Objective: Penetrating atherosclerotic ulcer (PAU) of the aorta is defined as an atherosclerotic lesion with ulceration of the aortic intima and media and rupture of the internal elastic lamina. PAU induces aortic dissection, aortic rupture and saccular aortic aneurysm, and typically occurs in elderly hypertensive patients with severe atherosclerosis. Although it has been reported that atherosclerosis similarly occurs in the abdominal aorta, its natural history and treatment are still unclear. This study investigated the clinical features, natural history, and treatment of PAU of the abdominal aorta. Method: Between April 2006 and March 2009, 4 diagnoses of PAU in the abdominal aorta were made by computed tomography (CT) and magnetic resonance imaging (MRI). These 4 cases were analyzed along with 61 previously reported cases from the literature with diagnoses of PAU in the abdominal aorta, aortic rupture and isolated abdominal aortic dissection over the past 15 years for a total of 65 cases. Results: The patients were men with an average age of 63.5 years. All 4 had hypertension, and 2 had concomitant coronary artery disease. Two patients were asymptomatic, the other 2 were symptomatic and transmural rupture had occurred. All diagnoses were made by CT and MRI. All 4 patients underwent open surgery with a knitted Dacron graft, with no postoperative deaths. In the literature, 53% of cases were symptomatic including pain (40%, n=26), shock (4.6%, n=3), and lower limb embolism (9.2%, n=6). The remaining 40% of cases were asymptomatic (n=26). Six patients were treated medically, while 58 patients underwent surgery, with 2 postoperative deaths. Conclusion: We suggest that surgical treatment (open surgery or endovascular stent grafting) should be performed to prevent an aortic catastrophe such as intramural hematoma, dissection or rupture.

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Objectives: The radial artery-cephalic vein shunt in the forearm is a standard operation for hemodialysis. Because an ulnar artery-basilic vein fistula needs vein translocation from the posterior side, and the artery and vein are small, the second choice of shunt location is usually at the cubital region. After ultrasonography of vessels in the forearm, we constructed ulnar artery-basilic vein shunts using the brachial artery. The clinical results of ulnar artery-basilic vein shunts are described. Methods: Over the previous 9 years, 552 arteriovenous shunts were performed in our hospital in the past, including 44 ulnar artery-basilic vein shunts (8%). The patients were 30 men and 14 women, and their ages ranged from 35 to 87 years (median, 68). The observation periods were from 1 day to 106 months (median, 4 months). The shunt patency rates were calculated using the Kaplan-Meier method. Results: Two patients died from brain infarction and suicide within 1 month after operation. There was no occurrence of vein hypertension or steal syndrome. A further 21 patients developed occlusion or stenosis of the shunts. The primary patency rates were 45.1% at 1 year, and 27.0% at 4 years. Five patients received percutaneous catheter balloon dilatation for occlusion or stenosis of the shunts for a maximum of 7 times in 1 patient. The secondary patency rates were 51.6% at 1 year, and 41.3% at 4 year. Conclusion: For long-term continuation of hemodialysis using arm blood access, the ulnar artery-basilic vein shunt should be considered before establishing a shunt at the cubital region.

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A 67-year-old woman had undergone end vascular therapy, and had recieved self-expanding stents in the superficial femoral artery (SFA) for peripheral arterial disease at the ages of 65 and 66. Six months later, we used lower extremity angiography to examine intermittent recurrent claudication of the left lower limb. A thrombus was noted in self-expanding stents in the left SFA. Thrombolytic therapy was initiated with 720,000 U/day urokinase, but this was in effective and the left ankle brachial index (ABI) could not be estimated. Thus, we performed a Fogarty thrombectomy for the left SFA with the self-expanding stents inside, and significant amounts of thrombus were removed. Postoperatively, the left ABI improved, to 0.78. We postulated that the specific properties of self-expanding stents, such as flexibility and resistance to, or recovery from deformation by external forces, and balloon pressure could facilitate the procedure.

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An 84-year-old man, who had attended our hospital as an outpatient with complete occlusion of the right superficial femoral artery (SFA), was hospitalized with pyelonephritis. He presented with acute onset of swelling and pain in the right thigh. Based on computed tomography (CT) findings, we made a diagnosis of pseudoaneurysm of the SFA with a very large abscess, and planned a 2-stage operation. In the initial operation for limb salvage, we ligated the SFA which was feeding the pseudoaneurysm and performed femoroposterior tibial artery bypass via a subcutaneous route using a saphenous vein graft. In the second operation we performed resection of the aneurysm and open drainage of the abscess. Escherichia coli was cultured from the abscess, similar to findings of pyelonephritis. The patient was ambulatory when discharged on the 67th postoperative day.

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Abdominal aortic aneurysm (AAA) associated with horseshoe kidney is rare. The aim of this case series was to report on the reconstruction of accessory renal artery (ARA) in patients who presented with AAA and horseshoe kidney. We enrolled 3 men (mean age 71.7 years) with asymptomatic AAA (mean diameter, 55 mm). The patients displayed anomalous blood supply to the kidney, and AAA with horseshoe kidneys were confirmed in all cases on three-dimensional computed tomography (3D-CT). Patient 1 had an ARA originating from the aneurysm. Patient 2 had 2 ARAs originating from the aneurysm. Patient 3 had an ARA, and the inferior mesenteric artery (IMA) originated from the aneurysm. Division of the renal isthmus and its reimplantation into the aortic graft to preserve the isthmic branch of the ARA were transperitoneally performed. Briefly, ARAs more than 5 mm in diameter were reconstructed using the Carrel patch technique. Renal protection during aortic clamping was not performed in 2 cases, and cold lactated Ringer solution was injected into the ARA in 1 case. In patient 3, the ARA and IMA were simultaneously reconstructed to prevent postoperative ischemic colitis, since the lesion invaded into the internal iliac arteries. All patients successfully underwent prosthetic graft replacement with division of the isthmus of the horseshoe kidney. Postoperative complications related to the separation of the isthmus have not occurred at the time of writing.
(Jpn J Vasc Surg 2010;19:749-755)

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The mortality of ruptured abdominal aortic aneurysm (rAAA) remains high. Endovascular therapy with a stent-graft (EVAR) is minimally invasive and is used in rAAA. We treated a 74-year-old woman with rAAA by emergency stent grafting. Upon arrival, her blood pressure was only 55/32 mmHg and her heart rate was 104/min. Enhanced computed tomography (CT) revealed rAAA. The proximal neck was 14 mm in length and EVAR appeared feasible. We operated 52 minutes after her arrival, and repaired the rAAA by EVAR. After stent grafting, her hemodynamic status stabilized. The next day after surgery the abdominal cavity was punctured and 1400ml blood was removed. Her postoperative recovery was uneventful, there was no endoleak on postoperative enhanced CT and she was discharged 14 days after surgery. To perform EVAR in emergency situations, several preparations are required. However, emergency EVAR for rAAA may be selected for more rAAA patients in Japan in the near future.

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We report the case of 2 brothers with autosomal dominant polycystic kidney disease (ADPKD) with acute aortic dissection. Case 1 (the older brother) had been undergoing kidney dialysis since age 48 years. On the development of acute aortic dissection (type A) at age 50, he underwent ascending aortic replacement. Case 2 (the younger brother) the development of acute aortic dissection (type A) at age 58, he underwent an emergency operation consisting of ascending aortic replacement and partial arch replacement. To the best of our knowledge, a case of brothers with ADPKD complicated by aortic dissection has not been reported in the literature. Hypertension resulting from abnormal vascular function due to genetic mutation and a fragile vascular structure caused by extracellular matrix abnormalities may contribute to aortic dissection in patients with ADPKD. Therefore, strict control of blood pressure is mandatory in patients with ADPKD.

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We encountered a rare case of bilateral internal jugular vein thrombosis associated with lung cancer. A 66-year-old man was transferred to our hospital with a diagnosis of bilateral internal jugular vein thrombosis and lung cancer. He had complained of severe headache and facial edema. We therefore planned emergency thrombectomy in addition to the intravenous administration of anticoagulants. A thrombus was noted, extending from the bilateral internal jugular vein to the superior vena cava. To avoid intraoperative pulmonary thromboembolism, we selected direct clamping of the superior vena cava via a median sternotomy, followed by thrombectomy using an Argyle^® suction tube. Immediately after the procedure, a temporary vena cava filter was placed in the superior vena cava via the femoral vein, because a residual thrombus of the right internal jugular vein was detected on ultrasonography. We continued anticoagulation for 3 months, and the thrombus disappeared completely.

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A 66-year-old man with horseshoe kidney was admitted to our hospital with a non-pulsatile abdominal tumor. He had undergone endovascular aortic repair with a hand-made stent graft at age 57, and an exclusion operation for type 1 endoleak at the age of 61. Computed tomography (CT) showed redilation of an excluded abdominal aortic aneurysm and an imaging effect of backflow of the lumbar arteries. The aneurysm was exposed and opened, and 1 pair of lumbar arteries which showed back bleeding was closed. Postoperative CT did not reveal an imaging effect the aneurysm sac. The patient was discharged on the 14^th postoperative day. This case suggests that type 2 endoleak for lumber arteries may cause aneurysmal dilation after endovascular aortic repair.

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A 56-year-old man with an abdominal aortoduodenal fistula underwent abdominal aneurysm replacement with a graft, duodenal closure and omental filling. Fever developed after 1 month, and antibiotics were given. However, his high fever continued and an abscess was diagnosed by CT. The graft was ablated, the abdominal aortic stump closed and axillofemoral bypass performed. Peritoneal bleeding occurred 3 years later, when aortic stump bleeding was diagnosed and abdominal aortic replacement was performed using a thoracoabdominal oblique incision. After 2 years, anemia has not developed and his course is good.

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