Objectives: The management of hemodialysis fistulas and grafts greatly influenced survival and quality of life in patients undergoing hemodialysis. Salvage of vascular access (VA) occlusion can be performed by interventional therapy (IVT) using balloon angioplasty or surgical reconstruction after thrombectomy and angiography. The purpose of this study is to compare the outcomes of each type of salvage procedures in restoring vascular access occlusion.
Methods: Between April 2001 and July 2008, we treated 378 consecutive cases of VA occlusions. The type of dysfunctional hemodialysis fistulas were 111 arteriovenous fistulas (AVF) and 267 arteriovenous grafts (AVG). The thrombectomy (TH)-alone group: 11 AVFs and 48 AVGs were treated with thrombectomy alone using a Fogarty balloon catheter. IVT group: 12 AVFs and 93 AVGs with stenosis predominated in the venous outflow leading to increase venous pressures were treated with balloon angioplasty after thrombectomy. The surgical reconstruction (SR) group consisted of 37 AVFs with stenosis predominately in the anastomotic area, the majority leading to inflow problems, which were reconstructed by proximal anastomosis, and 90 AVGs which could not receive balloon angioplasty were reconstructed by a jump graft to normal vein. The new VA group consisted of 51 new AVFs and 36 new AVGs. We compared the patency rates of each treatment using the Kaplan-Meier method.
Results: The 6- and 12-month patency rates after each treatment for AVF occlusions were respectively as follows: in the TH-alone group (n = 11) they were 66%, 66%, in the IVT group (n = 12) 54%, 46%, in the SR group (n = 37) they were 95%, 83%. In the new VA group (n = 51) they were 69%, 61% (AVF) and 58%, 52% (AVG). The patency rate for AVG occlusions were respectively as follows: in the TH alone group (n = 48) they were 34% and 22%, in the IVT group (n = 93) they were 45% and 28%, in the SR group (n = 90) they were 47% and 35%. In the new VA group (n = 36) they were 50%, 50% (AVF) and 69%, 61% (AVG). In AVF occlusions, the patency rate was significantly better in the SR group (83% at 12 months) than the TH-alone group (66%) and IVT group (46%) (log rank test, p < 0.05). In AVG occlusion cases, there was no statistically significant difference of the patency rate between the SR group (35% at 12 months), the TH alone group (22%) and IVT group (28%).
Conclusion: The patency after surgical reconstruction in AVF occlusions exceeds that observed in AVG. We concluded that it is possible to improve the patency of vascular access to attempt to restore using autogenous fistulae and to avoid AVG as much as possible given their poor outcome.

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A 63-year-old woman was referred to us because of ischemic pain in the left foot. An arteriogram showed a classic “string-of-beads appearance, involving the bilateral superficial femoral to popliteal arteries and bilateral internal carotid arteries. The left popliteal artery was occluded below the knee. Bilateral common iliac artery aneurysms measuring 6 cm on the left, 4 cm on the right were also found. Her iliac aneurysms were first successfully excised and reconstructed with a Y graft. After one month, her left leg ischemia was treated with reversed saphenous vein bypass from the femoral to the peroneal artery. With histological examination of the resected superficial femoral artery and the characteristic findings on angiography, her femoro-popliteal lesion was diagnosed as fibromuscular dysplasia.

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Deep venous thrombosis (DVT) is a complication of several diseases. However, DVT caused by infrarenal abdominal aortic aneurysm (AAA) is rare. Here we describe the successful management of such a case. A 62-year-old man was admitted to our hospital with swelling of the lower extremities. Contrast computed tomography scan of the abdomen and lower limbs showed a 73-mm infra-renal AAA and thrombotic occlusion of the inferior vena cava (IVC) and veins of lower limb. Prior to the operation, an IVC filter was placed in the IVC above the renal vein in order to prevent pulmonary embolism (PE). Among the surgical findings, there was severe adhesion around the AAA. Straight grafting was carried out with cross-clamping the abdominal aorta, right femoral artery, and left external iliac artery.
The postoperative course was problem-free, and the patient is doing well 13 months after the operation. We think this strategy is useful for high-risk patients in order to prevent PE.

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Background: We encountered a rare case of intravenous leiomyomatosis extending to the inferior vena cava. Case: The patient was a 47-year-old woman, who had a history of total hysterectomy due to uterine leiomyoma two months previously. Enhanced computed tomography revealed tumor extending from the hepatic inferior vena cava to the right common iliac vein, and the left femoral vein. Result: The tumor was removed by balloon catheter without cardiopulmonary bypass. The postoperative course was uneventful. Conclusion: We should decide on the use of cardiopulmonary bypass or venous reconstruction based on tumor characteristics.

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Blunt traumatic aortic dissection is a potentially life-threatening situation. We report a 72-year-old woman with traumatic aortic dissection from a traffic accident 5 years previously. She underwent conservative therapy because of the absence of mediastinal hematoma, enlargement of the descending aorta, or multiple injuries such as cerebral bleeding, rib fracture, and lung laceration. During follow-up for 6 years, the descending aorta enlarged from 35 mm to 55 mm in diameter on computed tomography. We performed graft replacement of the descending aorta under femoro-femoral venoarterial cardiopulmonary bypass. The pathological specimen from the aorta demonstrated a dissecting aneurysm, not a pseudoaneurysm. The postoperative course was uneventful without any complication.

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Background: Gastroduodenal artery aneurysm is very rare among visceral aneurysms. Once it ruptures, however, the outcome can be fatal. We report treatment of a case of non-ruptured gastroduodenal artery aneurysm.
Case: The patient was a 76-year-old man with a past history of only hypertension. He was introduced to our hospital to examine a pulsatile mass on the right upper abdomen accidentally detected by ultrasonography by a local doctor. Based on the findings of computed tomography and angiography we diagnosed gastroduodenal artery aneurysm with a maximum diameter of about 5 cm. On angiography, we found the proximal neck of aneurysm to be very short and could not perform interventional radiology (IVR). We decided to perform a surgical operation.
Result: We performed laparotomy under general anesthesia, and the common hepatic artery (CHA), right and left hepatic artery (RHA, LHA), and gastroduodenal artery (GDA) were clamped. The orifice of the GDA was sutured. Reconstruction of the hepatic artery was performed with direct anastomosis of the CHA and the proper hepatic artery (PHA).
Arterial blood flow to the liver was clearly detected by ultrasonography both intraoperatively and postoperatively, and on laboratory investigations, the indicators of liver function, alanine aminotransferase, aspartate transaminoferase etc. were normalized by the third postoperative day.
Conclusion: We report a rare case of non-ruptured gastroduodenal artery aneurysm treated successfully with surgical repair.

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Background: We report 2 patients who underwent thoracic endovascular aortic repair (TEVAR) for type I endoleak after open stent surgery for thoracic aortic arch aneurysms.
Cases: Case1: An 80-year-old man had undergone aortic valve replacement and total aortic arch repair with the open stent method for aortic valve incompetence and distal aortic arch aneurysm 3 years previously; he developed type-I endoleak 6 months later. Case 2: A 60-year-old man had undergone total arch replacement for type-A aortic dissection 9 years earlier; 5 years later he underwent open stent repair for pseudoaneurysm and reconstruction of the right subclavian artery which had originated from the descending aorta, however, type I endoleak was observed at the anastomotic site. He received resection and suture of the anastomosis and the endoleak disappeared. Then, one year later, follow-up computed tomography (CT) showed type I endoleak at the tip of the stent-graft.
Results: Stent-graft placement was technically successful; neither patient developed major complications. In Case 1 type I endoleak due to migration of the stent-graft developed after the first stent placement, therefore, we performed TEVAR again one year after. In both cases, CT performed during follow-up demonstrated complete thrombosis and patency of the stent-graft during the follow up period.
Conclusion: We performed TEVAR for type I endoleak after open stent surgery for thoracic aortic arch aneurysms in two cases. TEVAR was minimally invasive, safe and effective treatment for type I endoleak after open stent surgery for thoracic aortic arch aneurysms.

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Background: Anastomotic pseudoaneurysm (APA) may occur as a complication after surgical reconstruction of the aorta. We evaluated the effectiveness of endovascular stent-grafting (SG) for APA.
Methods: Eight men with a mean age of 74 years, with 10 APAs after surgical reconstruction of the aorta and its branches underwent SG. The location of APAs included 4 in the descending aorta, 2 in the abdominal aorta, and 4 in the iliac artery. The average interval from the prosthetic graft placement was 10 years. Four patients were symptomatic. We performed coil embolization in 4 patients for prevention of type II endoleak. They were followed with computed tomography (CT) angiographic study at 1, 3, 6 months, and every 6 months after the procedure until 6 years and annually thereafter.
Results: SG placement was technically successful in 9 of the 10 APAs; post-procedure aortography showed complete exclusion of the APA. In these 8 APAs, CT obtained during the follow-up period (12–72 months) demonstrated complete thrombosis of the APA and patency of the stent-graft; no major complications developed. One patient suffered recurrence of the APA at the proximal descending thoracic aorta after SG placement at the distal site, but the external iliac artery was inadvertently dissected during the second SG placement and the procedure was stopped. One patient with perforation of the duodenum occurred SG infection after 1 month, so we performed surgical reconstruction.
Conclusion: SG exclusion of APAs is a minimally invasive and safe alternative to open surgical reconstruction.

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Background: Endovascular aneurysm repair (EVAR) for abdominal aortic aneurysm is a minimally invasive regimen, but iodine contrast media is necessary and can be contraindicated in cases of iodine allergia or renal dysfunction. We treated a case with EVAR using carbon dioxide (CO₂) angiography. Case: An 87-year-old man who had undergone 4 laparotomies was receiving treatment for bladder stones. He had renal dysfunction. CO₂ angiography revealed a saccular abdominal aortic aneurysm caused by an ulcer-like projection. EVAR was indicated. Since EVAR requires contrast medium, the angiography was performed using medical CO₂. Conclusion: CO₂ is useful for angiography when iodinated contrast medium cannot be used. This method could increase operable cases of EVAR.

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A 50-year-old women presented with a swollen right leg. She had a history of osteoarthritis of both knees. In December 2004, she noticed a mild diffuse swelling of her entire right lower limb. Computed tomography demonstrated a 3 × 3 cm low density mass anterior to the iliopsoas muscle, compressing the femoral vein. We diagnosed iliopsoas bursitis because of the cystic mass near the iliopsoas muscle. We performed aspiration of the cystic mass under ultrasound-guided puncture. Surgical removal of the cyst was performed because the residual mass was compressing femoral vein even after aspiration. At operation a large, thick-walled cystic mass was found extending to the femoral vein, extending from the right iliac fossa. Postoperative course was uneventful.

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