Objectives: The case loads and varieties of vascular therapies in each vascular institution are very important factors in obtaining the Japanese Board of Cardiovascular Surgery Certification. At the Department of Vascular Surgery at our institution, we investigated the number of surgeons eligible to take this board examination, the number of surgeons who were able to perform endovascular aortic repair (EVAR) and thoracic endovascular aortic repair (TEVAR) and the required number of proctors for EVAR and TEVAR as defined by the Japanese Committee for Stent-graft Management. We compared these figures before and after 2006, when Professor Takao Ohki came to our institution and launched a new vascular and endovascular program.
Methods: From July 2006 to December 2009, we performed a total of 2,465 vascular procedures, 95% of which were for arterial disease. We analyzed the case loads and distribution from 2007 to 2009.
Results: The annual case load was 658 in 2007, 834 in 2008 and 720 in 2009. In 2005, we performed 7 abdominal aortic aneurysm (AAA) and 11 peripheral arterial disease (PAD) procedures, whereas in 2009, we performed 236 AAA repair procedures (EVAR: 206, open surgery: 30), 79 thoracic aortic aneurysm (TAA) repair procedures, 24 thoracoabdominal aortic aneurysm (TAAA) repair procedures, 14 chronic aortic dissection repair procedures, 106 PAD procedures (endovascular treatment [EVT]: 35, bypass: 35, amputations, others: 36), 18 visceral artery aneurysm procedures, 23 renal artery stenosis repairs, 30 carotid artery stenosis (CEA: 19, EVT: 11) repairs, and 190 other procedures. A wide variety of vascular diseases was treated with either EVT or open surgery utilizing 3 operating rooms, including 2 hybrid vascular operating rooms equipped with a fixed fluoroscopy system. Of the 2,212 procedures performed between 2007 and 2009, 1,492 cases (67.5%) were eligible as cases for required experience to qualify to take the examination for the Certification of the Japanese Board of Cardiovascular Surgery.
Conclusions: The launch of an endovascular program increased our aortic case load by 50-fold. Although both renal and carotid interventions require advanced EVT skills, neither is eligible for qualification to take the cardiovascular board examination. Each vascular teaching institution needs to provide a sufficient case load and variety of procedures including both EVTs and open surgery.

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Background: There are number of young Japanese medical graduates coming to the United States for clinical training. Method: Based on own experience, the risks and benefits of US training were exhibited. Results: The largest benefits of the residency in the US are systemic operative and didactic training. However, there are many hurdles go though before, during and after training, including license, visa, English, and jobs. Conclusion: Those who would like to do US residency should realize the risk as well before going to the training in the US.

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Objective: To review the surgical results of common femoral artery (CFA) endarterectomy in which a stent had been previously placed. Patients: We performed surgical revascularization in 3 patients who had already undergone percutaneous transluminal angioplasty with stenting in the CFA. All patients were men with vessel claudication. Self-expanding stents were placed in 2 patients, and an expandable balloon stent was placed in 1. In each patient, femoral endarterectomy with partial or total stent removal was performed. Previous stents extending to the superficial femoral artery (SFA) were transected just distal to the origin of the deep femoral artery. In 2 patients with iliac stenosis, concomitant iliac stenting was performed. Results: All the patients recovered well with resolution of their claudication. Conclusion: Femoral endarterectomy can be performed successfully even in patients with previously stented CFA. Total removal of the previous stents which extended to the SFA was not necessary.

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A 61-year-old male rectal cancer patient receiving chemotherapy experienced hoarseness. Chest CT revealed a right subclavian artery aneurysm 33 mm in diameter protruding into the pleural cavity. Our surgical approach was via a right collar incision and median sternotomy. The aneurysm was resected after clamping the right carotid, right subclavian, and brachiocephalic arteries. The right subclavian artery was reconstructed with a primary end-to-end anastomosis. The important issues in subclavian aneurysm repair are the method of surgical approach and the maintenance of cerebral blood flow. Therefore, careful preoperative assessment should be undertaken for each case.

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Occlusion of the popliteal artery due to blunt trauma is not common, but failure to restore adequate blood flow in such cases is a major cause of limb loss. We encountered a rare case of late-onset popliteal artery occlusion after blunt trauma following a traffic accident. A 17-year-old woman was involved in a traffic accident, and her right lower extremity had been swollen for 2 weeks. Four months later, she complained of intermittent claudication of the right calf. Magnetic resonance angiography showed segmental occlusion of the right popliteal artery. We therefore performed a right above-the-knee popliteal artery to below-the-knee popliteal artery bypass using an in-situ autologous saphenous vein graft. Postoperatively, her ischemic symptoms resolved, although she experienced transient mild foot drop. In cases of blunt trauma around the knee joint, late-onset popliteal artery occlusion should be considered.

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We describe a patient who underwent an emergency aneurysmectomy for a ruptured renal aneurysm following cesarean section, in whom renal function was preserved. A 31-year-old woman presented with gestational diabetes mellitus at a local hospital. She underwent an emergency cesarean section because of placental abruption. Left low back pain and upper back pain suddenly developed 17 hours after childbirth. A computed tomographic scan revealed a ruptured aneurysm of the left renal artery, and we performed coil packing of the aneurysm. However, complete packing was impossible because of the large size of the aneurysm. We therefore decided to operate. The ruptured aneurysm was removed through a retroperitoneal approach, and the renal artery was directly reconstructed by end-to-end anastomosis. Renal aneurysms are considered to be at high risk of rupture during pregnancy. However, to the best of our knowledge, no study has reported rupture of a renal aneurysm after cesarean section. Surgical treatment yielded a good outcome, and renal function was preserved.

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The isolated dissection of the splanchnic artery is relatively rare and there is no consensus on the optimal treatment strategy. We report 4 cases of isolated splanchnic dissection. The mean patient age was 54 years (range, 47–64), and all were treated with conservative therapy during the period of observation. In all 4 cases, conservative management successfully resolved the isolated dissection of a splanchnic artery, with a benign clinical course and no evidence of progression of the dissection on multidetector computed tomography following the therapeutic periods. It is considered common that isolated splanchnic dissection progression is limited during the period of observation and furthermore, develops little 6 months after onset. Multidetector computed tomography is useful not only for accurate diagnosis in isolated splanchnic artery dissection, but also when considering its treatment. Based on our experience, cases without acute intestinal ischemia or aneurysmal changes can be treated conservatively.

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We performed combined treatment of endovascular aneurysm repair (EVAR) and off-pump coronary artery bypass (OPCAB) in 2 cases of abdominal aortic aneurysm and coronary artery disease. A 70-year-old man and an 83-year-old man were referred to our hospital both with triple-vessel coronary artery and abdominal aortic aneurysm. In both cases, EVAR was first performed, followed by OPCAB after heparin administration. Both patients were discharged from hospital without complications. The combined treatment of EVAR and OPCAB yielded excellent surgical outcomes for these complex cases.

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A 66-year-old man underwent immunosuppressive therapy for aplastic anemia and was in partial remission. However, marked bleeding was observed and disseminated intravascular coagulation (DIC) was diagnosed, with advanced fibrinolysis due to an abdominal aortic aneurysm. Since DIC is often non-responsive to internal medical therapy, we performed surgical repair of the abdominal aortic aneurysm. Postoperatively, the bleeding tendency improved. Aplastic anemia is a condition which is rarely concomitant with DIC. We therefore report this case in which we performed appropriate surgery despite the occurrence of severe DIC as a rare complication.

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Pancreaticoduodenal artery aneurysm (PDAA) is a rare splanchnic aneurysm. Its etiology is thought to be an increase in blood flow and pressure in the pancreaticoduodenal artery region caused by celiac axis stenosis. We report a case of PDAA treated by combined therapy consisting of aorto-hepatic bypass grafting and a coil embolization of the aneurysm. A 61-year-old man undergoing a routine physical examination was found to have an asymptomatic pancreatic tumor on abdominal ultrasonography. A helical CT scan revealed a 15-mm × 20-mm aneurysm arising from a proximal mesenteric artery branch on axial images. Reformatted volume-rendered three-dimensional and sagittal multiplanar images showed a calcified aneurysm arising from the inferior pancreaticoduodenal artery and a “hooked” appearance of the celiac artery. On laparotomy, we explored the celiac artery and hepatic artery, and the stenosis of the celiac axis was found to be due to compression by the arcuate ligament. However, considering the probable incomplete release of the compression by division of the ligament, we elected to create an aorto-hepatic bypass using a saphenous vein graft. After completion of the bypass grafting, the patient was moved to an angiography suite and underwent successful coil embolization of the aneurysm using several coils via a 5-Fr catheter through the superior mesenteric artery. The clinical course of the patient was uneventful, with a low-grade increase in serum amylase level, and the patient was discharged on postoperative day 21. Combined therapy consisting of bypass grafting and transarterial embolization provides a less invasive therapy for PDAA, and avoids the potentially serious pancreatic juice leakage which can result from manipulating the pancreatic parenchyma.

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We describe 2 cases of DeBakey type I acute aortic dissection with renal and limb malperfusion. The mechanism of unilateral renal ischemia in both cases was the compression of the true lumen, resulting in a decrease of blood flow to the renal artery which branched from the true lumen. The contralateral kidney, which functioned normally without ischemia, was perfused from a renal artery which branched from the false lumen in Case 1 and from the true lumen in Case 2. Unilateral leg ischemia (Case 1) and bilateral leg ischemia (Case 2) occurred by the same mechanism as true lumen collapse. Both patients underwent emergency graft replacement of the ascending aorta and proximal arch including resection of the primary entry tear to re-establish antegrade blood flow into the true lumen. However, the postoperative course of each patient was quite different. In Case 1, the patient required hemodialysis because bilateral renal dysfunction developed. Perfusion to the right kidney markedly decreased after central aortic repair, and left renal dysfunction continued despite improved left renal arterial flow, leading to bilateral renal dysfunction. In contrast, Case 2 showed adequate urinary output without the need for hemodialysis, because perfusion to the normally functioning right kidney had been maintained during central aortic repair despite sustained left renal dysfunction. Limb ischemia was improved by central aortic repair without the need for additional revascularization in both cases.

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