Between July 2000 and December 2005, the long-term results of 98 patients with arteriosclerosis obliterans who underwent 105 femoro-above-knee popliteal bypasses, 11 femoro-below-knee popliteal bypasses and 9 other bypasses using precuffed expanded polytetrafluoroethylene grafts (Distaflo^TM) were examined. Anastomotic bleeding occurred in one patient, graft infection occurred in two and myonephropathic metabolic syndrome occurred in two after operation.
The primary patency rates were 88% and 88% at 3 and 5 years in the femoro-above knee popliteal bypass group, and 64% and 64% in the femoro-below knee popliteal bypass group, respectively. The long-term results with Distaflo^TM graft implantation were favorable.
Even if anastomotic myointimal hyperplasia should occur, significant stenosis will not occur at the anastomotic sites because the Distaflo^TM graft is a graft of cuff configuration. Improvement of late results may be expected with the use of this graft. The results from a randomized control trial are required before more definitive conclusions can be made.

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Background: Vascular surgeons are sometimes called on to complete an ongoing surgical procedure or to repair an intraoperative vascular injury by other surgical specialists. We have analyzed our experiences in these cases. Methods: Since 1992, 28 patients in other departments were operated jointly with vascular surgeons. Six patients were operated in the gynecology department, 3 in urology, 1 in pediatric surgery, 1 in otology, 1 in orthopedics, and 16 in general surgery. The procedures were repair of intraoperative vascular injury, repair or extraanatomic bypass for infuse-a-port complication, and concomitant vascular resection and reconstruction with neoplasm removal. Results: Postoperative morbidity and mortality were acceptable except for the cases complicated with infected infuse-a-port. Especially in the patients with malignancies, the extended operations were safely performed and an improvement of quality of life was obtained. However, long-term survival could not be obtained, except for the patients with renal cell carcinoma. Conclusion: The conditions for calling on vascular surgeons for assistance in the operations at other department were divided in repair of the intraoperative vascular injury, delayed vascular complication of the catheter treatment, and concomitant vascular resection and reconstruction in neoplasm removal. Vascular complication with infection had a poor outcome. Although extended operation for the malignancies with concomitant vascular resection could be performed with acceptable morbidity and mortality, such operations could be justified only in cases of renal cell carcinoma, in terms of long-term survival.

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Aim: Conventional stripping requires two incisions (groin and distal side). We report experience with a new vein stripper, InvisiGrip (LeMaitre Vascular, Inc., Germany). It has already been authorized in Europe and the USA, and is in clinical use. InvisiGrip enables us to strip the great saphenous vein by an invagination method from one groin incision with little hemorrhage after operation. Methods: From November 2006 to August 2007, 34 patients with 44 limbs underwent the stripping operation with InvisiGrip. Six men (7 limbs) and 28 women (37 limbs) were aged from 29 to 78 years old (average age 58.0). The preoperative coexisting symptoms was one case of cardiac disease with Warfarin control and one hepatic disorder. Results: There were remarkable complications. Although 31 great saphenous veins were successfully removed with the invagination method, 13 great saphenous veins were traditionally removed. Although 29 great saphenous veins were successfully removed with one procedure, 10 veins needed two procedures. He additional incision has been required for stripping. There was no subcutaneous hematoma after operation in 36 limbs. Although 8 subcutaneous hematomas were recognized 7 days after operation, all subcutaneous changes were diminished within one month after operation. In addition, body mass index did not affect the success rate for the surgical procedure. Conclusion: No remarkable complications have been recognized with the used the new vein stripper, InvisiGrip. It allows us to remove the great saphenous vein from one groin incision safely and successfully.

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The purpose of this study is to examine the long term results of hemodialysis access placement and maintenance procedures in order to clarify the most effective strategy for maintaining the functional access over long periods of time. Of patients who underwent hemodialysis access procedure in our facility in the 23 years dating from December 1984 to November 2007, long term follow-up data was available for 1895 patients that were involved in the study. Hemodialysis access procedures using autogenous conduits were performed on 1560 patients (82.3%), whereas prosthetic conduits were used on 114 patients (6.0%). Percutaneous transluminal angioplasty was performed on 221 patients (11.7%). The 1, 3, and 5 year secondary patency rates for each modality were as follows: snuff box arteriovenous fistula (AVF) 61, 53, 44%; Brescia-Cimino AVF 70, 59, 54; radial-cephalic direct forearm access 78, 69, 58; antecubital brachial-cephalic AVF 87, 72, 55; prosthetic forearm loop access 59, 39, 24; prosthetic upper arm loop access 63, 36, 27; patch angioplasty 64, 64, 53; PTA 59, 49, 46. The best 3 year secondary patency rate was the 87.6% which was seen in upper arm vein transposition coupled with antecubital AVF procedure. Thrombosis of the fistula peaked at two different periods; the first 2 years following the operations and re-emerges after the 10-year mark. Postoperative surveillance should be focused on these periods. Excellent results of procedures using autogenous vessels, including deep vein transposition, encourage more use of these conduits in vascular access procedures.

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We report a case of an extremely elderly patient with Stanford A acute aortic dissection who underwent successful graft replacement of the ascending aorta. The patient was a 95-year-old woman, capable of everyday independent activity. She had sudden loss of consciousness at mealtime. She visited a clinic where a chest X-ray showed abnormalities, and was then transferred to our hospital. Computed tomography scan revealed aortic dissection with cardiac tamponade. Emergency surgery was performed to save her life. Although the postoperative course was not problem-free, patient entered remission on day 77 following admittance and was subsequently moved to another hospital for rehabilitation.
Stanford type-A acute aortic dissection has a high degree of urgency and severity with poor prognosis if managed conservatively in patients whom surgery is indicated. Even with current stable surgical techniques, the likelihood of excessive surgical stress remains unchanged, with varied opinions on the legitimacy of applying such techniques to elderly patients. Recently, however, with the intention of performing entry closure, a number of studies have focused on avoiding extended surgery, aiming to perform less invasive surgery. This is thought to be of particular use in performing life-saving surgery on elderly patients.

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A 70-year-old man had undergone at age 69 prosthetic graft replacement for an infected abdominal aortic aneurysm. Eight months after discharge, he was readmitted because of anemia and loss of consciousness. Gastrointestinal endoscopy showed no abnormalities. On the fifth day after admission, he suddenly developed melena. Since emergency computed tomography revealed a pseudoaneurysm at the distal site of prosthetic graft anastomosis and the presence of gas in the aneurysmal sac, he was admitted to our center. Graft-enteric fistula was diagnosed and he underwent an emergency operation. Since he was in shock, the left axillary artery was exposed first, and an aortic occlusion balloon catheter was inserted into the descending aorta. Laparotomy revealed disruption of the distal anastomosis with pseudoaneurysm formation and fistulation into the duodenum. We performed left axillobifemoral bypass, prosthetic graft removal with omental filling, and finally fistulectomy with duodenojejunostomy. After surgery, cultures of blood and perigraft abscess fluid revealed methycillin resistant Staphylococcus aureus, and vancomycin hydrochloride was administered. His subsequent course was uneventful, and 1 month later, he was discharged. Although this patient was in shock on admission, he was successfully treated by controlling bleeding using an aortic occlusion balloon catheter, performing extra-anatomic bypass and omental filling, and effective antibiotic administration after surgery.

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The combination of common iliac vein occlusion and ipsilateral multiple internal iliac arteriovenous fistulae (AVF) is very rare. We report favorable results by venous reconstruction for this rare case. The patient was a 83-year-old woman, her chief complaint was painful left lower extremity swelling. Initially, a covered stent was implanted in the internal iliac artery to occlude the AVF, but only 1 month later, she was readmitted because of swelling of her left lower extremity and congestive heart failure. Operartion was performed, which consisted of division of left internal iliac artery, ligation of main left iliac AVF and bypass grafting between the left external iliac vein and inferior vena cava using a ringed ePTFE graft. Swelling of the left lower extremity and heart failure markedly improved. From her past history, the etiology of multiple AVF was neither traumatic nor iatrogenic, so we speculate that congenital and subclinical AVF was progressed by common iliac vein occlusion.

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A 70-year-old man presented with a Baker cyst in his left knee. Two months previously he had undergone a femoro-popliteal artery bypass graft above the knee under a diagnosis of the arteriosclerosis obliterans. Baker cysts are often associated with intra-articular disorders of the knee joint, especially osteoarthritis, rheumatoid arthritis and meniscal tears. To the best of our knowledge, there has been no report about Baker cyst occurring after a femoro-popliteal bypass without an intra-articular disorder of the knee joint. We describe this rare case and its clinical course from onset to operation.

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Spinal cord ischemia after infrarenal abdominal aortic aneurysm repair is a rare but catastrophic event. We present a case of paraplegia following elective repair of an infrarenal aortic aneurysm. An 82-year-old man was admitted for elective repair of a 6-cm infrarenal aortic aneurysm involving the left common iliac artery. Left external iliac occlusion was also noted. In a routine operation, the abdominal aorta was cross-clamped below the level of the renal arteries, a Dacron bifurcated graft was anastomosed end-to-end to the infrarenal aorta and end-to-end to the right common iliac artery and the left hypogastric artery. The left external iliac artery was revascularized by the use of an interposed graft between the left limb of the graft and the left common femoral artery. Inferior mesenteric artery was implanted into the body of the Dacron aortic graft as a Carrel patch. The duration of the operative procedure was 266 min, and the aortic cross-clamp time was 40 min. Intraoperative blood loss was 1141 g, and a cell saver was used. On the first postoperative day paraplegia occurred, with intact proprioception and vibration sense. Faecal and urinary incontinence were also noted. He had loss of pain and temperature sensation below the L-2 dermatome (more to the left). Magnetic resonance imaging showed a zone of high-signal intensity (Th11-L2) consistent with edema after spinal cord infraction. The patient was placed under intensive physiotherapy and rehabilitation with minimal improvement, but remained paraplegic at discharge, 6 months after operation. Spinal cord ischemia after abdominal aortic aneurysm repair is a rare but devastating complication that appears to be random, unpredictable and until now no measures are available to completely prevent this dreadful complication.

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An 86-year-old man was referred to our hospital because of sudden left lower abdominal pain. He had undergone infrarenal abdominal aortic aneurysm (AAA) repair at the age of 80. Computed tomography revealed a ruptured large left internal iliac artery aneurysm and the intact site of the previous repair. An emergency operation was performed and he was discharged on the 32nd postoperative day on foot. Ruptured internal iliac artery aneurysms following AAA repair are rare. We recommend a retroperitoneal approach and endoaneurysmorraphy as surgical treatment for this challenging condition.

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We report a case with superior mesenteric arterial thrombosis, for which revascularization using a pedicled in-situ right gastroepiploic arterial graft was performed. The patient was a 65-year-old man with sudden onset of abdominal pain. The urgent operation was performed 16 hours after onset since atherosclerosis of the abdominal aorta was noted. The right gastroepiploic artery was harvested, and end-to-side anastomosed to the distal superior mesenteric artery. The postoperative course was uneventful and he had a good clinical course. Revascularization using the right gastroepiploic artery is possible in cases of superior mesenteric arterial thrombosis, and this procedure should be considered as one choice.

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A 59-year-old man was admitted for repair of an infrarenal abdominal aortic aneurysm. He had also been receiving continuous ambulatory peritoneal dialysis (CAPD). We performed hemodialysis using a double-lumen catheter from 7 days before the operation, and bifurcated grafting was accomplished through the right retroperitoneal approach. Hemodialysis was continued for 3 weeks postoperatively, and then returned to CAPD. He was discharged 34 days after the operation without any decrease in his activities of daily life. This is apparently the first case of repair for abdominal aortic aneurysm associated with CAPD in Japan.

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A 67-year-old man was admitted to our hospital for surgical repair of a 93-mm descending thoracic aortic aneurysm (TAA) and a 72-mm infra-renal abdominal aortic aneurysm (AAA). He also had an ischemic heart disease and renal dysfunction. In an attempt to decrease the risk associated with simultaneous thoracotomy and laparotomy, we performed combined thoracic stent graft placement and abdominal aortic replacement. Although the greater radicular artery was preserved, he exhibited delayed paraplegia 13 hours after surgery in conjunction with obstruction of spinal drainage, a hypotensive episode and anemia. This symptoms improved after aggressive blood pressure support, spinal drainage and administration of corticosteroid. This patient was ambulating at discharge. Contrast computed tomography showed complete thromboexclusion of TAA with a stent-graft.

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