Objective: Endovenous laser ablation (EVLA) with a 980-nm diode laser has been covered by the Japanese National Health insurance system since 2011. The aim of this study was to demonstrate the early treatment outcomes of EVLA of incompetent great saphenous veins (GSV) with a 980-nm diode laser in an ambulatory setting. Methods: From January to April 2011, 319 patients (354 limbs) with incompetent GSV treated with a 980-nm EVLA were studied. In all patients, laser energy was administered at 8 W to 10 W of power with constant pullback of the laser fiber under tumescent local anesthesia. The patients were assessed postoperatively by clinical examination and venous duplex ultrasonography at 48 hours, 1 week, 1 month and 4 months follow-up. Results: The mean operating time was 34.9 minutes. The mean length of treated veins was 36.3 cm. The mean linear endovenous laser energy (LEED) output was 86.3 J/cm. Major complications such as deep vein thrombosis and skin burns were not observed. There were 136 limbs (38.4%) involving pain and 230 limbs (65.0%) with bruising of the thigh which had all resolved by one-month follow-up. There were 55 limbs (15.5%) with endovenous heat-induced thrombus (EHIT). The cumulative occlusion rate calculated using the Kaplan-Meier method at 7 months was 98.1%. Conclusion: EVLA of the GSV using a 980-nm diode laser is a minimally invasive, safe and efficient treatment as an outpatient procedure and can be considered a standard treatment for primary varicose veins. It is essential for vascular surgeons to learn EVLA using this method.
Objective: To evaluate the feasibility and efficacy of simultaneous combined endovascular and open lower extremity arterial reconstruction. Patients and Methods: Between April 2008 and March 2011, 16 patients (17 limbs) underwent hybrid therapy. The patients comprised 13 men and 3 women, with an average age of 73 years. The treatment outcomes included incidence of postoperative complications, postoperative mortality and patency. Results: The technical and clinical success rates were 100% and 88%, respectively. There was no perioperative mortality. The primary patency, assisted primary patency, secondary patency and limb salvage rates at 24 months were 73%, 100%, 100% and 100%, respectively, in Fontaine stage II, and 50%, 83%, 83% and 83%, respectively in Fontaine stage III and IV patients. Conclusions: Hybrid procedures provide safe and effective treatment for multilevel lower extremity arterial disease.
Objective: We previously reported the development of a new surgical technique named “Less Invasive Quick Replacement (LIQR)” for treating type A acute aortic dissection. In this study, we examined the early and mid-term outcomes of patients who underwent LIQR. Methods: During the last 5 and half years, 88 patients underwent LIQR. The average age of the patients at the time of onset was 65.8 ± 14.2 years old. There were 18 patients (20.5%) who had independent operative risk factors such as vital organ malperfusion or preoperative cardiopulmonary arrest. Circulating blood in the cardiopulmonary bypass circuit was warmed to maximum level during open distal anastomosis, with a rectal temperature of 28°C without any cerebral perfusion. As soon as the distal anastomosis was completed, rapid re-warming was initiated by warm blood perfusion. We assessed the early and mid-term outcomes in terms of survival and freedom from reoperation rate. Results: The durations of circulatory arrest, cardiopulmonary bypass, overall operation, postoperative mechanical ventilation, and hospital stay were 19.1 ± 5.2 minutes, 83.6 ± 14.7 minutes, 147.3 ± 22.3 minutes, 10.5 ± 8.4 hours, and 9.7 ± 2.0 days, respectively. The need to perform re-exploration for bleeding, brain damage, and respiratory failure requiring tracheostomy occurred in 5 (5.7%), 4 (4.5%), and 3 (3.4%) patients, respectively. The hospital mortality rate was 3.4% (3 patients). There was no incidence of renal failure. Survival and freedom from reoperation rates at 5 years were 83.1% and 89.7%, respectively. Conclusion: LIQR is safe and effective. It is a very useful option that can contribute to maintaining a mid-term good quality of life for critical patients with type A acute aortic dissection.
We report a case of late conversion for abdominal aortic aneurysm (AAA) dilatation caused by a type II endoleak after endovascular aneurysm repair (EVAR). A 77-year-old man underwent EVAR for AAA in September 2007. Postoperative computed tomography (CT) showed type Ib endoleak and he received treatment of transarterial embolization and EVAR. However, the type II endoleak remained; he was followed up in an outpatient clinic, and was subsequently admitted for open surgery in April 2011. His lumbar arteries were clipped from the external aspect with a transperitoneal approach and the aneurysm was incised. Stent explantation was not required. Transarterial or translumbar embolization is the main treatment for a type II endoleak after EVAR, but there are few reports of either surgical approach in Japan. The current method might be less invasive, and it is unnecessary to remove the stent and perform replacement with a new graft.
We report 2 successful surgical cases of arteriovenous axillary crossover grafts (AVACG) for hemodialysis by using 4-mm to 6-mm polytetrafluoroethylene (PTFE) tapered grafts. Patient 1: A 91-year-old woman was admitted with vascular access failure (VAF), and a brachial-basilic arteriovenous fistula (BBAVF) was initially created. However, the BBAVF became occluded due to severe rigidity of an upper extremity. Both her upper and lower extremities were also rigid, making vascular access in the extremities difficult. However, AVACG using a 4-mm to 6-mm PTFE tapered graft was successfully performed to prevent heart failure or steal syndrome due to high flow VA, and the AVACG became effective without any hemodynamic compromise at postoperative day (POD) 14. She was discharged at POD 40 following recovery from aspiration pneumonia. Patient 2: An 84-year-old woman was admitted with VAF after twice receiving treatment of radiocephalic arteriovenous fistula. She had difficulty keeping both her upper and lower extremities straight. Surgical intervention of AVACG using a 4-mm to 6-mm PTFE tapered graft was performed successfully, but she died from worsening respiratory failure due to pneumonia. However, the AVACG remained patent just prior to death. From these results, AVACG with tapered graft may be an effective surgical method to maintain VA in elderly patients with rigid extremities.
In cases with malperfusion due to acute aortic dissection, the mortality rate is high if intestinal ischemia occurs. We herein report 2 cases in which a successful outcome was obtained by carrying out iliac artery to superior mesenteric artery bypass surgery for intestinal ischemia due to acute aortic dissection. Case 1: A 30-year-old man had occlusion of the left common iliac artery due to type B acute aortic dissection upon observed on computed tomography (CT). Although the dissociation of the superior mesenteric artery (SMA) was extended, no occlusion was observed. However, a peritoneal irritation occurred 3 days following femoro-femoral artery bypass surgery and SMA occlusion was observed on CT, and therefore an emergency laparotomy was performed. The entire small intestine demonstrated a pale color, and therefore a right common iliac artery-SMA bypass surgery was performed using the greater saphenous vein. Resection of the necrotic area of the small bowel was carried out in 2 stages, leading to the successful recovery of the patient. Case 2 was a 63-year-old man who presented with type A acute aortic dissection which was associated with cardiac tamponade on CT, and although the dissociation of the SMA root was extended, no occlusion was observed. However, abdominal pain occurred 15 days after an emergency surgical replacement of the ascending aorta, true lumen narrowing of the SMA was observed on CT, and the condition subsequently became aggravated. However, the patient recovered thereafter due to successful left external iliac artery-SMA bypass surgery.
We report a case of inguinal lymphorrhea curatively treated by omentopexy. The patient was a 69-year-old woman who underwent artificial graft bypass surgery comprising endarterectomies in her bilateral common femoral arteries, right axillobifemoral artery bypass and a right femoro-popliteal artery bypass because of severe ischemia in both lower limbs. Postoperatively, she demonstrated inguinal region intractable lymphorrhea. Suture closure, wound adhesion and regional compression were performed, but lymphorrhea recurred. As the wounds expanded in size, we performed omentopexy, which is sometimes performed for artificial graft infection and lymphoedema. Her postoperative course was uneventful, and there has been no sign of recurrence at the time of writing. To the best of our knowledge, omentopexy for intractable lymphorrhea has not previously been reported. We report a case with review of the relevant literature.
We report the case of an 89-year-old man with a mycotic femoral artery aneurysm. He had a past history of hemiplegia and chronic renal failure secondary to pneumonia which had required hemodialysis. He presented with redness, swelling and an approximately 6-cm pulsatile mass of the right lower abdomen and groin. Computed tomography (CT) showed a ruptured right common femoral artery pseudoaneurysm. Methicillin-resistant staphylococcus aureus (MRSA) was detected by blood culture. An emergency obturator bypass, proximal anastomosis to the right external iliac artery, and a below-the-knee distal anastomosis to the right popliteal artery was performed, and the femoral artery was ligated proximally and distally. Postoperatively, the wound healed with a series of local therapy. However, at 7 months postoperatively, he demonstrated swelling in the mid-thigh, separate from the previous inguinal wound. We diagnosed a ruptured right superficial femoral artery (SFA) pseudoaneurysm by CT. Intraoperatively, a sparse zone of calcification of the SFA ruptured, and hematoma formed among his muscles. Emergency ligation of the proximal and distal femoral artery was therefore performed. Moreover, MRSA was also detected in the hematoma but the patient was discharged without severe complications. We present a case in which mycotic aneurysm ruptured metachronously, and we strongly suspected persistent MRSA infection in the throat and nasal vestibule which contributed to the aneurysms. Obturator bypass is considered one of the best options to treat critical femoral artery infection in a compromised patient.
We report the case of a 63-year-old man with severe lumbago and an exercise disorder of the right lower extremity of unknown etiology. He had been previously been seen by an orthopedic surgeon and a urological surgeon for several months. Computed tomography (CT) revealed a huge infrarenal abdominal aortic aneurysm (AAA) with a diameter of 120 mm that had spread into the retroperitoneal space and caused lumbar vertebral erosion. A hematological examination revealed mild anemia and an elevated C-reactive protein (CRP) level. However, his hemodynamics were stable. Chronic rupture of an AAA was diagnosed, and emergency surgery was performed. The intraoperative findings included a broad punched-out defect on the posterior wall of the AAA. There was no evidence of any infectious abscess. He became febrile on the 7th postoperative day, but otherwise his general condition was good. However, a CT scan obtained 10 days later revealed massive fluid collection with air surrounding the prosthetic graft body and limbs. The CT and physical findings indicated graft infection and infective spondylitis. A culture of fluid aspirated under CT guidance revealed the presence of Campylobacter species. His neuropathy of the right lower limb gradually improved with corset treatment and physical rehabilitation. The patient was discharged 47 days postoperatively under an oral antibiotic that was effective against the cultured organism. The patient’s condition has been maintained on long-term systemic antibiotic therapy, and he has been doing well with no recurrence of infection 21 months after the operation.
We report a case of a fistula from an abdominal aortic aneurysm (AAA) draining into an anomalous renal vein. An 80-year-old man with IgA nephropathy complained of back and abdominal pain. His abdomen was slightly distended and a pulsatile mass was observed near the navel. A blood test revealed inflammatory changes and slight renal damage. Enhanced computed tomography (CT) showed an AAA penetrating into an anomalous left renal vein. An emergency operation was performed and the aneurysm was replaced with a bifurcated prosthetic graft, whereupon the fistula was closed. The postoperative course was uneventful. Aortovenous fistula, especially to an anomalous left renal vein, is a very rare complication of AAA; enhanced CT can be a useful modality for diagnosing such complications.
A 42-year-old man with Marfan syndrome who had undergone ascending and aortic root replacement with a composite graft for acute type A aortic dissection 3 months prior was admitted to our department. He underwent an abdominal aorta replacement for an abdominal aortic aneurysm and suffered from a high grade fever and right upper limb paralysis due to a cerebral mycotic aneurysm rupture. Chest computed tomography (CT) showed a pseudoaneurysm in the aortic root, and blood culture revealed MSSA-positive cultures. Positron-emission tomography-CT showed positive signs only on the aortic root and ascending vascular prosthesis. Re-aortic root replacement with a rifampicin-soaked vascular prosthesis was performed after antibiotic therapy was administered for 2 weeks following the cerebral hemorrhage. However, dehiscence of the suture line on the aortic annulus of the non-coronary cusp was observed. Therefore, 2 days later, an omentopexy around the aortic root was performed. Antibiotics were administered intravenously for 6 weeks postoperatively, and the right upper limb paralysis improved with rehabilitation. The appropriate therapeutic strategy is important for vascular graft infections with cerebral complications. We herein report the successful outcome of multidisciplinary treatment.
Surgical management of ruptured juxtarenal abdominal aortic aneurysm (JR-AAA) involves complex repair of the aneurysm. Accordingly, the mortality rate for ruptured JR-AAA repair is high. An 83-year-old man with a diagnosis of ruptured JR-AAA underwent emergency surgery. The proximal edge of the aneurysm was reconstructed by aneurysmal wall crenation. Three vertical interrupted plicating sutures were placed to reduce the size of the aorta from a diameter of 50 mm to 22 mm. A second horizontal plicating suture was added to fold the plication and strengthen the suture line. This technique can be a useful option in the emergency repair of a ruptured JR-AAA.
We report a successful surgical case of endovascular stent-graft treatment and secondary abscess drainage via thoracotomy for infected thoracic pseudoaneurysm. A 73-year-old woman with colostomy and total pelvic exenteration for rectal cancer at the age of 71 received subsequent chemotherapy and radiation therapy. During treatment for sepsis and pyelonephritis, she complained of appetite loss and general fatigue. Echocardiography revealed cardiac effusion and pleural effusion. Computed tomography (CT) revealed a pseudoaneurysm of the thoracic descending aorta and left pleural effusion. She was successfully treated by a 2-stage hybrid surgical procedure consisting of endovascular stent-grafting with abscess resection and drainage with a small thoracotomy. She was discharged on day 60 after the abscess drainage with a drainage tube. Drainage tube removal was effective for 8 months following endovascular repair without an inflammatory response for infection. At 2 years after the endovascular repair, CT revealed the disappearance of the aneurysm and an abscess cavity. For patients with rupture of an infected thoracic aortic aneurysm, this 2-stage hybrid surgical procedure, consisting of endovascular stent graft repair and abscess drainage, can yield an acceptable long-term outcome.