Introduction:Obstructive arteriosclerosis (ASO) is a common disease associated with atherosclerosis and its incidence is increasing. However, there is little consensus regarding blood viscosity and coagulation in ASO progression. Objection: To investigate the risk markers of ASO progression. Design: Retrospective observation study. Patients and study site: One hundred-forty seven ASO patients required surgical treatment or angioplasty in tertiary teaching hospital. Methods: The preoperative Fontaine classification was extracted from retrospectively collected database. For definition of the ASO, patients were divided into two Fontaine groups; mild cases (Fontaine grade I and II), and severe cases (Fontaine grade III and IV). The parameters of ankle-brachial pressure index (ABI), blood cultures, and coagulation factors were evaluated by bivariate and the multivariate logistic regression analysis in association with the Fontaine-defined ASO groups. Results: The hematocrit and the serum fibrinogen concentration were found to be associated with the Fontaine classification. The hematocrit (OR 0.882, p < 0.01) and serum fibrinogen (OR 1.003, p < 0.05) were significantly different in subjects Fontaine I/II from III/IV, suggesting these to be strong predictive parameters for ASO. Conclusion: In examination of low ABI, we should be aware of the high risk of progression to ASO in cases of decreasing hematocrit and increasing serum fibrinogen. Routine screening of these parameters by laboratory test would enhance the detection of critical ASO and would allow secondary treatment to prevent critical limb ischemia.

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Background:This study was aimed to clarify the characteristics and outcome of elderly patients who had required aortic arch replacement, compared with the younger population. Methods: We performed aortic arch replacement using selective cerebral perfusion in 89 patients between 1992 and 2006, and the patients were divided into two groups (Group O; patients of 70 years or more, Group Y; patients less than 70 years) and reviewed for the characteristics, operative variables, and outcome. The average age was 74±3 years in Group O and 61±9 years in Group Y. Risk factors were analyzed for mortality by forward stepwise logistic regression analysis. Survival curves was evaluated by the Kaplan-Meier methods and evaluated by multivariate Cox regression analysis. Results: Non-atherosclerotic aneurysm (Group O; 27% vs Group Y; 53%, p = 0.02) and redo operation (Group O; 2% vs Group Y; 16%, p = 0.03) were more common in Group Y. Operative time (Group O; 526±97 minutes vs Group Y; 599±165 minutes, p = 0.013) and selective cerebral perfusion time (Group O; 90±23 minutes vs Group Y; 107±34 minutes, p = 0.008) were significantly longer in Group Y. There were no differences in in-hospital mortality (Group O; 8.9% vs Group Y; 4.5%), incidence of postoperative neurological deficit (Group O; 6.7% vs Group Y; 6.8%), and survival rate. The period of respiratory support after surgery was significantly longer in Group O. In addition postoperative neurological deficit (p = 0.008), aortic cross-clamping time (p = 0.025), selective cerebral perfusion time (p = 0.042), redo operation (p = 0.024) were also significant predictors for mortality, and cardiopulmonary bypass time (p = 0.03) and preoperative shock (p = 0.03) were associated with survival rate in Group O. Conclusion: Aortic arch replacement can be performed safely in elderly patients with no significant increase in perioperative morbidity or mortality compared with younger patients. Elective and skillful operation associated with brief period of cardiopulmonary bypass time is required to improve outcome of aortic arch operation in elderly patients.

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Celiac artery aneurysm is rare disease, but when ruptured it causes critical events such as shock. We report a case of saccular aneurysm of celiac artery operated with aneurysmectomy. A man with a symptom of abdominal pain was found to have the aneurysm by computed tomography. He was 50-year-old, and had received gastrectomy for a duodenal ulcer when he was 17. The laboratory data were almost normal with the exception of positive skin reaction to tuberculin. Gallium scan showed accumulation at the site of the aneurysm. The operation was performed under laparotomy, the celiac artery was ligated at its origin, and then the aneurysm was resected. A bypass using saphenous vein was done from the infra-renal aorta to the splenic artery and common hepatic artery. The resected aneurysm was 23 mm in diameter, and had arterial dissection. In cases of celiac artery aneurysm, it is important to consider the exact diagnosis, to select most effective therapy, and, if surgery is indicated, to perform most suitable operative procedure.

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We report a rare case of adventitial cystic disease of the popliteal artery causing intermittent claudication. About one month previously, the patient, a 48-year-old man, had sudden intermittent claudication in the right leg. In May 2007, he was examined and admitted to our hospital. He had a cold sensation in the right leg and no pulse in the leg was palpable below the right popliteal artery. The right and left ankle brachial pressure indexes (ABI) were 0.49 and 1.14, respectively. Angiography demonstrated smooth, localized narrowing in the right popliteal artery above the knee and computed tomography demonstrated occlusion of the artery external to the vessel. From the above, we made a diagnosis of adventitial cystic disease of the popliteal artery and performed arteriectomy of the right popliteal artery above the knee using a posterior approach, followed by a revascularization procedure using the great saphenous vein. Among the surgical findings, there was compression of the artery lumen due to a cyst which subadventitially contained jelly-like material. Postoperatively, the right ABI improved to 0.89.

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A 58-year-old man given a diagnosis of Behçet disease and who had been followed up for 7 years, complained of fever, abdominal pain, and arthralgia. Computed tomography (CT) revealed a saccular abdominal aortic aneurysm up to 4.8 cm in maximum diameter. The aneurysm wall had a shaggy contrast effect and involved a low density area with an irregular septum implying an abscess cavity. Laboratory data showed moderate inflammation (WBC 11700/mm³, C-reactive protein 4.1 mg/dl). We gave antibiotics (IPM/CS 500 mg x 4/day) for 11 days preoperatively supposing aneurysmal infection. We performed aneurysm resection, debridement, and Y-graft replacement (right branch to left common iliac artery and left to right common femoral artery: passing through the retroperitoneal-suprapubic route). Horseshoe kidney was a burdensome factor in this case. The resection of the isthmus necessary for aortic clamping and closure, as well as accessory renal artery ligature might increase the surgical stress. Although the culture of aneurysm wall was negative, the possibility of aneurysm infection was thought to be high. Long term antibiotic prescription and the CT examination of the anastomotic site thought be necessary.

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A 46-year-old man with Beçhet disease was admitted to our hospital for abdominal pain and we diagnosed impending rupture of a celiac arterial aneurysm. We performed urgent aorto-common hepatic artery bypass grafting with expanded polytetrafluoroethyrene. During 2 years, the patient has been free from complications, receiving predonisolone postoperatively.

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An 87-year-old woman, who had previously undergone ligation and bypass surgery for popliteal artery aneurysm (PAA), was referred to our hospital with a huge pulsatile mass in the right lower femoral region. The computed tomography angiography showed a remarkable enlargement of the excluded thrombosed PAA, 70 mm in maximum diameter, in addition to a proximal anastomotic aneurysm. Operation was performed through a medial approach. A large quantity (1250 g) of old thrombus was removed from the thrombosed PAA, followed by interruption of its patent branches, in a bloodless field under a thigh tourniquet. Reconstruction was performed from the superficial femoral to the below-knee popliteal artery with a reversed vein graft. She had an uneventful postoperative course with a patent graft. Careful long-term follow-up is mandatory for expansion of an excluded PAA.

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A 62-year-old woman with a history of homograft replacement for infectious thoracoabdominal aortic aneurysm was admitted to our hospital for hypertension 4 months after the previous operation. On the night of admission, she suddenly complained of severe low back pain and a pulsatile mass was noticed in the lower left back. Enhanced computed tomography revealed a saccular type aneurysm, with a diameter of about 80 mm, what had ruptured into the left extra peritoneal space. Taking into consideration her poor preoperative status, emergency endovascular stent-grafting was performed. The postoperative course was uneventful. She was discharged 3 weeks after surgery and is now doing well as an outpatient.

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