Objectives: To compare two methods of treatment for carotid arterial stenosis, carotid endarterectomy (CEA) and carotid artery stenting (CAS), by means of diffusion-weighted MR imaging (DWI). Methods: Nineteen treatments in 18 cases during the 2007 academic year were included in this study. CAS was performed for 9 cases with 10 lesions (10 procedures), while 9 cases with 9 lesions (9 procedures) were treated by CEA. Patients were examined by a neurologist before and after the procedure, and had pre- and post-procedural DWI. Results: No strokes or TIAs were observed in these cases. New DWI lesions were found in 7 out of the 10 procedures of CAS imaged 24 hours postprocedure, (average: 2.0 lesions). No new lesions were detected on DWI of CEA cases (χ2 = 8.33, p = 0.0039). Conclusions: Certain high-risk subsets may respond well to CAS with a very low incidence of clinically-evident neurologic events, but with significantly higher incidence of periprocedural micro-brain embolism. Currently, CEA should be the first choice of treatment for atherosclerotic carotid artery stenosis.
Objectives: Since 2007, the EVAR (endovascular abdominal aortic repair) grafts, Zenith, Excluder and Powerlink had been commercially available in Japan. However, a small iliac artery, typical of Japanese population especially in women, was a limiting factor to indicate EVAR. We analyzed the suitability of EVAR in Japanese population according to the inclusion criteria of Zenith AAA stent graft in the current study. Methods: From January 2006 to December 2007, 106 AAA (abdominal aortic aneurysm) patients (88 men, 18 women) with a mean age of 73 years were investigated in our institution by multi-slice CT scan in terms of suitability of EVAR, then we measured their abdominal aorta and iliac artery parameters as follows; 1) proximal neck diameter (PND) and length (PNL), 2) common iliac artery diameter (CIAD) and length (CIAL), 3) suprarenal (SNA) and infrarenal neck angulation (INA), 4) external iliac artery diameter (EIAD) and 5) aortic length from the lowest renal artery to the aortic bifurcation (AOL). The inclusion criteria for Zenith AAA stent graft treatment were; A) PND: 18–28 mm, PNL more than 15 mm, B) unilateral CIAD less than 20 mm, CIAL at least 10 mm, C) SNA less than 45 degree and INA less than 60 degree, D) unilateral EIAD more than 7.5 mm. Results: The indication of EVAR was 25.5% (27 / 106 patients), and was especially very low in women (5.6%) strictly according to the inclusion criteria of the Zenith AAA stent graft. The main reason of exclusion of EVAR was proximal short neck (40.5%), small iliac artery (30.4%) and infrarenal aortic neck angulation (29.1%). In our analysis, female AAA patients had small PNL and EIAD with angulated neck compared with male AAA ones. Conclusions: Anatomical suitability of EVAR in Japanese population strictly following by the inclusion criteria of Zenith AAA stent graft was low due to their characteristic differences from EU and US patients, such as short proximal neck, steep neck angulation and small iliac artery, especially in women. More flexible or branched/fenestrated grafts with a low profile sheath may be essential to be indicated EVAR in more Japanese AAA patients.
Background: For colonic ischemia following abdominal aortic repair, there has been no specific treatment other than resection of necrotic colon or bowel rest with fluid replacement and administration of antibiotics. Here, we report the usefulness of octreotide for non-transmural colonic ischemia. Methods: From 2000 to 2007, colonoscopic studies were done for cases who experienced diarrhea or high fever after abdominal aortic or iliac arterial aneurysm repair. We administered octreotide subcutaneously (50–100μg twice a day) to patients with colonic ischemia of the mucosa (grade 1) or of the mucosa and the muscular layer (grade 2), confirmed by endoscopy. Effectiveness of octreotide was determined by lessening of diarrhea and endoscopic improvement. Results: During this period, 187 cases (42, rupture; 145, non-rupture) underwent abdominal aortic or iliac arterial aneurysm repair. Seven cases (4, rupture; 3, non-rupture) of colonic ischemia were identified by colonoscopy. The incidence of colonic ischemia was 9.5% for rupture and 2.1% for non-rupture. After administration of octreotide, fever or diarrhea improved within 24 hours in 6 of the 7 cases (86%), and complete resolution of diarrhea within 2 days was observed in 5 cases. Improvement of colonic ischemia (narrowing of ulcer and regeneration of surrounding mucosa) was also recognized by colonoscopy. No patients required colectomy for secondary colonic stricture. Conclusions: Although the mechanism is unclear, octreotide seemed to be effective for non-transmural colonic ischemia (grades 1 and 2) following abdominal aortic aneurysm repair.
Objectives: Previous reports on spontaneous isolated superior mesenteric artery (SMA) dissection have failed to achieved consensus about optimal therapy. Methods: Seven patients (1 woman) with a mean age of 55 (39-82) years were reviewed, received conservative therapy for isolated SMA dissection between October 2006 and November 2008. Results: All patients had severe abdominal pain, but since none of them had signs of peritoneal irritation, we selected conservative therapy. Five patients were hospitalized and treated conservatively by hypotensive therapy, anticoagulation, and administration of prostaglandin E1. No patient had progression of the lesion during follow-up. Four patients underwent repeat CT, which showed a decrease or disappearance of the false lumen, and there was no aneurysmal change. Conclusion: Conservative treatment was successful in all 7 patients with isolated SMA dissection. Based on our experience, patients without acute intestinal ischemia and aneurysmal changes can be treated conservatively.
An inferior pancreaticoduodenal arterial (IPDA) aneurysm was incidentally pointed out in a 43-year-old man by computed tomography (CT) for examination of another disease. CT and angiography showed a 12-mm saccular type IPDA aneurysm and severe stenosis of the celiac axis by median arcuate ligament, and celiac axis compression syndrome (CACS). It also showed that the IPDA was a good collateral pathway for the celiac artery. Therefore, it was important to prevent perioperative ischemia of the abdominal organs. First, we divided the median arcuate ligament, and subsequently resected the IPDA aneurysm. After surgery the patient recovered without significant incident. We believe that it is necessary to organize the strategy for surgical treatment for IPDA aneurysm with CACS.
We successfully treated saccular aneurysms of the infrarenal abdominal aorta using the Powerlink endograft system. Preoperative multi-detector row computed tomography (MDCT) revealed that the abdominal aortic aneurysm was of saccular type, with a very narrow terminal aorta, 12 mm in diameter. The other commercially available stent graft devices, Zenith and Excluder, which presently can be used in Japan as authorized by the Ministry of Health, Labour and Welfare, were not suitable for this case, because the narrow terminal aorta made it impossible to access the contralateral leg gate. On the other hand, the Powerlink endograft system has a unique unibody bifurcated design, enabling it to be implanted safely and effectively. After treatment, no graft related endoleak was identified during follow up period.
Background: The operative risk for patients on antiplatelet therapy is greater for aortic operations. We present two patients on antiplatelet therapy who underwent elective surgery for impending ruptured thoracic aortic aneurysms after conservative treatment in the acute phase. Case 1: A 75-year-old man with back pain was admitted to our hospital and a ruptured thoracic descending aortic aneurysm was diagnosed on computed tomography. As he was on antiplatelet therapy, we selected conservative treatment. He underwent a scheduled descending aortic aneurysm repair 24 days after admission. Case 2: An 81-year-old woman was transported to our hospital with a ruptured distal aortic arch aneurysm. As she was on antiplatelet medications and her vital signs were stable, we treated her conservatively for 12 days before she underwent a total arch replacement. Both patients were discharged with no complications. Conclusion: Although a ruptured thoracic aortic aneurysm is an indication for urgent surgery, patients on antiplatelet therapy can be treated conservatively with subsequent elective surgery if their vital signs and symptoms can be stabilized by anti-hypertensive therapy.
Background: Aortic infection is comparatively rare, but the course is sudden. Case: A 75-year-old man was given a diagnosis of polymyalgia rheumatica 6 year previously, and had been taking steroid drugs. A month previously, he was admitted to our hospital with chest back pain, and we diagnosed acute type B aortic dissection. Result: We suspected aortic dissection associated with infection because of high fever and inflammatory reaction around the aorta at CT scan. Then antimicrobial treatment was started. Salmonella was detected by blood culture. Five weeks later after admission, the sudden waist back pain was appeared. Aortic re-dissection and right leg ischemia were identified on CT scan. The Right axillary artery-right femoral artery bypass was performed. Conclusion: Aortic infection is comparatively rare, but has a sudden course. In Stanford B type aortic dissection, strict control of blood pressure and antibiotic therapy are important. However, the risk of rupture, rapid expansion and re-dissection of the aorta is very high. It is necessary to perform surgical treatment promptly when some complications of aortic dissection occur.
An 80-year-old woman with left common iliac artery occlusion had received right external iliac- left common femoral artery crossover bypass using 6-mm gelatine-coated Dacron graft. Postoperative angiography revealed no evidence of graft stenosis. The left ankle-brachial pressure index (ABI) had improved from 0.49 to 0.84 after the operation. Thirty-two months later, left intermittent claudication appeared again, and the ABI decreased to 0.56. Angiography demonstrated a localized stenosis in a non-anastomotic site, straight portion of the graft. A re-do operation was performed and the fibrotic, funnel-shaped stenotic thrombus was removed. No restenosis was seen 38 months after the second operation and the ABI remains 0.73. The mechanism of stenosis was not clear but turbulent flow caused by temporary compression of the graft, might have led to a clot formation in the non-anastomotic site.
Radiation therapy for cancer sometimes causes vascular occlusion, and is known as radiation arteritis. We report two successfully treated cases of suspected radiation arteritis with intermitted claudication. In both cases artery reconstruction was performed by avoiding direct incision, because it was reported that direct incision to radiated area had a high complication rate. Case 1 was a 53-year-old man, who had received irradiation for testicular seminoma at the age of 35. The occlusion was located in the right external iliac artery and we performed extra-anatomical bypass. Case 2 was a 59-year-old woman, who had received the irradiation for uterine carcinoma at the age of 40. The occlusions were located in bilateral external iliac arteries and we performed percutaneous trasluminal angioplasty with stenting. Both had an uneventful postoperative course and no postprocedured intermittent claudication after procedure.