Objective: To assess the influence of diabetes mellitus (DM) and end-stage renal failure on hemodialysis (HD) on the healing time of tissue lesions and blood flow to the foot following a paramalleolar bypass in patients with critical limb ischemia (CLI). Methods: Consecutive patients with CLI and tissue loss (24 limbs) were followed up retrospectively after paramalleolar bypass, and the healing time of tissue lesions, graft patency, limb salvage and survival rates were analyzed. The blood flow to the foot was assessed by skin perfusion pressure (SPP) pre- and postoperatively. The delta SPP was calculated as the difference between the SPP before and after bypass. The patients were divided into 3 groups: diabetic (DM, n=9); end-stage renal failure on hemodialysis (HD, n=10); or neither (n=5). Results: A total of 15 dorsal and 9 plantar artery bypasses were performed. The median follow up was 7.3 months (range, 1–18 months). No patients required major amputations, and all tissue lesions healed. The mean duration to complete tissue healing of the DM, HD and neither groups was 2.2, 2.5 and 1.2 months, respectively, was and these were not statistically significant. A significant improvement in the delta SPP after paramalleolar bypass was observed in the neither group compared with both the DM and HD groups. Conclusion: Blood flow to the foot was not sufficiently improved in CLI patients with DM and HD, despite paramalleolar bypass. This may be the cause of the prolonged tissue healing duration of CLI patients with DM and HD.

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Background: Microporous polysaccharide hemospheres (MPH) have been developed to promote hemostasis using controlled-porosity spherical particles made from potato. We investigated the initial clinical efficacy of MPH in peripheral vascular surgery in our institution. Methods: We enrolled 25 patients in this study. Between January 2008 and December 2009, 10 patients (group A) were given 1 g MPH (Arista AH^®), while 15 (group B) were treated with 1 ml fibrin sealant (Beriplast P^®) at the anastomosis between the prosthesis and native vessel intraoperatively. In group A, 6 patients demonstrated lower extremity revascularization and 4 patients showed vascular access. In group B, 10 patients demonstrated peripheral arterial revascularization and 5 required arteriovenous grafts. We evaluated the perioperative results and complications including graft patency, wound problems and postoperative general condition in both groups. Results: The amount of bleeding during surgery differed slightly between group A (10–80 ml; mean, 30.5 ml) and group B (10–300 ml; mean, 83.0 ml), but this difference was not statistically significant (p=0.051). In group A, major complications were non-infective wound edema in 1 case, seroma formation in 1 case, and reversible mild liver dysfunction in 1 case. In group B, fatal aspiration pneumonia occurred in 1 case and renal dysfunction deterioration occurred in 1 case. There was no wound infection in either group, and all prosthetic grafts in both groups remained patent without the development of stenosis or pseudoaneurysm at the anastomosis site in the early phase. Conclusion: Based on these results, the use of MPHs can be a safe and effective treatment for hemostasis during peripheral vascular surgery. Further studies will be needed to elucidate the precise clinical effects of MPH.

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Objective: The objectives of this study were to examine the patterns of diagnosis, management and outcomes of all patients with ruptured abdominal aortic aneurysm (AAA) who came to our hospital. Methods: the diagnosis, management and outcome data of 79 consecutive patients with ruptured AAA between May 2002 and May 2011 were examined by reviewing their medical records. Result: The overall surgery rate for ruptured AAA was 61% and the survival rate was 48%. A total of 34 patients had received a diagnosis of ruptured aneurysm by the referring physician, while 45 did not have a diagnosis of ruptured aneurysm. Of these 45 patients, the AAA of 32 patients was diagnosed within 1 hour in our hospital, but a diagnosis of AAA in 3 patients took more than 6 hours. The patients who received a diagnosis within 1 hour had a low surgery rate (41%) and low survival rate (22%). All patients who did not receive a diagnosis within 6 hours died prior to surgery. Both groups were considered to have poor prognoses. Conclusion: The surgery and survival rates of ruptured AAA patients were very low. To further decrease the mortality rate, aneurysm must be detected before rupture and operated on electively. Sufficient education for emergency medical staff is also important to decrease the rate of the misdiagnosis of AAA rupture.

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We report the early results of thoracic endovascular aortic repair (TEVAR) for elderly patients over 80 years. From January 2007 to June 2010, we performed TEVAR in 119 patients. We divided the patients into 2 groups: group H (elderly patients over 80 years); and group C (elderly patients under 80 years). The preoperative, intraoperative and postoperative factors were compared between the 2 groups. The mean age of the patients was 82.4 years old in group H and 69.7 years old in group C. There was no significant difference in preoperative comorbidity or past history, except in cancer patients, between the 2 groups. The operative and anesthetic durations were 151.9±69.4 minutes and 243.2±77.4 minutes in group H, and 159.9±109.7 minutes and 243.2±113.1 minutes in group C, respectively. Postoperative factors, such as major complications, length of postoperative hospital stay and percentage of patients discharged to their own home were also similar in both groups. There were 5 early deaths (6.2%) in group C only. Conclusion: TEVAR can be performed safely in elderly patients over 80 years as well as in elderly patients under 80 years.

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Objective: To evaluate the early and mid-term results of simultaneous TEVAR and EVAR operations for combined thoracic and abdominal or thoracoabdominal aortic aneurysm. Methods: Between December 2007 and September 2009, we performed TEVAR in 57 patients in our hospital. Among these, we performed simultaneous TEVAR and EVAR operations in 9 patients (15.7%). The median age was 78 years (range, 57–83). There were 7 men and 2 women and the median follow-up period was 19.8 months (range, 10.5–29.6). Combined TAA (distal arch; n=3, proximal descending arch; n=1, chronic type B dissection; n=2). AAA was diagnosed in 6 patients, TAAA and AAA were diagnosed in 2 patients, and acute type B dissection and AAA were diagnosed in 1 patient. Results: The thoracic aortic stent grafts used were a TAG (n=8) and a Najuta (n=1). The abdominal aortic stent grafts used were the Excluder (n=8) and the Powerlink (n=1). Three patients underwent a debranching procedure first, followed by TEVAR and EVAR. RSCA to LCCA and LSCA bypass (n=1), LCCA to LSCA bypass (n=1), REIA to RRA, LEIA to SMA and LRA bypass (n=1) were performed in these patients. The intercostal arteries at the T8 to T12 levels (Adamkiewicz artery was apparent) were covered in 4 patients. The LSCA was covered in 2 patients, and the unilateral IIA was covered in 2 patients. There was no simultaneous covering of the LSCA or ipsilateral IIA. Cerebrospinal fluid (CSF) drainage was not performed in any cases. There was no occurrence of postoperative stroke or paraplegia. During the follow-up periods, there were no occurrences of Type I endoleak. Although Type II endoleak developed in 3 patients, the diameter of the aneurysms did not increase during the follow-up period. There were no instances of early or late death. Conclusion: Simultaneous TEVAR and EVAR for the treatment of combined thoracic and abdominal aortic aneurysms were safe and effective. There were no complications such as paraplegia.

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An 82-year-old woman was admitted with acute back pain and anemia. Enhanced computed tomography (CT) showed infrarenal an abdominal aortic aneurysm (AAA) with acute type IIIa aortic dissection. As the thoracoabdominal aorta showed severe kinking, the extension of aortic dissection was obstructed due to this rare anatomical feature. Medical therapy was initially performed in the intensive care unit to maintain systemic blood pressure control and improve anemia. Graft replacement of the AAA was then performed without any complications 40 days after the onset of acute aortic dissection. Regular follow up with enhanced CT did not indicate a remarkable change in the type IIIa aortic dissection, which showed a contrast-enhanced pseudolumen. However, sudden death, which we suspected to be due to retrograde aortic dissection, occurred approximately 2 years postoperatively. Surgical intervention for type IIIa aortic chronic dissection with non-thrombosed pseudolumen and severe kinking of the thoracoabdominal aorta can be performed, even in elderly patients.

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In this study, clot removal and blood vessel prosthesis implantation was effective in a patient with superior vena cava syndrome. A 53-year-old man presented with symptoms of superior vena cava syndrome, such as swelling from the head and neck area to the upper limbs, neck-vein distension, a top-heavy feeling, and a rush of blood to the head, which appeared during admission for investigation of upper abdominal discomfort. Superior vena cava syndrome caused by superior vena cava invasion by lung cancer was diagnosed, and surgery for partial dissection of the tumor, clot removal in the brachiocephalic vein and non-specific veins, and blood vessel prosthesis implantation using an 18-mm J-graft were performed as palliative therapy. The symptoms rapidly vanished, and at 6 months postoperatively no occlusion of the artificial blood vessel has been observed, with the patient maintaining good progress. The removal of clots with blood vessel prosthesis implantation for superior vena cava syndrome was effective in the present case.

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We report 3 cases of infected thoracoabdominal aortic aneurysm without any occurrence of hospital death. Case 1 was a 74-year-old man. Staphylococcus aureus (methicillin-sensitive) was positive in a blood culture preoperatively. We used a rifampicin-soaked branched prosthesis to replace the thoracoabdominal aorta. The prosthesis was covered with the omentum. About 3 years after surgery, the patient died of pneumonia, but no complications in his aorta were observed postoperatively. Case 2 was a 75-year-old woman. Three months after lower gastrointestinal endoscopy, thoracoabdominal aortic aneurysm developed. A branched prosthesis was used to replace the aorta. Streptococcus pneumoniae was isolated from the aneurysm wall. Rifampicin was not used because it had not been prepared, and neither was the omentum used because it was atrophic after colon surgery. However, the patient is alive without vascular problems at 5 years after surgery. Case 3 was a 75-year-old man. A rapidly expanding thoracoabdominal aortic aneurysm was observed during investigation of a previous small aneurysm. Blood culture showed Staphylococcus capitis. A rifampicin-soaked branched prosthesis was used and covered with the omentum. He has been healthy for 2.5 years after surgery. In summary, our strategies, including in-situ reconstruction using a rifampicin-soaked branched prosthesis, omental covering, and intravenous antibiotic administration for at least 1 month after surgery, may provide good mid-term results. In addition to the multimodal control of infection, a multidisciplinary approach toward minimally-invasive treatment against thoracoabdominal aortic aneurysm may be warranted.

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We describe a case of successful surgical reconstruction of isolated spontaneous superior mesenteric artery (SMA) dissection in a 54-year-old man. However, follow-up enhanced computed tomography (CT) after 7 weeks revealed progressive enlargement of the false lumen from 18.5 mm to 27.0 mm and stenosis on the distal side. To maintain the patency of all branches, we resected the intima to eliminate the stenosis and perform endoaneurysmorrhaphy of the dilated false lumen. Postoperative CT scans showed improved patency in the SMA, and no significant changes were observed after 18 months.

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Infected abdominal aortic aneurysms (IAAs) are rare, and their surgical treatment remains difficult. We describe a rare case of effective surgical treatment for an IAA patient with spondylitis. The surgical treatment of choice for IAA with spondylitis is considered to be extra-anatomical bypass. We performed in-situ reconstruction using rifampicin-bonded gelatin-impregnated Dacron grafts and covered the prosthesis with the omental flap. Spondylitis is difficult to diagnose because its symptoms can be similar to those of IAA, and moreover, imaging is difficult in the early stages.

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We report a rare case of localized aortic dissection superimposed on an infrarenal abdominal aortic aneurysm (AAA). The patient was a 79-year-old woman who had been given a diagnosis of infrarenal AAA at another hospital, and thereafter the maximum aneurysm diameter had remained at 36 mm for 2 years. However, the patient subsequently suffered sudden abdominal and back pain, and computed tomography demonstrated a localized infrarenal aortic dissection superimposed on the AAA. The entry point was located within the AAA. The false lumen extended to the aorta around the renal artery, and the false lumen of the proximal aorta was thrombosed. The maximum diameter of the AAA was 40 mm, but 5 months after the onset of dissection, the aneurysm enlarged to 55 mm, and the patient presented to our hospital. Vascular reconstruction was performed via a bifurcated graft. The thrombosed false lumen of the proximal aorta had disappeared in the previous 5 months, which enabled the clamping of the neck of the aneurysm, and we secured it by suturing in the usual manner.

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An 83-year-old man was admitted with intermittent claudication (IC) on walking 50 m and lower leg pain at rest. Enhanced computed tomography (CT) showed multifocal peripheral arterial disease (PAD) involving total occlusion of the right common iliac artery and severe stenosis of the left common iliac artery and superficial femoral artery (SFA). He was given a diagnosis of polycythemia vera based on high whole blood cell counts. Hybrid surgical and endovascular therapy (EVT) was scheduled for the multifocal PAD. Under local anesthesia, EVT with a self-expandable shape-memory, alloy-recoverable technology stent was applied to the left-side PAD. However, thrombus formation was observed from the SFA to the popliteal artery. Percutaneous thrombectomy using a vascular catheter was successfully performed. Subsequently, surgical intervention by femoro-femoral crossover bypass using an 8-mm polytetrafluoroethylene Maxiflo prosthetic graft was performed under general anesthesia. Anticoagulant therapy with heparin was immediately performed postoperatively, and then 2 anti-platelet agents and coumadin were prescribed to prevent thrombotic complications postoperatively. The postoperative clinical course was uneventful, and postoperative enhanced CT demonstrated good patency of the stents and prosthesis. His clinical symptoms improved, and his IC had improved up to a distance of 650 m at discharge. Therefore, hybrid intervention for multifocal PAD could be an effective and minimally invasive approach to treat complicated PAD, such as in the present elderly patient with polycythemia vera.

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A 35-year-old woman with schizophrenia was brought to our hospital because of multiple fractures as a result of a fall. Catheterization was performed via her right internal jugular vein as treatment in the intensive care unit. After 12 days of hospitalization, she had a fever of 39°C; as a result, catheter infection was suspected, and the catheter was removed. Blood culture revealed Enterococcus faecium. Antibiotic therapy was administered during the subsequent 19 days of hospitalization. However, pus discharge was observed from her right cervix. Computed tomography showed thrombophlebitis extending from the brachiocephalic vein to the right internal jugular vein. A risk of pulmonary embolism and the need for infection control necessitated surgery. We adopted a 2-operation approach—a right cervical incision and median sternotomy—and performed thrombectomy of the brachiocephalic vein and excision of the internal jugular vein. Operative therapy was effective for the management of infective thrombosis refractory to antibiotic therapy.

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We report a surgical case of a 79-year-old woman with thoracoabdominal aortic aneurysm complicated by emphysema. We planned a 2-stage hybrid repair of the aneurysm which consisted of the insertion of a stent graft into the thoracoabdominal aorta, excluding the branches of the visceral arteries, and bypass grafting to the visceral branches. In the first stage of the procedure, after aorto-bi-iliac repair of the infrarenal abdominal aortic aneurysm with a bifurcated Dacron graft, we attached a knitted quadrifurcated graft inversely from the left limb of the bifurcated graft to the celiac, superior mesenteric, and bilateral renal arteries. Subsequently, all 4 visceral arteries were double-ligated proximal to the site of anastomosis. Because follow-up computed tomography showed residual branches of the superior mesenteric artery proximal to the site of ligation, coil embolization was performed at the origin of the superior mesenteric artery. In the second stage of the procedure, the right limb of the bifurcated graft was accessed via a right retroperitoneal approach. Successful endovascular repair of the thoracoabdominal aortic aneurysm was performed from distal to proximal using 3 TAG endoprostheses. The postoperative course was uneventful and there was no occurrence of paraplegia.

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