Background: Endovascular aneurysm repair has gained widespread acceptance and there has been a significant increase in the number of aneurysms treated by stent grafts. However, the endovascular technique alone is often not appropriate for anatomically complex aneurysms involving the neck branches. We used the TAG stent for thoracic aortic aneurysms (TAAs) and report our initial results.
Patients and Results: We deployed 80 TAG stents in 65 patients electively treated with TAAs between June 2006 and June 2008. Thoracic endovascular aneurysm repair (TEVAR) was performed in 45 cases of descending aortic aneurysm with no morbidity or mortality. A combination of open surgery and thoracic endovascular TEVAR was performed in 11 out of 20 cases with aneurysms of the arch and distal to the prior total arch replacement and elephant trunk procedure in 3, total debranching in 5 and carotid-carotid artery bypass in 3 cases. Meanwhile, TEVAR with coverage of the left subclavian artery was performed in the remaining 9 distal arch cases. In 3 cases with extremely short necks, a 0.018" guide wire was inserted percutaneously in a retrograde manner via the common carotid artery (CCA) into the ascending aorta to place the stent graft in close proximity to the CCA (wire protection). In 1 of these 3 cases, the TAG stent was deployed through the CCA, and the 0.018" guide wire was used to deliver a balloon-expandable stent in order to restore the patency of the CCA. In arch and distal arch aneurysm cases, perioperative mortality and incidence of stroke were both 5.0%; dissection of the ascending aorta was seen in one case (5.0%).
Conclusion: As treatment for descending aortic aneurysms, TEVAR can replace conventional open repair. However, TEVAR for arch aneurysms are problematic, and further improvement is necessary.

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A 75-year-old man was admitted for treatment of ischemic necrosis of his left foot. An angiogram showed the occlusions of the left external iliac, common femoral, superficial femoral, deep femoral, popliteal, and crural arteries. Only the sural artery and distal segmental part of the posterior tibial artery were patent. A reversed vein bypass from the contralateral femoral artery to sural artery was performed. As a result, thigh amputation was avoided, and a below-knee amputation was performed. We demonstrated the usefulness of a rare sural arterial bypass using an autogenous saphenous vein graft. (Jpn J Vasc Surg 2010;19:557-560)

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74-year-old woman had undergone endovascular aneurysm repair with a homemade stent graft at age 71 because of obesity. Follow-up computed tomography 31 months after this first operation showed a type I endoleak due to stent graft migration. A Zenith device, with a barb at the edge of proximal bare stent was chosen for re-EVAR. The patient was discharged with good course, withno evidence of endoleak. The reason for stent graft migration was thought to be that the custom-made stent graft had no device such as a barb or nitinol anchor to secure it in place.
(Jpn J Vasc Surg 2010;19:561-564)

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A 61-year-old man to his local hospital with anterior dislocation of the left shoulder, and the dislocation was reduced without difficulty. About 2 weeks later, the patient was admitted to the same hospital with increasing pain and swelling in the left side of the shoulder and axillary region. Because there was no disorder found associated with the shoulder joint or humerus, conservative management was applied for the next 2 weeks. However, the pain and swelling progressed and CT angiography was taken which revealed a pseudoaneurysm of the axillary artery. The patient was transferred to our hospital for surgical treatment. The surgical procedures consisted of replacement of the axillary artery with a prosthetic graft and pseudoaneurysm resection. The brachial plexus paresis, which had been observed at the time of transfer, remained after surgery. Although vascular complications are rare in cases following simple dislocation of the shoulder, axillary pseudoaneurysm as a possible but serious complication should be considered.
(Jpn J Vasc Surg 2010;19:565-568)

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We present a case of a peroneal artery aneurysm. A 68-year-old woman, who had been suffering from pain in the right calf, was admitted to our hospital. Ultrasonography and computed tomographic angiography demonstrated 50×32-mm aneurysm of the peroneal artery with mural thrombus. The patient successfully underwent aneurysmorrhaphy via a posterior approach. We recommend surgical treatment via a posterior approach for a large aneurysm of the peroneal artery.

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Even recently, most popliteal aneurysms are diagnosed symptomatically. We encountered 6 surgical cases of popliteal aneurysm all of whom were men, whose ages ranged from 62–81 years old. Three had acute ischemia, 1 had chronic ischemia, and the remaining 2 had ruptured aneurysms. All popliteal aneurysms were diagnosed by contrast enhanced computed tomography, which indicated a surgical approach. An emergency operation was performed in 4 cases. Except in 1 case of direct repair, aneurysmectomy and graft replacement were performed in all cases. All patients had uneventful postoperative courses with good arterial perfusion.

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We report a case of popliteal artery pseudoaneurysm in Behçet disease. Popliteal-posterior tibial artery bypass was successfully performed via a posterior approach. A 28-year-old man, who had been given a diagnosis of having Behçet disease 4 years previously, presented with a 2-month history of acute-onset left calf swelling accompanied by pain. Computed tomography demonstrated a saccular aneurysm arising from the anterior wall of the popliteal artery around the origin of the anterior tibial artery. The popliteal artery had been shifted posteriorly by the aneurysm wall, and the anterior tibial artery was found to be obstructed. Surgical treatment via a posterior approach was performed. This revealed a chronic organized pseudoaneurysm wall with inflammation, and gave a direct view of the popliteal artery and the tibioperoneal trunk, which were ligated after the pseudoaneurysm had been incised. A popliteal-posterior tibial artery bypass was then established, using an autogenous vein graft. The posterior approach for posterior tibial artery bypass is not standard. In this case, however, the posterior approach was required to obtain a direct view of the popliteal artery and the tibioperoneal trunk, and was effective for the simultaneous creation of a popliteal-posterior tibial artery bypass.

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Arteriovenous fistulas (AV fistulas) are uncommon, and are associated with severe complications such as abdominal aortic aneurysm and iliac artery aneurysm. Varying degrees of clinical symptoms are observed depending on the size of the fistula and the duration of the disease. We report a case of an 85-year-old woman with a right common iliac artery aneurysm complicated by an iliac AV fistula, presenting with left leg swelling and left leg pain caused by deep vein thrombosis (DVT), and suffering from acute renal failure. Abdominal early-enhanced computed tomography showed a right common iliac artery aneurysm and surrounding dilated iliac vein. An iliac AV fistula was definitively diagnosed by angiography. Emergency surgery was performed, and a right common iliac aneurysm, 5.5 cm in size and which was connected to the left common iliac vein, was resected and replaced with a prosthetic graft, in addition to closure of the AV fistula with the aneurysmal wall. The patient had an uncomplicated postoperative recovery, and her renal failure improved rapidly within a few days after the operation. Anti-coagulation therapy was performed 12 days after postoperatively for DVT of the left leg. The patient was discharged 52 days after surgery without any disability. We encountered an iliac artery aneurysm with an AV fistula, which caused DVT of the left leg and renal failure. Because of the varying degrees of its clinical symptoms, this disease should be kept in mind during the differential diagnosis of abdominal aortic aneurysm and iliac artery aneurysm, as it may otherwise fail to be detected, especially in the emergency phase.

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Chronic myelomonocytic leukemia (CMMoL) is an atypical myeloproliferative disease which may cause acute leukemoid reaction or progress to leukemic transformation after bone marrow stress, when it can be fatal after cardiovascular surgery. An 86-year-old man with hypertension, chronic thrombocytopenia and mild anemia was admitted with an abdominal aortic aneurysm. Open surgery was chosen because he was in good general condition and the shape of the aneurysm was not suitable for endovascular repair. We performed a Y-graft replacement under general anesthesia and epidural anesthesia. Because of the complex shape of the aneurysm, the operation took long time, but was completed without complications. However, extreme leukocytosis, up to 100,000 /ul was seen from an early postoperative period. Bone marrow examinations were carried out which revealed CMMoL. He developed respiratory failure and died due to multiple organ failure on the 2nd postoperative day. In retrospect, perhaps we should have chosen treatment with a lower possibility of infestation such as endovascular repair, and this should be considered if preoperatively the patient has CMMoL.

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Although thoracoabdominal aneurysms are uncommon in Behçet’s disease, surgical therapy for anastomotic aneurysms is usually unsuccessful. A 35-year-old man was admitted to our hospital complainting of chest and back pain. He had an oral aphthous ulcer, acne, sagittal sinus thrombosis and chorioretinitis. Computed tomography (CT) demonstrated aneurysms of the descending thoracic and abdominal aorta. He was given a diagnosis of Behçet’s disease. The celiac-superior mesenteric common trunk, bilateral renal and Adamkiewicz arteries were reconstructed. Anastomotic suture lines were wrapped with a polyester fabric. On serial CT scans, there has not been any sign of abnormality at the anastomotic sites for more than 5 years as of the time of writing.

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