Objective: Shunt obstruction is usually treated by removing the thrombus using a Fogarty balloon catheter. However, once patency has been restored, treatment of the cause of obstruction is often disregarded. We devised a one-stage endovascular treatment for obstruction, including removal of the thrombus, treatment of the lesion responsible for obstruction, and postoperative dialysis, that can be performed without hospitalization. From January 2007 to September 2009, we treated graft (treated artificial shunt graft) obstruction by PTA using a percutaneous thrombectomy catheter (hydrolyzer) (hydro-PTA) in 59 patients. The therapeutic results were evaluated, and the period until restenosis was compared, before and after the introduction of a high-pressure balloon catheter (Conquest). Results: The initial success rate was 97%, and re-obstruction was noted in 9 patients in 7 of whom recanalization was achieved by hydro-PTA. The primary patency rate at 1, 3, 6 and 12 months were 91.9%, 59.4%, 29.7%, and 16.2% in the Conquest group, and 75%, 40%, 15%, and 5% in the non-Conquest group. There were significant differences in both groups (p<0.05). Early restenosis or occlusion was often observed in patients with marked stenosis at the venous anastomosis site. Complications were observed in 4 patients: bleeding at the sheath puncture site after dialysis in 1, mild vascular rupture due to overdistension in 1, and re-obstruction due to recoil in 2 patients. However, we did not encounter any pulmonary embolism, which was our greatest concern. The mean time until restenosis was 79.3 days before and 146.7 days after the introduction of a high-pressure balloon, showing significant prolongation after its introduction (p<0.05). Conclusions: Hydro-PTA was useful in artificial graft occlusion. Presently, the level of patient satisfaction is high, and the procedure can be considered as the first treatment of choice for shunt obstruction. However, evaluation of how to prolong further the period until restenosis is necessary.

View full abstract

A 19-year-old woman underwent lumbar discectomy at another hospital. She developed hypotension and abdominal distension during surgery. Abdominal computed tomography (CT) revealed a left common iliac artery injury. She was admitted to our hospital and underwent an emergency operation. A large retroperitoneal hematoma was found, and the left common iliac artery had completely ruptured. The injured artery was repaired with an interposition of a graft. Surgeons should be aware of the possibility of this event. When there is a high possibility, prompt diagnosis and surgery are required.

View full abstract

The case was a 53-year-old woman. Her blood pressure not often been correctly measured since age 30. Hypertension was pointed out in an annual check-up the previous year, but it was not treated. In March 2009, she had dyspnea and went to a local hospital. A diagnosis of hypertensive heart failure was made and she was transferred to our hospital. Enhanced computed tomography (CT) revealed severe stenosis of the descending aorta at the level of the diaphragm. Atypical aortic coarctation was strongly suspected, and an extra-anatomical bypass was performed to reduce the afterload. The postoperative course was uneventful and she was discharged 22 days after her operation.

View full abstract

Persistent sciatic artery (PSA) is a rare congenital anomaly and often results in aneurysmal or occlusive changes. A 66-year-old woman was referred with complaints of left buttock pain with sciatic neuralgia and intermittent claudication of the left leg. The left ankle-brachial index was 0.7, and computed tomography (CT) and magnetic resonance (MR) angiographies showed a left PSA aneurysm with occlusion of the distal portion of the PSA. Surgery was performed in the right semi-lateral position. The internal iliac artery was exposed retroperitoneally, and the proximal portion of the PSA was ligated at the bottom of the pelvic cavity. Subsequent resection of the aneurysm was performed through the Moore posterior approach at the buttock. To restore the blood flow to the left lower extremity, the distal PSA was exposed through a posterior incision of the mid-thigh, and an obturator bypass was performed from the internal iliac artery to the distal PSA using a ringed 8-mm ePTFE graft. One year later, she has no leg claudication, buttock pain or sciatic neuralgia, and the graft is patent.

View full abstract

Conventional management of prosthetic graft infections includes total excision of the infected graft, which is associated with a high mortality rate. However, the conventional graft excision approach is clearly not feasible in some patients with severe comorbid medical illnesses or anatomical difficulty of excision. We report 2 cases of prosthetic graft infection treated successfully with drainage and postoperative irrigation with gentian violet solution. Case 1 developed prosthetic graft infection due to methicillin-resistant Staphylococcus aureus (MRSA) following bypass surgery (aortofemoral graft) for pseudoaneurysm at the proximal anastomosis of an iliac-femoral bypass graft. Drainage was performed and the abscess cavity around the infected graft was irrigated with 0.02% gentian violet solution. Inflammatory reactions gradually improved. Case 2: A prosthetic graft infection developed due to MRSA following double bypass surgery (aortobifemoral, and aorto-aorto graft) for abdominal aortic aneurysm. After drainage and irrigation with 0.02% gentian violet solution, he free from infection, and was discharged on the 102nd postoperative day. Drainage and irrigation with gentian violet solution can be considered an alternative to infected prosthetic graft removal in patients with poor general health.

View full abstract

Isolated internal iliac artery aneurysms are rare and at high risk of rupture with an associated high mortality. We report 2 cases of ruptured isolated internal iliac artery aneurysm presenting with rectus sheath hematoma in the lower abdomen with difficult diagnoses. Case 1: A 77-year-old man presented with lower abdominal pain. A computed tomography (CT) scan revealed an isolated aneurysm of the right internal iliac artery and a hematoma expanding from the outer layer of the peritoneum beneath the lower rectus abdominis muscle, through the bladder to the right pelvic retroperitoneum. However, there was no evidence of hematoma around the aneurysm and thus a definitive diagnosis of rupture was not made. On Day 2, exacerbation of his anemia was noted and an explorative laparotomy was performed which revealed a rupture at the base of the aneurysm. The blood flow was blocked from within the aneurysm, and aneurysmorrhaphy was performed but the patient died from a postoperative complication of pneumonia. Case 2: A 76-year-old man who presented with lower abdominal pain underwent a CT scan that revealed an isolated left internal iliac artery aneurysm with a small surrounding hematoma, and a rectus sheath hematoma in the lower abdomen, and thus we diagnosed a ruptured aneurysm. The blood flow was blocked from within the aneurysm, and aneurysmorrhaphy was performed. The patient was discharged without complications. Although rapid diagnosis and appropriate treatment are needed for ruptured aneurysms to improve the survival rate after rupture, diagnosis is difficult in atypical cases of a rare disease without evidence of hematoma around an aneurysm. If a ruptured aneurysm is suspected, exploratory laparotomy should be performed.

View full abstract

A 61-year-old man underwent a right-to-left femorofemoral crossover bypass using an artificial conduit for occlusion of the left common iliac artery. He was referred to our department 2 weeks later with fever and purulent exudate from the left groin. The wound was opened for debridement and rinsed with warm saline every day for two weeks. Methicillin-resistant Staphylococcus aureus was grown from a groin culture. After the infectious inflammation was brought under control, the patient underwent graft removal. Immediately after the second operation, the left leg developed acute ischemia. A crossover bypass using a greater saphenous vein graft was performed. A proximal anastomosis was made at the right external iliac artery, and the graft was tunneled through the preperitoneal space. Distal anastomosis was made with a 5-cm onlay patch from the left external iliac artery to the common femoral artery. At 36 months, he had no evidence of recurrent infection, and the graft remained patent. The treatment of infected femorofemoral crossover bypass grafts is a difficult problem. We suggest that reconstruction with a saphenous vein graft passing behind the rectal muscle is a viable option. Long onlay anastomosis from the external iliac artery to the common femoral artery might diminish the risk of vein graft kinking.

View full abstract

A high origin of the radial artery (brachio-radial artery; BRA) is the most common variation in the upper extremity. However, the clinical significance of this variation is rarely recognized in daily practice. We experienced a case of anastomotic aneurysm of an arterio-venous graft (AVG), which had been created between the BRA and brachial vein. Preoperatively, the AVG was mistakenly interpreted as the one between the brachial artery and vein. Such arterial variants in the upper extremity should be recognized when encountering unusual situations in vascular and endovascular interventions.

View full abstract

Infected femoral pseudoaneurysm has been reported as a result of arterial access for diagnostic and endovascular procedures. We successfully treated it by debridement with arterial revascularization. The patient was a 61-year-old man with a history of hepatocellular carcinoma. He developed redness and swelling in the right groin after the insertion of a catheter into the right femoral artery. Computed tomography revealed a femoral artery pseudoaneurysm. We conducted resection of an infected aneurysm with arterial reconstruction, using a great saphenous vein which was placed laterally. The infection was well controlled and blood flow to the leg was maintained. He was discharged without recurrence of the infection. Arterial reconstruction through a lateral route is a good option for cases of femoral artery pseudoaneurysm with limited infection.

View full abstract

A 73-year-old man presented complaining of pain and numbness in the right leg. MDCT showed an infrarenal abdominal aortic aneurysm 4.8 cm in maximum diameter which had completely thrombosed, extending from just below the bilateral renal arteries to the bilateral external iliac arteries. This was a case of high aortic occlusion. The bilateral common femoral arteries were visualized via collateral circulation. The right superficial femoral artery was also occluded. Because the superior mesenteric artery arose from the same level as the bilateral renal arteries, it was difficult to clamp the aorta for anatomical bypass. In addition, due to his poor pulmonary function we selected an extra-anatomical bypass (axillo-bifemoral bypass graf) and a right femoro-popliteal bypass grafting without aneurysmectomy. The postoperative course was uneventful. There was no change in the diameter of the aneurysm or thrombosis 2 years later. In this type of case careful postoperative observation is needed because of the possibility of delayed aortic rupture and thrombotic progression into the proximal abdominal aorta.

View full abstract