Background: Blunt traumatic rupture of the aorta is a life-threatening condition and has a high mortality rate. However, no therapeutic algorithm has not been established. Endovascular repair has gained rapid acceptance and some excellent results have been reported. The aim of this study is to evaluate the short-term surgical results for blunt aortic injury. Methods: Data from 14 patients (mean age, 36 years; range 16 to 61 years; 12 male, 2 female) with acute traumatic aortic injury treated by surgery between 1985 and 2006 were reviewed retrospectively. The trauma injury score (TRISS) was used to evaluate patients. Probability of survival (Ps) was 55–97.5% (mean 0.89 ± 0.03). Patients were divided into three groups; Group I (Ps < 80%), Group II (80 ≤ Ps < 95%), Group III (Ps ≥ 95%) and surgical results were compared. Results: One patient in Group I, 2 patients in Group II and 5 patients in Group III underwent emergency operations. Elective surgery was performed in 2 patients from Group I, 3 patients from Group II and 1 patient from Group III. Endovascular stent grafting was performed in 1 patient in Group II, and direct suture of the aorta was performed in 1 patient from Group II and 1 patient from Group III. Nine patients were treated with femoro-femoral cardiopulmonary bypass, 1 patient underwent left heart bypass and simple cross-clamping of the aorta was performed in 2 patients. Selective cerebral perfusion was required in 2 patients and circulatory arrest was employed in 2 patients. There was one operative death due to retroperitoneal bleeding. Conclusion: Patients who suffer blunt traumatic rupture of the aorta with multiple organ injury should be evaluated properly on admission. Endovascular stent grafting should be considered especially for high-risk multitrauma patients.

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Background: Tumescent local anesthesia (TLA) has widespread applications in cosmetic surgery. We report over 80 cases of vascular surgery with TLA. Patients: Between September 2003 and March 2008, 82 patients underwent the vascular surgery with TLA. There were 37 men and 45 women aged from 40 to 89 years (mean 64.9 years). Because of several risk factors for general anesthesia or the wishes of the patient, we performed vascular surgery under TLA only or added TLA. Results: Operation was performed as these: Stripping for varicose veins 47, peripheral artery surgery 22, shunt implant 6, endovascular aortic repair 4, pacemaker implantation 2, remove and debridment of infected prosthesis for hemodialysis 1. Surgery underwent with TLA-only (n = 35), or added-TLA to the local/intravenous/spinal/epidural anesthesia (n = 47). There was no mortality, morbidity related to the surgery, surgical site infection or conversion to general anesthesia with intubation. Because 4 of the patients who underwent with TLA-only method could not remain immobile, they received intravenous anesthesia (n = 3) or isoflurane inhalation with a facemask (n = 1). Conclusion: Although the TLA technique may have possible application for peripheral arterial surgery on patients with risk factors for general anesthesia, indications of TLA-only procedures might be limited to procedures above inguinal lesion in peripheral artery operation.

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Introduction: The archives of The 36th Annual Meeting of Japanese Society for Vascular Surgery held in April, 2008 (CD-ROM version) were mailed to members. The new attempt made by Professor Nanao Negishi was examined from the viewpoint of message theory. Methods: The contents of Symposium 5 “Results and Problems of Regeneration Therapy / Gene Therapy” contained in the abstracts of The 36th Annual Meeting of the Japanese Society for Vascular Surgery were summarized according to target diseases, treatments, indications, results, and medical safety / efficacy / problems, which were compared with the content of the archives (CD-ROM version). Results: The results of the Symposium differed greatly from the content of the abstracts. The “Chairperson’s Summaries” in the archives have the following characteristics: (1) they try to help members understand through comparison of the content of different presentations; (2) they attempt to explain differences in conclusions among different speakers in order to promote concept formation which would enable common understanding. Conclusion: The Chairperson’s Summary in the archives is not a mere record of the Annual Meeting of the Society. It performs the extremely valuable functions of increasing transparency, fulfilling accountability to society, and explaining the limitations of the possibility of medical practice, especially regarding medical lawsuits, to the legal community. It is a valuable means by which to show the real problems in medicine to society and the legal community. In addition, issues related to medical ethics and social missions were included.

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Background: Graft infection, in most cases caused by surgical site infection, is a serious complication in arterial operations. Prevention is thought the most effective prophylactic method. After encountering one fatal infection, we changed our strategy for surgical site infections. In this study we evaluated the effect of our new strategy. Methods: We divided 197 patients who underwent graft insertion for arterial disease in our hospital into 2 groups; the pre-group consisting of 101 patients operated before changing our strategy, and the post-group consisting of 96 patients operated on after changing. Our new strategy was; 1) prophylactic antibiotic infusion before the initial skin incision, 2) skin disinfection with chlorhexidine gluconate ethanol, 3) limitation of the use of brushes at the surgical scrub, 4) ample saline washing of the wound before closure, 5) use of a expanded polytetrafluoroethylene graft, 6) film dressing for packing the wound after the operation, and 7) limiting of wound opening after the operation. There were no differences between two groups in terms of age, gender, co-morbidity of diabetes, end stage renal disease, use of steroids, and operative methods. Results: Surgical site infection occurred in 7 cases in the pre-group, whereas there were no infections in the post-group; the incidence being significantly reduced in the post-group by the chi square test. The incidence of infection did not differ with co-morbidity of diabetes, end stage renal disease, use of steroids, and operation-related indices. In the pre-group, hospital death occurred in 7 cases, 3 of these were associated with the wound infection, but while hospital death occurred 4 in the post-group, there were no cases of wound infection (no statistically significantly different). Conclusion: Our new strategy was shown to be functional, producing good results and avoiding surgical site infections in arterial operations. It might also have led to a decrease in the incidence of hospital deaths as well as reducing health care costs associated with treatment of infections.

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Background: Infrarenal aortic dissection, superimposed on chronic abdominal aortic aneurysm is rare. Case: A 58-year-old woman presented with severe lower back pain. On contrast computed tomography, she was found to have acute infrarenal aortic dissection and chronic infrarenal abdominal aortic aneurysm. At surgery, the proximal extent of the dissection was located near the renal arteries. A bifurcated graft was sewn to the dissected neck of infrarenal aorta, incorporating a felt strip to reinforce the true and friable false lumina onto the graft. Results: Her post operative course was uneventful. She was discharged 16 days after operation. Conclusion: This experience suggested that surgical repair during acute period, which calls into question tissue friability, can be accomplished with standard techniques.

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Background: Complications caused by transluminally-placed endovascular prosthetic grafts (TPEGs) can be fatal in high-risk patients. Case: An 82-year-old man with chronic renal failure, coronary artery disease, carotid/cervical artery disease and bladder cancer (postoperative state) complicated with a descending aortic aneurysm received a TPEG. Results: The abdominal aorta and external iliac artery were damaged when the delivery sheath was removed. An aortic occlusion balloon was immediately applied and emergency surgical laparotomy was performed. The abdominal aorta was ruptured and the intima of external iliac artery was totally skeletonized from the adventitia. Graft replacement of the abdominal aorta and right external iliac artery resulted in rescue of the patient. Conclusion: The possibility of fatal complications of TPEGs requires careful consideration.

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Background: Pseudoaneurysm of the internal thoracic artery caused by blunt trauma is very rare. Case: We report a case of subcutaneously protruding psedoaneurysm of the internal thoracic artery following blunt trauma. Results: A 76-year-old man fell from a ladder. On the next day, he was admitted to a local hospital because of general discomfort. Right hemo-pneumothorax, with fracture of the pelvis and left radius were diagnosed. A protrusion from the right anterior chest wall with pain was observed and the protrusion was incised experimentally by a general surgeon 2 weeks later, whereupon arterial blood oozed out. But, the origin of bleeding could not be found. Therefore, it was compressed to achieve hemostasis. Pseudoaneurysm of the right internal thoracic artery by catheter angiography was diagnosed after another 2 weeks. Then, he was transferred to our hospital, and ligation of the right internal thoracic artery was performed immediately. He recovered, and was discharged on the 22nd day after operation. Conclusion: We reported a very rare case of subcutaneously protruding pseudoaneurysm of the internal thoracic artery following blunt trauma.

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Background: Acute arterial emboli of the bilateral lower extremities caused by an aortic aneurysmal thrombus are rare. Case: A 77-year-old man was admitted our hospital because of bilateral lower leg pain at rest. We diagnosed the case as atherothromboembolism of the lower legs, which had originated from an abdominal aortic aneurysm and bilateral common iliac aneurysms. Results: A graft replacement was performed to remove the embolic source on the 16th day after the onset. As a result of careful dissection and clamping and the use of some devices in anastomosis and declamping, his postoperative course was uneventful. He was discharged on the 14th day after the operation. Conclusion: Acute arterial emboli of the bilateral lower extremities caused by an aortic aneurysmal thrombus are rare, but this should be taken into consideration as one possible cause.

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A 75-year-old man was admitted with a diagnosis of suprarenal abdominal aortic aneurysm (SRAAA), 70 mm in maximum diameter. Three-dimensional computed tomography showed two polar renal arteries (RA) on both sides, and three of them arose from the aneurysm, except for the left upper RA. Operation was performed through a median full laparotomy. After suprarenal aortic clamping and opening of the aneurysm, a temporary shunt was employed from the left axillary artery to three polar RAs using a heparin-coated tube. Proximal anastomosis was performed with 18 × 9 mm woven Dacron bifurcated graft, and three polar RAs were anastomosed to the graft in order, under infusion of 150 ml cold Ringer’s solution for each. The distal anastomoses were made to the bilateral common iliac arteries, and the inferior mesenteric artery was finally reconstructed to the graft. He went an uneventful postoperative course without deterioration of renal function, and discharged 22 days after surgery. In surgical treatment of SRAAA, this technique is very useful because it can shorten the renal ischemic time and provide physiologic organ perfusion during graft replacement.

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Background: Insertion of tubular stentgrafts in the management of the thoracic aortic aneurysm has recently become a popular alternative to open surgery. The classical surgical procedure for ruptured thoracic aortic aneurysm is associated with mortality rates of up to 50% and prolonged intensive care hospitalization. However, endovascular procedures have been associated with significantly lower morbidity and mortality rates. Case: A 64-year-old man was transferred to our hospital due to back pain and dyspnea. He was alert, with a blood pressure of 124/60 mmHg and a pulse of 100/minute, and the conjuctivae were pale. Chest X-ray and ultrasound examination revealed extensive left hemothorax, chest-abdominal contrast computed tomography (CT) identified an aneurysm with a maximal diameter of 8 cm at the level of Th 6–10, and ruptured thoracic aneurysm was diagnosed. Considering the aortic diameter at the proximal and distal site of the aneurysm and a sufficient landing zone, endovascular stent-graft placement appeared viable. However, we postponed the surgery until the next morning due to the preparation of devices, and monitored him under strict control of blood pressure. He entered the operation room under general anesthesia, and a Dacron covered Z stent was implanted via a cut-down of the right femoral artery. After the surgery, intra-aneurysm thrombus formation was favorable. The respiratory condition was poor due to marked obesity, and tracheotomy was required. Results: The general condition gradually improved thereafter, and he was discharged 24 days after the operation. He has been monitored for 18 months, and chest CT scan after four months showed disappearance of aneurysm and hematoma. Conclusion: We think endovascular stent-graft repair seems to be technically feasible for critical patients with ruptured descending aortic aneurysm.

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