Background: The aim of this study was to evaluate graft patency and limb salvage rates of popliteal-to-distal bypass for patients with critical limb ischemia. Patients and Methods: Between 2003 and 2008, 10 patients with toe gangrene underwent popliteal-to-distal bypass. The mean age at operation was 72.7 years; 7 were men, 8 (80%) had diabetes, and 1 (10%) had end-stage renal failure with hemodialysis. The inflow source in 7 patients was the supragenicular popliteal artery and the infragenicular popliteal artery in 3 pataients. Distal outflow was to the posterior tibial artery in 6 patients and to the dorsalis pedis artery in 4 patients. In 2 cases, percutaneous balloon angioplasty was perioperatively added for multiple short stenoses in the superficial femoral artery. Results: Initial success was obtained in all cases, and skin perfusion pressure elevated from 20.5 ± 9.3 mmHg to 67.5 ± 23.9 mmHg postoperatively. Minor amputation was necessary in 6 but none required major amputation. With an average follow-up period of 15.9 months, secondary patency was obtained in all cases and 9 out of 10 patients survived with complete healing of their toe gangrene. There was no new lesion or restenosis in the superficial femoral artery during the follow-up period. Conclusions: Popliteal-to-distal bypass, with or without an additional angioplasty, for lesions of the superficial femoral artery can yield good long-term results for appropriately selected patients with critical limb ischemia.

View full abstract

Background: An extra-anatomical bypass (axillo-femoral bypass) is generally performed for an infectious aneurysm and prosthetic graft infection in the aortoiliac region. However, this procedure has the risk of rupture at the aortic stump and has a low graft patency rate in the long term. Therefore, in recent years anatomical reconstruction has been performed using an autogenous vein graft or prosthetic graft (ePTFE or rifampicin-bonded prosthetic graft etc.). Case report: We performed anatomical reconstruction using an autogenous vein graft (on the superficial femoral vein) in two cases, and obtained good results in both. The first case an infectious aneurysm, and the second was a prosthetic graft infection. Results: The postoperative courses were difficult because the operations were prolonged owing mainly to severe adhesion, and reoperation for perforation of the duodenum. However, the final outcomes in both cases were successful. Conclusion: This surgical procedure may become a standard method for graft infection or infectious aneurysm. We report 2 cases and discuss the literature.

View full abstract

Adventitial cystic disease (ACD) is rare, affecting mainly young men. The majority of ACD occurrs in the popliteal artery. We report a 73-year-old man with ACD of the femoral artery. The diagnosis was made with duplex ultrasound which showed the multiple cystic lesions around right femoral artery and computed tomography. We resected the femoral artery, together with the cysts. To our knowledge, this is the most elderly case of ACD to have been reported.

View full abstract

It is widely accepted that a native arteriovenous fistula (AVF) and an arteriovenous graft (AVG) in the upper extremity are the first and second choices for chronic hemodialysis access, respectively. However, it is increasingly common to encounter patients whose options for vascular access have been exhausted and in some patients the creation of vascular access is contraindicated. For 4 such patients we created arterio-arterial prosthetic loops (AAPL) for hemodialysis.
Case 1: An 80-year-old woman had severe chronic cardiac failure due to mitral regurgitation. Case 2: A 50-year-old man had critical steal ischemic syndrome in the right upper extremity. Both cases 3 and 4 had inadequate veins for the creation of vascular access and it was impossible to place indwelling catheters.
We successfully applied an AAPL in all patients using a thoratec vascular graft under local anesthesia. The AAPL was a very efficient method to establish vascular access for hemodialysis in patients in whom conventional vascular access could not be established.

View full abstract

Acute arterial occlusion of the lower extremities is a medical emergency, usually requiring catheter thrombectomy to achieve remission. However, in certain pathological conditions it may be difficult to determine the need for additional treatment such as bypass grafting. We attempted to select treatment strategies using multidetector-row CT (MDCT) scanning. We report 2 cases. The first patient was given a diagnosis of superficial femoral artery embolism which was determined to be treatable by catheter thrombectomy alone. In the second patient a diagnosis of arteriosclerosis obliterans of the iliac artery was made, with embolic occlusion extending to the popliteal artery caused by thrombosis in the obstructed area of the iliac artery and which we determined required a femoral-femoral arterial bypass. Both patients were successfully treated by surgical procedures determined by MDCT. MDCT is a rapid, minimally invasive method, which is also useful for assessing vessel wall condition and also detecting other lesions. Its use in the differentiation of causes of acute arterial occlusion of the lower extremities, and the selection of optimal treatment strategies for improving blood flow can contribute to further improvement of limb salvage rates and prognoses.

View full abstract

We report a rare case of inferior pancreaticoduodenal artery aneurysm with celiac axis occlusion and superior mesenteric artery (SMA) stenosis at its origin. A 42-year-old man with no specific history of disease was referred to our hospital because an asymptomatic visceral artery aneurysm had been found on computed tomography scans during a routine health check. Abdominal aortography revealed celiac trunk occlusion and 90% stenosis of the SMA ostium. In addition, selective SMA angiography scans showed an aneurysm of the inferior pancreaticoduodenal artery 20 mm in diameter and retrograde blood perfusion to the hepatic and splenic artery supplied by the SMA via the pancreaticoduodenal arcade as a collateral pathway. We suspected that the median arcuate ligament caused compression of these arteries. However it was too difficult to detect the ligament because of severe adhesion around the aneurysm and abdominal aorta. Therefore we performed an aneurysectomy and an aorto-splenic bypass with a saphenous vein graft, and the postoperative course was good.

View full abstract

A 69-year-old woman with back pain was admitted to our hospital 3 months previously due to a type-A acute aortic dissection with megaaorta syndrome. The aortic aneurysm extended from the ascending aorta to the bilateral iliac arteries. Initially, a total arch replacement with elephant trunk installation and an abdominal aortic aneurysm repair were performed simultaneously. One month after the first stage operation, the thoracoabdominal aortic aneurysm was repaired, applying distal perfusion, mild hypothermia, CSF drainage, segmental aortic clamping, reconstruction of intercostal and lumbar arteries, and edaravone for spinal cord protection. Transcranial motor evoked potentials (tc-MEP) were monitored during the operation. Although tc-MEPs disappeared due to spinal cord ischemia during aortic cross-clamping, the amplitude of tc-MEP recovered after hypertension treatment and a quick reattachment of the intercostal arteries. The 8th, 10th and 11th intercostal arteries and the 1st lumbar artery were reconstructed. This patient was discharged 20 days postoperatively without any neurologic deficit.

View full abstract

Prosthetic graft infection after abdominal aortic graft replacement is a serious complication with high mortality. We report a successful two-staged treatment of an abdominal aortic graft infection caused by methicillin-resistant Staphylococcus aureus (MRSA). A 66-year-old man had undergone prosthetic graft replacement for an abdominal aortic aneurysm, but a MRSA graft infection occurred 3 months after surgery. Drainage was performed and the cavity was irrigated intermittently every day using electrolyzed strong acid solution for 2 months. However, MRSA was detected in a blood culture. The infected graft was removed and in situ reconstruction with an expanded polytetrafluoroethylene (e-PTFE) graft was performed. Because he had undergone a total gastrectomy, a pedicled omental flap could not be used. Moreover, the left rectus abdominis muscle had been transected because of the left retroperitoneal approach used in the graft replacement. Therefore, we wrapped an e-PTFE vascular prosthesis with a pedicled right rectus abdominis muscle flap. The postoperative course was uneventful and there has been no recurrence of the infection for 23 months. The present case shows that a pedicled rectus abdominis muscle is available as a backup flap instead of the omentum.

View full abstract