pressure (SPP) before and after vascular surgeries. Results: There was no intraoperative death. Two–year primary and secondary patency rates were both 100% in above–knee femoro–popliteal bypass, both 91.7% in below–knee femoro–popliteal bypass, and 57.9% and 68.4% in tibio–peroneal bypass. The value of SPP significantly elevated from 21.1 ± 10.8 mmHg to 60.4 ± 26.1 mmHg (p < 0.01), and the limb salvage rate was 85.4%. Thirteen of them died in the early postoperative or follow–up period, and 1– and 3–year survival rates were 75.0% and 53.0%. Conclusion: Bypass patency and limb salvage rate in this series were satisfactory, but not the survival rate. SPP is a reliable diagnostic tool to assess the local blood flow before and after vascular surgery for critical limb ischemia, and favorable wound healing can be expected when the SPP is over 40 mmHg.
Academic societies send various messages to their membership through society meetings. It is important what message the membership receives and how it is understood. The message to which the membership consents is documented in the activities of the society because important messages are repeatedly delivered until the membership consents. Accordingly, in regard to venous thromboembolism, we examined the main sessions of past general meetings from 1999 to 2006 of the three societies that comprise the Japanese Board of Cardiovascular Surgery and analyzed the theme (session theme) presented in each session. We applied this method specifically to officially accepted medical judgment. The lawsuit in question was an appeal hearing in which it was asked whether there was a violation of the standard of care in 1999 for prevention of pulmonary embolism by preventing deep vein thrombosis. The method of pulmonary embolism prevention in Japan has for a long time been diagnosis and treatment of deep vein thrombosis at the early stage, and I needed to clarify the situation in 1999 as an expert witness. The result of examination of session themes was that no pertinent session on prevention of pulmonary embolism was presented by the Japanese Association for Thoracic Surgery or the Japanese Society for Cardiovascular Surgery. However, since 2001, the Japanese Society for Vascular Surgery had presented five sessions. The method of preventing pulmonary embolism by prevention of deep vein thrombosis was first discussed in 2006 by the Japanese Society for Vascular Surgery. Thus, the medical treatment performed in this case did not violate the standard of care in 1999. And it has become clear that proposed session themes characterize the specialty and identity of the society. The “standard of medical treatment at the time,” which the laws require to pass judgement, can be published from the specialists’ standpoint because by tracing consensus, the “upper limits” of allowable medical treatment can be shown. From now on, if the consensus resulting from each session is recorded, a more detailed analysis could be made of the message to which the membership has consented.
Cancer sometimes causes venous thromboembolisms (VTE) including pulmonary embolisms (PE), which impedes aggressive treatment such as chemotherapy. From January 2003 to March 2007, there were 120 hospitalized patients with existing VTE in The University of Tokyo Hospital. Among them we reviewed 39 patients with cancer who required aggressive chemoradiotherapy and examined whether inferior vena cava (IVC) filtration was necessary in addition to ordinary anticoagulant therapy. The clinical stage of cancer was stage I in 7, stage II in 4, stage III in 11, and stage IV in 17. Most were advanced cancer. Of the 39, 9 underwent an IVC filter placement (filter group) and 30 did not (no-filter group). All of them received regular anticoagulant therapy. In the long-term follow up averaging 16.9 months, one patient of the filter group required discontinuation of chemotherapy due to symptomatic PE, but there was no such a case in the no-filter group. Filter-related complications such as IVC occlusion or migration did not occur. Computed tomography showed VTE in the long-term course in 27 out of 39 patients, and suggested increased thrombi in cases of recurrent cancer and those with poor outcome. Seventeen died of cancer but no one died of PE during the study. This study showed that IVC filters offered no beneficial effect for the patients with existing VTE who receive aggressive chemotherapy.
Here we report a case in which a graft-enteric erosion between a bifurcated graft and the ileum caused a recurrent,septic embolism. A 71-year-old man, who had undergone an aorto-bifemoral bypass due to arteriosclerotic occlusionof the bilateral iliac arteries, has been suffering from high fever and blue toes in his left leg, followed by remission ofthe symptoms by administration of antibiotics. We was admitted because of the recurrence of the symptoms. Computedtomography revealed an occlusion of the left limb of the bifurcated graft and a small amount of perigraft fluidcollection. A presumptive diagnosis of graft infection in the left limb of the bifurcated graft was made and excision ofthe infected graft and revascularization were carried out. We found that the ileum was strongly adherent to the graftbody, with formation of the graft-enteric erosion. Resection of the involved ileum, total excision of the bifurcated graft,and extra-anatomical vascular reconstruction were performed. Mural thrombi inside the infected graft contained aseptic mass and were thought to be the source of the recurrent septic emboli. This postoperative course was uneventful.The patient received oral administration of amoxicillin for 6 months. So far there is no sign of infection, 18 month afterthe operation.
We report two surgical and interventional cases of hepatic artery aneurysm. In the first case, an aneurysm from the common hepatic to the proper hepatic artery was treated by aneurysmectomy and vein graft replacement. In the second case, an aneurysm in the right hepatic artery was treated by transcatheter coil embolization. The two cases had uneventful postoperative courses. Aneurysms of the hepatic artery are relatively rare. As rupture case is lethal, hepatic artery aneurysm requires surgical or interventional treatment before rupture.
The present case was a 69-year old man who at age 63 underwent transcatheter stent graft placement for a Stanford type B dissecting aortic aneurysm with a maximum diameter of 55 mm. Six years later, prosthetic graft replacement was performed due to enlargement of the descending thoracic aorta to 60 mm. The ulcer-like projection at the proximal portion of the stent graft was observed. The descending aortic was replaced. The extracted stent graft was deformed in shape, and its connecting struts were disconnected. Furthermore, part of the stent had perforated the aortic wall. These findings suggested that the stent graft was not flexible and that its shape was incompatible with the proximal descending aorta. In conclusion, stent grafts should be improved to be more compatible with the shape of aorta.
A 78-year-old man had abdominal aortic aneurysm and iliac artery aneurysms resected and replaced with a bifurcated Dacron graft. Two months later he was admitted to our hospital because of anorexia, fever and left lower quadrant abdominal pain. Computed tomography scan revealed gas bubbles within fluid collection surrounding the prosthetic grafts. Following this study he was taken to surgery and bilateral axillo-femoral (8 mm Dacron) grafts were implanted. After these incisions were closed, the aortic graft was removed and six drains were left with a retroperitoneal approach. He underwent transverse colostomy eight days later, since fistulagraphy through drains showed a communication between the paraprosthetic space and the sigmoid colon. His recovery while on broad spectrum antibiotics was uneventful, and he is doing well 2 years postoperatively.
We performed aorto-uniiliac stent grafting with a Zenith device (using a converter device) for abdominal aortic aneurysm. A 78-year-old man had undergone exclusion of his left iliac artery aneurysm and femoro-femoral crossover grafting. After the procedure, an abdominal aorta aneurysm appeared and increased in size. He received aorto-uniiliac stent grafting via his right femoral artery in our institute. The postoperative course was uneventful. We reported here a successfully treated a case of aorto-uniiliac grafting following exclusion of the left iliac artery.
We encountered a patient with a superior mesenteric artery aneurysm that was surgically treatable. The patient was a 75-year-old woman who had undergone a prior gastrectomy 30 years previously and who presented with abdominal pain and an abdominal mass. Abdominal computed tomography scan revealed an aneurysm (40 × 47 mm) in the superior mesenteric artery and angiography showed inadequate collaterals to the distal small bowel and colon from the celiac trunk and inferior mesenteric artery. Operation was accomplished by aneurysmectomy and an interposition of saphenous vein graft for revascularization. The excised aneurysm was found to have cystic medial necrosis. Preoperative assessment was useful to avoid the resection of intestine. The postoperative course was uneventful.
A 76-year-old man developed pain and swelling in his left thigh. The next day he was admitted to our hospital and computed tomography scan revealed aneurysms of bilateral deep femoral arteries, and the left-sided aneurysm was ruptured. Emergency operation was performed. The distal artery of the aneurysm could not be exposed because of intramuscular hematoma, so we ligated the deep femoral artery. The patient complained of leg swelling after the operation. Twenty days after the first operation, graft replacement of the right deep femoral artery aneurysm using a 6-mm expanded polytetrafluoroethylene prosthetic graft was performed. The postoperative course was uneventful and he was discharged 13 days after the second operation withour leg swelling.