Objectives: The survival rates of patients long-term dialysis are increasing with the improvement of the survival rates of dialysis patients in general. Although arteriovenous fistula (AVF) is usually the first choice for vascular access because of its long patency rate and low complication profile, there are sometimes cases in which it is difficult to perform AVF because of poor vascular conditions in elderly patients or in those on long-term dialysis. In such cases, an artificial vascular graft (AVG) must be implanted. There are various types of AVG. We used 2 types of AVG, both of which can be punctured in the early stage and campaired their patency. Methods: From July 2006 to November 2009, we implanted Thoratec or Advanta polytetrafluoroethylene (PTFE) grafts in patients with chronic renal failure and analyzed their patency. AVG implant surgery was performed under general anesthesia. After passing the AVG under the skin, the end of the graft was anastomosed to the vessel using a 5-0 polypropylene or CV-5 ePTFE graft in a continuous fashion. Results: We implanted a total of 66 grafts (39 Thoratec and 27 Advanta). The mean age did not significantly differ between the 2 groups. In the Thoratec group, 18 patients died and 2 were lost during follow up in the Thoratec group, and 9 died in the Advanta group. We calculated the cumulative patency rates using the Kaplan-Meier method including primary (problem-free) and secondary (revised or functional) patency rates. At 1 and 2 years, primary patency rates were 37.2% and 23.2%, respectively, in the Thoratec group and 72.5% and 60.4% respectively, in the Advanta group (p=0.0098). At 1 and 2 years, the secondary patency rates were 67.5% and 67.5%, respectively, in the Thoratec group and 96.3% and 96.3% respectively, in the Advanta group (p=0.0118). The mediam interval between surgery and first graft implantation was 3 days in the Thoratec group and 9 days in the Advanta group. The Thoratec graft could be punctured earlier than the Advanta graft (P=0.0044). Conclusions: The Advanta was superior to the Thoratec in both primary and secondary patency.

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Iatrogenic vascular complications resulting from lumbar disc surgery are uncommon but serious problems in vascular surgery and their clinical manifestations vary, from fatal retroperitoneal hemorrhage which requires an immediate laparotomy, to late consequences including false aneurysm and arteriovenous (AV) fistula. Since Linton and White presented the first case of an AV fistula after lumbar disc surgery in 1945, it has been well recognized as a late complication of this type of surgery and is diagnosed by the manifestation of high-output congestive heart failure late after the procedure. We encountered a case of an iliac AV fistula treated by endovascular procedure 21 years after lumbar disc surgery. A 45-year-old woman consulted a general practitioner complaining of general malaise. On physical examination we detected a bruit in her right lower abdomen. Her clinical history was completely unremarkable except for a laminectomy of the L4–L5 vertebrae at age 24. A clinical examination demonstrated a pansystolic murmur audible in the periumbilical area, but without any evidence of leg edema. A chest X-ray firm demonstrated moderate cardiomegaly with 53% cardiothoracic ratio. Abdominal enhanced computed tomography scans revealed a hyperdense image of the inferior vena cava and irregular dilatation of the left common iliac vein and abdominal aortography showed a high-flow fistula between the right common iliac artery and the inferior vena cava. A hand-made stent graft was formed using a self-expanding spiral Z stent which was successfully deployed in the right common iliac artery, sealing the orifice of the AV fistula. Recently, less invasive endovascular techniques can help avoid the risk of substantial blood loss perioperatively. However, the durability of endoprostheses is unknown, and long-term studies are needed to confirm the efficacy of endovascular procedures for iatrogenic vascular complications.

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Type IV Ehlers-Danlos syndrome (EDS) is characterized by many vascular complications, including aortic and visceral arterial ruptures, aneurysms, and dissection. The surgical management of these complications is exceedingly challenging because of the high morbidity and mortality resulting from the profound fragility of the arterial tissue. We report a case of a 20-year-old man with type IV EDS associated with a subclavian arterial rupture, who was successfully treated with transcatheter coil embolization, but who suddenly died because of rupture of dissecting abdominal aortic aneurysm 1 year later.

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A 50-year-old man was hospitalized prior to undergoing surgery to remove a residual aortic aneurysm, which had expanded to 62 mm between descending thoracic and thoracoabdominal aortic artificial grafts. When he was 46 years old, he had undergone replacement of the proximal descending aorta because of chronic aortic dissection (DeBakey IIIb), and replacement of the artificial graft had been performed using a Coselli thoracoabdominal graft to reconstruct 4 abdominal branches, and a bifurcated graft for a thoracoabdominal aortic aneurysm (Crawford III) at age 47. During the present surgery, stent graft treatment was performed to reduce the risk of lung injury and bleeding caused by synechiotomy after 2 left thoracotomy procedures. Since the distal portion of the neck of the aortic aneurysm was short, and the landing zone of the stent graft distal end covered the abdominal branches of the previous thoracoabdominal artificial graft, hybrid endovascular repair was performed, in which the stent graft was deployed, after revascularization to the splenic artery and superior mesenteric artery. He improved and was discharged from the hospital without developing any complications. Hybrid therapy for residual aneurysm between grafts after replacement for the descending thoracic and thoracoabdominal aortas may increase the flexibility of the landing zone of the stent graft distal end, and thus is considered to be a safe and minimally-invasive treatment, especially for patients who may have lung injury caused by synechiotomy after left thoracotomy procedures.

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A 72-year-old man was referred to our hospital because of sudden pain at rest in the left lower limb. Three-dimensional computed tomography showed a left thrombosed popliteal artery aneurysm (PAA) 3.0 cm in diameter and a right PAA 2.5 cm in diameter, with a mural thrombus. Elective surgery was planned because the patient had minimal sensory loss (numbness), anesthesia and no complaints of muscle weakness. Embolectomy could not be performed due to an organizing thrombus in the left tibial artery, but thrombolysis was performed via a chatheter in the left femoral artery for 1 week. Simple ligation of the left PAA and superficial femoral artery-pedal arterial bypass was accomplished using an in situ great saphenous vein (GSV) graft because the pedal artery was visualized on angiography. An elective right PAA aneurysmectomy and superficial femoral-anterior tibial arterial bypass were also performed using an in situ GSV graft. In patients with acute limb ischemia categories I to IIa as defined by the Society of Vascular Surgery and International Society of Cardiovascular Surgery clinical categories, preoperative intra-arterial thrombolysis might be considered as an alternative to urgent surgery in patients with a thrombosed PAA.

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We report a rare case of acute type A aortic dissection with aortic regurgitation and coronary malperfusion secondary to intimo-intimal intussusception. A 51-year-old man complaining of back pain was given a diagnosis of acute type A aortic dissection. Intraoperatively, appearance, the whole surface of the intimal flap could be seen at the sinotubular junction. We speculated that the flap in the diastole had prolapsed into the left ventricle through the aortic valve, resulting in aortic regurgitation and coronary malperfusion. In case of acute type A aortic dissection with intimo-intimal intussusceptions surgery should be performed as soon as possible.

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An 80-year-old man was admitted to our hospital due to the sudden onset of severe chest pain. Contrast-enhanced computed tomography showed type B aortic dissection with an aortic rupture. Because of his age and the aortic rupture, we selected endovascular repair. To obtain an appropriate proximal landing zone, a bypass was created between the left common carotid artery and the right subclavian artery. The primary entry tear was then closed with hand-made stent-grafts. He tolerated all procedures and is doing well at present. The above measures may be a reasonable choice of treatment in cases of complicated aortic dissection, in which the primary entry tear is close to the cervical branches.

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An 85-year-old man was given a diagnosis of hepatocellular carcinoma. A reservoir port for hepatic arterial infusion (HAI) adjuvant chemotherapy was placed in the right brachial artery, and HAI chemotherapy was administered in June 2009. Redness and swelling with pain of the right arm developed, and the patient was admitted to our hospital with a diagnosis of infection at the site of the reservoir port in August 2009. After admission, bleeding from the right arm occurred frequently, and compression hemostasis was applied. However, the pulsatile tumor gradually increased in size, and a portion of the catheter because exposed. The reservoir port and the exposed catheter were removed. The pseudoaneurysm, 20 mm in diameter, was resected and end-to-end anastomosis of the right brachial artery was carried out. The postoperative course was uneventful, except for mild edema. The brachial artery became occluded due to long-term catheterization and ischemic changes in the forearm appeared due to the absence of major collateral pathways. However, reservoir port placement via the brachial artery is nevertheless considered to be acceptable because of the hygiene aspects of the placement and low incidence of complications, including psedoaneurysm.

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Bleeding is a risk factor which can lead to unsatisfactory initial results of the surgical treatment of acute aortic dissection. In the early 21st century, the approximation technique of the dissected aortic root, using gelatine-resorcin-formaldehyde (GRF) glue was performed in our hospital. No bleeding complication was observed with this method, but in 2 cases of aortic root pseudoaneurysm developed. From January 2006 through June 2008, we applied adventitial inversion to 16 cases of the Stanford type A acute aortic dissection, using the approximation technique in 16 cases. The mean age was 66.8 years old (range 58–74 years) and 10 were women. In 7 cases of ascending aortic replacement, adventitial inversion was performed at both ends. In 9 cases of total arch replacement, adventitial inversion (aortic root approximation) was used to and a distal approximation was performed with the elephant trunk method. There were no bleeding complications, and the 30-day mortality rate was 0%. There was no aortic root pseudoaneurysm formations detected on computed tomography for 3 years. This technique enabled a safe and secure anastomosis, and no bleeding complications occurred at from the anastomostic site.

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An aortic arch aneurysm was diagnosed in an 84-year-old man. Since it was a high-risk case, it was followed up. However, the size of aneurysm had expanded to 70 mm on computed tomography (CT) the next year. An adaptation of stent graft (SG) placement was diagnosed, and the patient was admitted to our hospital for surgical repair. The SG had been placed at the bifurcation of the brachiocephalic artery at the 10th thoracic vertebra. Paralysis of the left leg appeared 6 hours after surgery, and ischemia of the spine was considered to be the cause. The urgent administration of methylprednisolone and naloxone were begun, and cerebrospinal fluid drainage (CSF-D) was started. The patient improved gradually, until he could walk with a cane on the 20th day after surgery. Postoperative CT showed no evidence of endoleak or thrombo-obstruction. This case indicated that CSF-D, methylprednisolone, and naloxone can be effective in early stage paralysis in such cases.

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