Background: Recently, the importance of a Vascular Laboratory (Vascular Lab) has become firmly established. We describe the requirements for a Vascular Lab, considering the present situation in our hospital. Method: Blood pressure pulse tests, transthoracic echocardiography, carotid echo, and vein assessment were performed for revascularization patients. A postoperative duplex scan of graft surveillance was performed when possible. Results: A total of 41 patients underwent graft revision or revascularization due to graft failure in 2009 in our institution. Graft occlusion in patients with graft surveillance was significantly less than that in patients without graft surveillance (4.2% vs. 29.4%, p < 0.05). For technologists, knowledge about diseases themselves or their physiology is important. In our hospital, other imaging findings on integrated image information systems have been shown to be useful. When technologists are involved in outpatient clinics for graft surveillance they are guided by a physician. Conclusion: Despite a diversity of Vascular Labs according to the needs of each facility, a high level of technology is essential. Discussion with doctors, centralized management of results, comparison with other imaging findings and responding to urgent requests are also desirable.

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The installation of a Vascular Laboratory (Vascular Lab) and placement of a clinical vascular technologist (CVT) are important components in performing non-invasive examinations of vascular diseases including functional diagnosis. In 1999, a Vascular Lab was opened within the Department of Vascular Surgery at our institution, mainly to perform functional studies and obtain findings from accumulated test results. Treadmill walking tests showed an ability to evaluate walking performance and predict the effect of exercise therapy in patients with intermittent claudication. Non-invasive examinations such as ankle pressure tests, first toe pressure tests, skin perfusion pressure tests, and percutaneous oxygen partial pressure measurements for critical ischemia of the lower limbs proved useful to evaluate the curability of ischemic ulcers or amputation stumps. Particularly, the curability of a wound is low when the skin perfusion pressure and the first toe pressure are under 40 mmHg and 30 mmHg, respectively.
In Japan, characteristics of Vascular Labs vary, and their location within the hospital depends on the individual institution. Many Vascular Labs belong to clinical laboratories, while some physiological function departments are responsible for Vascular Labs. Therefore, few Vascular Labs focus on functional studies specializing in vascular surgery, and many are involved mainly in vascular ultrasound examination. There are many specialized Vascular Lab tasks which require training and laboratory technicians with advanced skills. Despite the cost, it is desirable that Vascular Labs will be established in many institutions for improved vascular care in future.

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Squamous cell carcinoma of the penis with inguinal lymph node metastasis frequently results in femoral artery bleeding leading to hemorrhagic shock and even death. A 73-year-old man with a diagnosis of squamous cell carcinoma of the penis underwent a partial penectomy, bilateral inguinal lymph nodes resection, and pelvic lymph node resection in 2008. An inguinal lymph node metastasis subsequently developed from a right common femoral artery invasion and a right inguinal skin fistula in 2009. A tailor-made stent-graft configured from a Gore-Tex graft and a Palmaz stent was successfully deployed through the right superficial femoral artery after coil embolization to the right profunda femoris artery. Following endovascular therapy, femoral artery rupture prevention was maintained for 3 months, during which time the patient died as a result of penile carcinoma. To the best of our knowledge, this is the first report of endovascular therapy in Japan for femoral artery invasion due to penile carcinoma.

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We report a case of abdominal aortic aneurysm invaded by periaortic malignant lymphoma. An 86-year-old woman who had had persistent abdominal pain for several days was urgently admitted to our hospital with suspected ruptured abdominal aortic aneurysm. An enhanced computed tomography scan showed an infrarenal aortic aneurysm with an area of soft tissue density in the retroperitoneal region, suggestive of hematoma. We performed emergency abdominal aortic reconstruction under a diagnosis of impending rupture of an abdominal aortic aneurysm. The intraoperative diagnosis was inflammatory abdominal aortic aneurysm, but the specimen from the abdominal wall revealed diffuse large B-cell lymphoma. She underwent chemotherapy, but died of multiple organ failure during the course of treatment.

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A 61-year-old man had epigastric pain. Abdominal computed tomography and digital subtraction angiography revealed a celiac artery aneurysm (20 mm) and splenic artery aneurysm (85 mm) but without any evidence of rupture. We performed resection of the spleen and splenic artery aneurysm, and ligation of the celiac and splenic artery, and simultaneously, infrarenal abdominal aorto-common hepatic artery bypass using an externally supported 6 mm ePTFE graft to maintain the hepatic blood supply. The ePTFE graft was covered with the omentum to prevent pseudoaneurysm and graft infection. The patient had a pancreatic fistula postoperatively but there was no direct contact with the graft, and he left the hospital without occurrence of a pseudoaneurysm or graft infection.

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An 87-year-old man was treated for abdominal aortic aneurysm (AAA) with an excluder stent graft. However, re-onset type II endoleak with significant aneurysm enlargement was observed 17 months after the procedure. Instead of embolization to the lumbar artery and inferior mesenteric artery (IMA), the diameter of his aneurysm increased. Finally, late open conversion was successfully performed with an infrarenal aortic cross-clamp, complete stent-graft removal, IMA ligation and Y-graft replacement 19 months after endovascular aortic aneurysm repair. No structural damage was observed on the removed stent grafts.

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We report successful endovascular aneurysm repair (EVAR) in an anatomically difficult case of abdominal aortic aneurysm (AAA) in a 92-year-old woman. An AAA of 30 mm in diameter was detected by computed tomography (CT) for gastric cancer in 2003. We decided to operate because her AAA enlarged to 55 mm in diameter in June 2009. Her medical history included gastrectomy for gastric cancer at 86 years old, an abdominal incisional hernia from 88 years old and chronic obstructive pulmonary disease and hypertension from 90 years old. The length of the normal aorta from the renal arteries to the aneurysm (proximal neck) was short (13 mm), and the terminal aorta was narrow (15 mm) and was severely calcified. We decided to perform EVAR with a Zenith^® AAA endovascular graft because laparotomy posed a high risk for this oldest-old patient with severe respiratory dysfunction and a hostile abdomen. Stenosis of the left leg, poor dilatation at the junction of the right leg, and type 1 endoleak of the proximal neck were observed by postoperative CT scan. Under local anesthesia, she underwent re-touch up of the proximal neck with non-compliant balloon dilatation and touch up of the narrow site and junction. CT confirmed the improvement of the leg stent alignment and the disappearance of the type 1 endoleak. She has been free of complications for 1 year, and the size of the aneurysm has reduced to 41 mm in diameter. We successfully performed EVAR on an oldest-old patient with AAA. EVAR itself is a minimally-invasive procedure: however, the limit of EVAR indications must be ascertained. The present case was unique because of its application in an oldest-old patient.

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Reconstruction of an aberrant renal artery (ARA) is one of the possible problems when operating on an abdominal aortic aneurysm (AAA) associated with a horseshoe kidney (HSK). We performed AAA repair with a HSK using a quadrifurcated prosthetic graft. A 48-year-old man was referred to our institution for AAA repair. Preoperative abdominal computed tomography (CT) revealed an AAA of 50 mm in diameter and an HSK with ARA. We performed the operation using a transperitoneal approach via typical median laparotomy. The AAA was replaced by a quadrifurcated prosthetic graft without division of the renal isthmus, and the ARA was reconstructed. His postoperative course was uneventful with no evidence of renal dysfunction. Postoperative CT showed a patent reconstructed ARA. We found that reconstruction of an ARA using a quadrifurcated prosthetic graft was useful for the replacement of AAA associated with HSK.

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A 65-year-old man who had received graft replacement for abdominal aortic aneurysm 6 years previously was transferred to our hospital because of severe abdominal pain. A computed tomography scan revealed para-anastomotic false aneurysm rupture and an emergency operation was performed. Under a midline laparotomy incision, we applied supraceliac clamping of the aorta through the lesser omentum and performed reconstruction with tube graft interposition between the aorta immediately below the renal arteries and the distal portion of the old graft. He recovered and was discharged 26 days after surgery. Non-infected para-anastomotic false aneurysm is rare within 5 years after aortic graft replacement, and its incidence gradually increases with time. Moreover, it is clear that ruptured or seriously complicated cases increase the operative risk, and therefore, patients who have undergone abdominal aortic graft replacement require long-term imaging follow up for early detection and elective repair of possible false aneurysms.

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The radial artery is not covered by muscle in the anatomical snuff box, where minor injuries can be associated with aneurysm formation. On the other hand, there are many individual differences in the periphery of the radial artery, and therefore it is important to evaluate peripheral blood flow intraoperatively to decide if revascularization after aneurysmectomy is indicated. A 48-year-old man was referred to our hospital complaining of an enlarged pulsatile mass in the left anatomical snuff box. Ultrasonography and magnetic resonance angiography revealed the presence of a 13-mm aneurysm of the radial artery. Considering the possibility of aneurysmal rupture, we performed aneurysmectomy. After interruption of the radial artery blood flow, transcutaneous oxygen tension (TcpO₂) of the thumb was significantly reduced. Therefore, revascularization of the radial artery was performed by end-to-end anastomosis between the radial artery and first metacarpal dorsal artery. After revascularization, the TcpO₂ of the thumb significantly improved. Pathological assessment identified it to be a true aneurysm, possibly caused by minor injuries. Only 6 cases of aneurysms in the anatomical snuff box have been reported in Japan. Here, we emphasize the importance of intraoperative blood flow evaluation and the usefulness of the measurement of TcpO₂.

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A 65-year-old man complaining of severe dyspnea was transferred to our hospital because computed tomography (CT) revealed his trachea to be almost completely collapsed by a large right common carotid artery aneurysm. As we assumed that the aneurysm was at risk of imminent rupture an emergency operation was conducted by a full sternotomy using cardiopulmonary bypass through both the femoral vein and artery. The carotid artery aneurysm originated from the orifice at the junction of brachiocephalic artery and totally occluded the distal bifurcation. The orifice was closed by direct sutures. Tracheal compression was relieved and the patient was discharged on the 21st postoperative day for referral for rehabilitation. However, 43 days after the initial operation, he presented with sudden syncope and dyspnea. Emergency CT revealed a recurrent carotid aneurysm which developed from the leakage of the orifice. Cancer nodules were also observed in both lungs. He was transferred to our hospital and intubated on the 7th day after readmission because of his worsening dyspnea. As multiple brain metastases of the lung cancer were suspected in the right cerebrum, we performed an endovascular repair with a custom made stent graft, which was successfully delivered via the right axillary artery to cover the right carotid artery orifice. He was weaned off the respirator and CT did not show any evidence of endoleak of the graft. However, consciousness impairment was sustained due to a new onset of left cerebral infarction. Tracheostomy was performed and the patient was discharged to a referral hospital on the 42nd day after endovascular repair.

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A 60-year-old man was referred to our hospital because of sudden onset of severe pain in the right leg, which appeared pale and exhibited sensory loss and motor weakness. Duplex ultrasonography could not detect a pulse in the right posterior tibial artery and dorsal pedis artery. Pulsatile masses were identified in bilateral popliteal fossae. A plain computed tomography (CT) scan showed bilateral popliteal artery aneurysms (PAAs), and the right-side one of 33 mm in diameter was located in the popliteal space. An enhanced magnetic resonance angiography (MRA) revealed almost total occlusion of the below-knee arteries with very low-grade collateral flow. The right PAA with acute ischemia (grade IIb according to Rutherford’s classification) was indicated for emergency surgical treatment. A posterior approach with the patient in the prone position was selected for aneurysmectomy with thromboembolectomy and prosthetic graft replacement. The below-knee trifurcation flow to the ankle was confirmed by intraoperative arteriography. The patient was discharged from the hospital on foot. When an emergency operation is adopted for severe acute ischemia caused by PAA, a quick decision must be made regarding the surgical approach, which can include a medial approach with bypass or a posterior approach with graft replacement. Our choice of operation was based on a plain CT image, obtained to confirm the shape of aneurysm, and an enhanced MRA to evaluate peripheral blood flow. Although this issue remains controversial, the present report may be of some help toward making such decisions.

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Microscopic polyangiitis (MPA) is characterized by the inflammation of small-sized vessels. We herein describe a patient with MPA who had suffered repeated large vessel diseases. A 63-year-old woman who had been given a diagnosis of MPA suffered Stanford type B aortic dissection 3 times in 3 months. Computed tomography (CT) after six months revealed that the descending aorta was dilated to 60 mm, and we performed descending aortic replacement. One year after the first operation, because CT showed a saccular aneurysm of aortic arch, we performed total arch replacement, without any complications.

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