Background: Atrial fibrillation (AF) often occurs as a complication following surgical repair of acute type A aortic dissection. Here, we investigated the postoperative effect of landiolol hydrochloride (Onoact^®) on AF by continuously administering the drug at a low dose following surgical correction of the aortic dissection. Methods: During the period from April 2005 to March 2008, of 75 patients treated surgically, 25 patients treated with landiolol hydrochloride were classified as group O, and 50 patients who were not treated with the drug were classified as group N. One hour postoperation, continuous administration of landiolol hydrochloride was started at 0.05 mg/kg/min for 120 hours. We then measured the variations in pulse rate, blood pressure, cardiac index, the frequency of occurrence of AF, and any complications during the dosing period. Moreover, we examined the frequency of occurrence of AF until the patients were discharged. Results: The variations in pulse rate, blood pressure, and cardiac index during the dosing period were not significant. In group N, the frequency of occurrence of AF during the postoperative 120-hour period was 48% (24 of 50 cases). On the other hand, in group O, it was 16% (4 of 25 cases) (p < 0.01). The frequency of occurrence of AF up to the time of discharge was 52% (26 of 50 cases) for group N, and 28% (7 of 25 cases) for group O. The complications were bradycardia, and atrioventricular block. In group N, 14 of 24 cases had tachycardia with a pulse rate of more than 100 beats per minute. In 4 cases of postoperative occurrence of AF in group O, the pulse rate was below 90 beats per minute, and tachycardia was not observed. Moreover, in group O, 18 cases with oral administration of a β-blocker after the dosing period had no AF and 3 cases without oral administration of a β-blocker had AF. Conclusion: Continuous administration of low-dose landiolol hydrochloride significantly suppressed the occurrence of AF following surgical repair of acute type A aortic dissection. After landiolol hydrochloride administration, its effect tended to continue, and oral administration of a β-blocker increased its effect. In cases in which postoperative AF occurred despite the administration of landiolol hydrochloride, tachycardia was suppressed and hemodynamic status was stable.

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Background: The aim of this study was to investigate the efficacy of “hybrid revascularization”, which consists of iliac endovascular surgery together with minimally invasive bypass grafting for arteriosclerosis of the leg. Methods: We studied 144 consecutive patients given a diagnosis of aortoiliac occlusive disease (AIOD) between 1998 and 2006. Their mean age was 69 years old. The study patients were classified according to sites of arterial sclerotic lesions. Results: The patient group consisted of 100 cases of segmental distal lesions and 44 cases of extended distal lesions. More patients with extended distal lesions initially presented with critical limb ischemia than those with segmental distal lesions (93% vs. 38%; P<0.01). Furthermore, the frequencies of hemodialysis treatment (39% vs. 17%; P < 0.01), previous history of cerebrovascular disease (59% vs. 41%; P < 0.05) and major amputation (48% vs. 4%; P < 0.01) were significantly higher among the patients with extended distal lesions than those with segmental distal lesions. A total of 74 patients underwent revascularization, including conventional bypass operation in 47 patients, iliac PTA/stent alone in 10, and PTA/stent and distal bypass grafting in 17. A transperitoneal approach was used in 27 of 47 patients undergoing conventional revascularization. Five of them had postoperative respiratory complications while no patients undergoing hybrid revascularization had such complications. Conclusion: Our results suggested that the patients who have AIOD with extended distal lesions may benefit more from the hybrid revascularization.

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Total knee arthroplasty is known as a relatively safe procedure and vascular complications are very rare. A 62-year-old man, who had undergone right total knee arthroplasty (TKA) 9 days before, was referred to our hospital with a popliteal artery pseudoaneurysm. The arterial perfusion of the leg below the knee was poor, with severe swelling. A emergency operation was performed through a posterior approach. The thrombus was removed and the artery was repaired directly. He had an uneventful postoperative course with good arterial perfusion and returned to the orthopaedist 3 days later. We obtained good results in this case of popliteal artery pseudoaneurysm after total knee arthroplasty.

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A 54-year-old woman had suffered from scleroderma and had taken corticosteroids from age 37. She complained of an abdominal pain in a region compatible with abdominal aorta and superior mesenteric artery aneurysms pointed out on computed tomography. Our diagnosis was symptomatic abdominal aortic aneurysm and we performed an operation replacing the abdominal aortic aneurysm with a bifurcated prosthetic graft and resecting the superior mesenteric artery aneurysm. The abdominal aortic aneurysm was a chronic contained rupture with vertebral destruction. Pathological examination revealed the arterial wall to be replaced with fibrous connective tissue. We speculated that the cause of the aneurysms was long term corticosteroid therapy.

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We report a rare case of situs inversus in an elderly patient complicated by ruptured visceral and unruptured abdominal aortic aneurysms. An 87-year-old man was admitted to the emergency service of our hospital after being given a diagnosis of intraperitoneal hematoma based on computed tomography (CT) findings at a nearby medical institution, where he had been admitted with a chief complaint of upper abdominal pain. CT revealed situs inversus of all organs in the chest and abdomen. A ruptured visceral aneurysm at the periphery where the superior pancreaticoduodenal artery joins with the superior mesenteric artery, an infrarenal abdominal aortic aneurysm and intraperitoneal haematoma extending from the upper abdomen to the left intraperitoneum were also detected. The patient was in a state of shock at the time of admission, and underwent emergency visceral aneurysmectomy and vascular graft replacement of the abdominal aorta. The stomach and pancreatic head had been displaced by the hematoma. Visceral aneurysmectomy was followed by bifurcated graft replacement of the abdominal aorta. Although concurrent disseminated intravascular coagulation (DIC), pancreatitis and ileus were caused due to hemorrhagic shock and compression of surrounding organs by the hematoma after the operation, the patient attained remission after conservative treatment.

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Background: A false aneurysm in the anterior tibial artery caused by blunt trauma is rare. Methods: Here we report the case of 70-year-old woman with a traumatic pseudoaneurysm in the anterior tibial artery complicated with peroneal nerve paresis. Results: An incision of the aneurysm revealed the 1.5 mm-segment of laceration in anterior tibial artery and the laceration was closed with interrupted sutures. The peri-operative course was uneventful. The symptom of drop foot recovered gradually. Conclusion: Our case was complicated with peroneal nerve paresis and needed surgical decompression. There are various options of treatment for pseudoaneurysms. We should choose the option suitable to each case.

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Background: Isolated spontaneous dissection of the superior mesenteric artery is rare. We encountered this rare entity and successfully treated it by endovascular stent placement. Methods: The patient was a 48-year-old man and he developed sudden abdominal pain. Contrast-enhanced computed tomography revealed dissection of the superior mesenteric artery and the true lumen was compressed by the partially thrombosed false lumen. Two PALMAZ^TM stents (7 × 20 mm and 8 × 20 mm) were deployed in the true lumen through a transfemoral approach. Results: Blood flow to the distal branches improved significantly after stent deployment. Immediately after the procedure he became asymptomatic and was discharged 9 days after the procedure. One year later, the superior mesenteric artery was shown to be patent by contrast-enhanced computed tomography. Conclusion: Endovascular therapy is a good option for anatomically feasible cases of isolated spontaneous dissection of the superior mesenteric artery.

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Spontaneous dissection of the superior mesenteric artery (SMA) is a rare occurrence, especially when not associated with aortic dissection. When it does occur, it commonly causes aneurysmal rupture or intestinal ischemia. The cause and natural history of isolated dissection of the SMA are unknown. Because of the scarcity of reported cases, no standard medical or surgical treatment has been established. Recently, some conservatively treated cases involving isolated dissection of the SMA have been reported. Five patients with isolated dissection of the SMA who were treated conservatively at our hospital between 2000 and 2006 were studied. The 5 patients comprised 4 men and one woman whose ages ranged from 39 to 62 years, with a mean age of 50 years. Because of increasing pain, one case underwent laparotomy, but surgical treatment was not needed because direct visualization of the intestine showed no ischemia. All five cases experienced full recovery with conservative management and remain free from this disease. Isolated dissection of SMA is rare, with only 56 patients, including our own, reported in the literature in Japan. This disease should be kept in mind for the differential diagnosis of abdominal pain as it may otherwise fail to be detected. Rapid diagnosis is necessary in order to choose the appropriate therapy (surgical or conservative) for isolated SMA dissection.

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We encountered 2 cases of vertebral artery transposition for the treatment of the vertebral artery stenosis. Case 1 was a 51-year-old woman. She had a visual disorder and careful examination revealed stenosis at the origin of the bilateral vertebral arteries and the left subclavian artery. Case 2 was a 66-year-old woman who frequently had sudden attacks of vertigo and careful examination revealed stenosis at the origin of the left vertebral artery and the left subclavian artery. Both cases were successfully treated with vertebral artery transposition and the clinical symptoms disappeared.
Unlike stenosis of the carotid artery and the subclavian artery, therapeutic indications for vertebral artery stenosis are unclear. Generally, surgical indications for the vertebral artery stenosis are thought to be lesions with clinical symptoms, however, consensus has not yet been obtained. Recently, there are many case series suggesting that endovascular surgery at this site is safe and effective. However, there have been no randomized trials comparing open surgery with endovascular surgery. Moreover, the long-term outcome of endovascular surgery also remains unclear. Further investigation is needed for endovascular surgery to become the first line treatment of vertebral artery stenosis.

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Background: Although the inferior vena cava filter is effective for protection against pulmonary embolism associated with deep vein thrombosis, several kinds of complications have been reported. Patient and method: A 79-year-old woman who suffered from dyspnea was admitted with deep vein thrombosis and pulmonary thromboembolism. Protein S deficiency was revealed by a significant decrease in protein S activity. A temporary inferior vena cava filter (tIVCF) was inserted to prevent new pulmonary thromboembolism. After 13 days of anti-coagulant therapy, cavography revealed complete occlusion of the vena cava at the tIVCF. We tried catheter-directed thrombolysis and catheter thrombectomy, but were unsuccessful. The patient then underwent vena cava ligation under open laparotomy. The surgery was successful and she was discharged on post-operative day 20. Conclusion: Although this is a rare complication, we must carefully observe patients after insertion of temporary inferior vena cava filters.

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