Objectives: We designed a surgical procedure using an expanding polytetrafluoroethylene (ePTFE) synthetic vascular prosthesis together with a Thoratec graft, to access a blood vessel and rectify a fault which developed in the Thoratec graft. We also investigated the results of the initial operation and mid-term follow up. Methods: From July 2005 to April 2010, we performed vascular access procedures in the forearms of 97 patients (58 women, 39 men). We used the straight portion of a Thoratec graft in an arterial anastomosis. An ePTFE graft was used in the loop portion and in the remainder of the venous side anastomosis. We retrospectively reviewed the case notes of all patients and calculated the patency rates using the Kaplan-Meier medthod. The mean follow-up period was 1.6 years. Results: After the surgical removal of a thrombus or extending graft, there were 3 permanent obstructions of grafts, but no other major complications. In the mid-term, major complications were graft infection in 11 cases, and venous hypertension and steal syndrome in 2 cases each. The rate of secondary patency was 94% at 1 year, 92% at 2 years and 89% at 3 years. Conclusion: This procedure offers excellent patency rates with acceptable major complication rates and should be appropriate to rectify Thoratec graft faults.

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Objective: A minilaparotomy for the repair of infrarenal abdominal aortic aneurysm (AAA) may be less invasive than a full laparotomy for AAA repair. However, the minilaparotomy technique has not been widely performed because it requires special surgical instruments to obtain an adequate operative field. In our institution, minilaparotomies for AAA (wound length; 13±1 cm) are regularly performed. We retrospectively compared the outcomes of minilaparotomy AAA repair with those of full laparotomy AAA repair. Methods: From January 2006 to November 2009, 38 patients under 75 years old underwent elective AAA repair with bifurcated graft replacement. Of these, 17 (group M) underwent minilaparotomy, and 21 (group C) underwent full laparotomy. In group M, we exposed the proximal neck with the Kent retractor (Takasago Surgical Instruments, Tokyo), with the patient in the arched-back position. The occurrence of back flow from the iliac arteries was controlled with a tourniquet to expose the iliac arteries during distal anastomosis, and thus sufficient exposure for distal anastomosis was obtained even with a limited skin incision. We compared and analyzed the perioperative courses between the 2 groups. Results: The patient demographics did not significantly differ between the 2 groups, and there were no hospital deaths in either group. Furthermore, there was sgnificant difference seen in the ratios of suprarenal aortic clamping (group M; 41%, group C; 24%, P=0.25) or internal iliac reconstruction (group M; 35%, group C; 24%, P=0.44). However, operation time, the removal of the nasogastric tube, oral intake and ambulation were all significantly shorter in group M. Average hospital stay was shorter in group M than in group C. Conclusions: Minilaparotomy for AAA with commonly used surgical instruments may be superior to full laparotomy for AAA repair.

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Objective: The purpose of the present study was to determine the perioperative factors associated with delayed wound closure in the repair of ruptured abdominal aortic aneurysm (RAAA).
Methods: A total of 64 patients underwent RAAA repair in our hospital between January 2006 and December 2009. We excluded 9 patients who had already experienced cardiopulmonary arrest before admittance our hospital and who died within 24 hours post operatively. The remaining 55 patients were divided into group A (38 patients with immediate wound closure) and group B (17 patients, delayed wound closure). We analyzed many factors in the 2 groups. Preoperative factors were age, systolic blood pressure, Rutherford classification, base excess (BE), hemoglobin (Hb) and creatine kinase (CK) levels; intraoperative factors were aortic clamp time, operative time, amount of blood loss, and red blood cell transfusion volume. We also compared operative mortality between the 2 groups.
Results: The mean age was (77.7±8.2 years in group A and 73.2±7.2 years in group B (p=0.048). Mean systolic blood pressure (114.5±28.6 mmHg, 80.4±21.2 mmHg) (p=0.0001), and BE (-4.96±5.67, -11.7±6.22) (p=0.0007) were higher in group A than in group B. The median Rutherford classification (2, 4), amount of blood loss (4105±1831 ml, 7417±4888 ml) (p=0.014), and transfusion volume (1467±592 ml, 2232±1056 ml) (p=0.01) were all lower in group A than in group B. The ratio of men to women (A=25:13, B=13:4) (p=0.431), CK level (A=914.6±4683 IU/l, B=98.1±76.9 IU/l) (p=0.29), Hb level (A=7.29±2.31 g/dl, B=6.85±1.63 g/dl) (p=0.419), aortic clamp time (A=28.7±17 min, B=29.6±25 min) (p=0.9), and operative time (A=284±87 min, B=335±102 min) (p=0.088) were all similar in both groups. The operative mortalies of the total of 64 patients, and of groups A and B were 27.7%, 5.3%, and 41%, respectively.
Conclusion: Mean age, systolic blood pressure, BE, amount of blood loss, and the amount of transfusion volume were all significant perioperative factors associated with delayed wound closure in the repair of RAAA in this study.

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The difficulies complications encountered in open surgical repair for infrarenal abdominal aortic aneurysm (AAA) with horseshoe kidney can be avoided by the use of endovascular aneurysm repair. However, the indications for aberrant renal artery reconstruction remain unidentified. A 72-year-old man was referred because of AAA with horseshoe kidney. His renal function was almost normal (cystatin C level: 1.21 mg/l, BUN: 16 mg/dl, creatinine: 0.86 mg/dl). A preoperative abdominal computed tomography (CT) scan revealed an abdominal aortic aneurysm and horseshoe kidney with a substantial isthmus, which was being perfused by an aberrant renal artery from the right common iliac artery. Intraoperatively, selective renal artery angiography showed that less than one third of the total renal mass was being perfused by this aberrant renal artery. We used a Powerlink endovascular graft (Endologix) without reconstruction of the aberrant renal artery. A postoperative enhanced CT scan showed only 17% of the total renal mass to be infaracted. In the present case, we performed endovascular repair without reconstruction of an aberrant renal artery which supplied less than 20% of the total renal mass, without serious deterioration in renal function.

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A 61-year-old man was admitted because of pain in the abdomen and the left lower extremity. Computed tomography (CT) showed rupture of an abdominal aortic aneurysm and occlusion of the left common iliac artery. We performed emergency graft replacement. However, while attempting to declamp the left lower extremity reperfusion occurred, therefore we decided to perform modified controlled limb reperfusion again attempting before declamping, which was successful. The patient’s postoperative course was uneventful. This method was a simple and rapid technique to prevent reperfusion injury.

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Heparin-induced thrombocytopenia is rare and its prognosis is poor. An 80-year-old woman underwent ascending aorta replacement for acute type A aortic dissection but pulmonary thromboembolism occurred on postoperative day 10. We initiated heparin administration, but pneumonia occurred and suffered septic shock on postoperative day 14. We started platelet transfusion because we suspected disseminated intravascular coagulation. However, her platelet count decreased rapidly to 4000/µl and the platelet factor 4-reactive heparin-induced thrombocytopenia antibody testing was positive. We stopped heparin administration and started intravenous argatroban resulting in an increase in her platelet count to 300,000/µl on postoperative day 30. It was difficult to distinguish between heparin-induced thrombocytopenia and disseminated intravascular coagulation in the present case.

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An 81-year-old man, who complained of a swollen left leg, was referred to our hospital. Enhanced computed tomography of the abdominal area and lower extremities showed abdominal aortic and bilateral iliac arterial aneurysms with an arteriovenous (AV) fistula extending from the right common iliac artery to the left common iliac vein. A shunt was observed on abdominal ultrasonography extending from the right common iliac artery to the left common iliac vein with a fistula of 14 mm in diameter. Further ultrasonography on admission revealed thrombosis in the external iliac and femoral veins on the left side. On a diagnosis of abdominal aortic and bilateral iliac arterial aneurysms with AV fistula from the right common iliac artery to the left common iliac vein with deep-vein thrombosis, we performed a Y-shaped vascular graft replacement (Intergard, 16 mm×8 mm) and simple closure of the AV fistula by manual compression, after insertion of a temporary inferior vena cava filter. We obtained good surgical results with the preoperative identification and localization of the AV fistula.

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A 73-year-old man suffering from left leg edema was found to have an abnormal abdominal mass. Preoperative 3-dimensional (3D) computed tomographic (CT) angiography revealed an abdominal aortic aneurysm with horseshoe kidney and an internal iliac artery aneurysm with venous fistula. Preoperative abdominal CT showed 2 accessory renal arteries. First, we successfully removed the aneurysm via a medial transperitoneal approach with a bifurcated graft, without resection of the renal isthmus. Second, we repaired the internal iliac artery aneurismal venous fistula via a retroperitoneal approach. Postoperatively, there was no evidence of renal dysfunction and the patient was discharged after an uneventful postoperative course.

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A 65-year-old man presented, complaining of severe left lower back pain. Computed tomography (CT) showed an infrarenal abdominal aortic aneurysm of 7.6 cm in maximum dimension, with acute abdominal aortic dissection which had ruptured in to the retroperitoneal space. Emergency surgery was performed and a massive hematoma was found in the retroperitoneal space. The point of rupture was on the proximal left lateral side of the aneurysm, where found an entry site. The proximal extent of the dissection was located near the portion of the transection and the dissection extended to the left common iliac artery. There was no evidence of a thrombus in the aneurysm. We anastomosed a Y-shaped graft to the dissected neck of the infrarenal aorta, incorporating a felt strip to reinforce the true and friable false luminae onto the graft. In both legs, we anastomosed the bilateral common femoral arteries. The patient’s postoperative course was uneventful and he was discharged 21 days post operatively.

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We report a successful surgical case of in situ graft replacement for mycotic thoracic aortic aneurysm following stent-grafting. A 76-year-old woman with hemosputum for 3 months was admitted to our hospital. Computed tomography (CT) revealed a pseudoaneurysm of the thoracic descending aorta. There were no infectious findings and we therefore performed stent-grafting of the lesion to prevent possible rupture. The patient was discharged on postoperative day 12, but 4 months later, she began vomiting blood and was immediately readmitted. Gastric endoscopy revealed bleeding from an ulcerous lesion, which was determined to be a Group V ulcer based on histopathological findings. Although the bleeding subsided, she again vomited blood 1 week after endoscopic hemostasis. However, on this occasion gastric endoscopy revealed no signs of bleeding. Emergency CT revealed enlargement of a thoracic descending aortic aneurysm, while laboratory findings showed an enhanced inflammatory reaction and a high fever. We diagnosed hemoptysis due to mycotic thoracic aortic aneurysm. We removed the stent-graft and replaced it with a prosthesis soaked in rifampicin. On postoperative day 33, the patient experienced lumbar pain and difficulty in walking. She also had an extradural abscess and underwent abscess drainage. The patient was discharged on postoperative day 190 and experienced no recurrence of infection for 18 months postoperatively. The indications of stent-grafting for aortic aneurysm should be carefully considered.

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