Objectives: In recent years, endovascular aortic repair (EVAR) of aortic aneurysms has become more widespread, but in cases of chronic kidney disease, there are few case reports concerning the impact of EVAR and graft replacement (GR) on renal function when utilized in conjunction with a contrast medium. We report a comparison of postoperative renal function in EVAR and GR patients. Methods: From August 2008 to October 2009, 25 patients (23 men, 2 women) underwent elective EVAR and the same number underwent elective GR. Dialysis patients were excluded from this study. All abdominal aortic aneurysms were of the infrarenal type. In cases in which EVAR was indicated, we selected EVAR regardless of renal function. In the GR group, all cases underwent clamping beneath the renal artery. In cases of chronic kidney disease which received EVAR, we performed preoperative and the postoperative hydration and controlled the amount of the contrast medium used, which ranged from 40 cc to 50 cc in EVAR patients. Based on estimated glomerular filtration rate (eGFR), we categorized chronic kidney disease (CKD) stage according to the guidelines of the Japanese Nephrology Society. We then compared the preoperative and the postoperative values. The eGFR levels naturally decreased, we considered a reduction beyond a postoperative eGFR value of 20% to be significant. Results: A difference in CKD stage was observed between the preoperative and postoperative (preoperative vs. postoperative) values in the EVAR group in stage 1 = (1:2), stage 2 = (15:14), stage 3 = (5:6), stage 4 = (4:2), and stage 5 = (0:1). Only 1 case showed deterioration preoperatively (4%). On the other hand, differences in pre- and postoperative values in the GR group were observed in stage 1 = (3:19), stage 2 = (4:7), stage 3 = (16:13), stage 4 = (2:4), but not in stage 5 = (0:0). A total of 6 cases in this group showed deterioration preoperatively (24%). Moreover, the number of cases in which the eGFR decreased, but which did so by not less than 20% of the postoperative value, was 2 in the EVAR group (8%), and 6 (24%) in the GR group. Conclusion: Even in cases of renal insufficiency, EVAR can be performed using pre- and postoperative hydration, and by minimizing the amount of the contrast medium used.

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Background: We report the usefulness of emergency thoracic endovascular aortic repair (TEVAR) for complicated acute type III aortic dissection. Methods: We studied a total of 20 patients with complications secondary to acute aortic dissection who were treated by emergency TEVAR from 2003 to 2010. Although fenestrated or non-fenestrated hand-made stent grafts (SG) were used in most cases, commercial SG have also been used, if anatomically suitable, since 2008. Results: The mean age was 69.7 years (range, 39-82) and there were 16 men in this study (80%). The types of aortic dissection were IIIa in 7 cases, IIIb in 8 and IIIbR in 5. Aortic dissection-related complications were rupture in 10 cases (50%), impending rupture in 5 (25%) and visceral or leg ischemia in 6, including 1 combined with rupture. A 79- and an 82-year-old patient with ruptured type IIIbR and IIIb aortic dissection, respectively, died due to re-rupture. The early mortality rate was 10%. Although 1 patient (5%) with left subclavian arterial dissection suffered cerebellar infarction following TEVAR, there were no cases of spinal cord ischemia as a complication of TEVAR. The thrombo-occlusion rate of type-IIIa false lumens was satisfactory (86%) in the follow-up period. The overall survival rate, aorta-related death-free rate and aorta-related event-free rate at 5 years after TEVAR were 73.5%, 100% and 84.4%, respectively. Conclusion: Emergency TEVAR was very useful for complicated acute aortic dissection. However, further investigation is necessary to more precisely define its indications for ruptured type IIIb aortic dissection.

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Objectives: We examined the operative results for ruptured abdominal aortic aneurysm (RAAA) and influences of diagnosis procedure combination (DPC) on medical service costs in the surgical treatment of RAAA. Methods: The records of 16 patients who underwent RAAA repair between March 2007 and April 2010 in our hospital were reviewed. The operative data according to perioperative factors, and the postoperative clinical courses in patients with (n=9, group G) or without (n=7, group B) complications were assessed and compared between the groups. The comparison of the cost reimbursed through the DPC system (DPC-f) with that received via the conventional cost compensation system (CCC-f) in, and between the groups was also evaluated. Results: The hospital mortality and morbidity rates were 18.8% and 43.6%, respectively. Neither preoperative or intraoperative factors between the groups were significantly different. Durations of mechanical ventilation, intensive care unit stay and hospital stay were significantly longer in group B than in group G. The major postoperative complications in group B were renal failure (n=5), respiratory failure (pneumonia, n=3, acute respiratory distress syndrome, n=1) and organ ischemia (severe lower limb ischemia, n=2, colon necrosis, n=2). The causes of surgical death were deep shock (n=1) and colon necrosis (n=2). One patient with a complication of abdominal compartment syndrome survived by optimal decompressive laparotomy and secondary abdominal closure. Both DPC-f and CCC-f were significantly higher in group B than in group G. DPC-f was significantly lower than CCC-f in both groups. The difference, that is [DPC-f-CCC-f], was significantly larger in group B than in group G (p=0.04), resulting in a decrease in medical income for the hospital. Conclusion: The operative results for RAAA were not considered satisfactory. These findings emphasized that optimal perioperative management is important to prevent and control severe complications and prolonged hospitalization after surgical treatment of RAAA, which is strongly related to organ ischemia and failure induced by deep shock or low output syndrome. Medical economical assessments suggested that it might be necessary to reconsider the indications of the DPC system in the calculation of fees for medical services in the surgical treatment of RAAA.

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Introduction: Open repair requiring suprarenal aortic cross-clamping is still the treatment of choice for juxtarenal aortic aneurysms (JAA), despite advances in endovascular aneurysm repair. We assessed rates of mortality and acute kidney injury after open repair for abdominal aortic aneurysm (AAA) requiring suprarenal abdominal aortic cross-clamping in our institution. Materials and Methods: We encountered 56 patients with suprarenal AAA and JAA and infrarenal AAA requiring suprarenal abdominal aortic cross-clamping between 1996 and 2010. We retrospectively reviewed 48 elective patients, excluding 6 who received hemodialysis and 4 cases of rupture. A total of 46 patients, comprising 42 men and 6 women with an average age of 70 ± 8 years were the subjects of this study. Surgically, the suprarenal aorta was exposed after the left renal vein (LRV) was mobilized or divided. Renal preservation was accomplished by the administration of mannitol (0.5 g/kg) before suprarenal aortic cross-clamping and the administration of 4°C cold Ringer solutions in cases of RA cross-clamping of over 30 minutes. A 6-mm ePTFE graft was anastomosed to a Y-graft body prior to end-to-end aorta-to-Y graft anastomosis, and then the RA was reconstructed when necessary. Results: There were 21 patients who had LV division and 14 patients (3 bilateral, 11 one-side) with renal artery reconstruction. The renal artery clamp time was 49 ± 14 and 30 ± 17 min in cases of renal artery reconstruction and no reconstruction, respectively. There were 5 patients with postoperative acute kidney injury (increase in sCr of ≥ 0.3 mg/dl or increase to ≥ 150%–200% from baseline). And there were 2 cases of in-hospital mortality due to cardiac failure and perforation of sigmoid colon cancer. Conclusion: The cause of the renal dysfunction was considered to be embolism, and therefore in future, the possibility of a mural thrombus at the site of the aortic cross-clamp should be determined before cross-clamping. However, open repair of non-ruptured JAA requiring suprarenal abdominal aortic cross-clamping was performed with acceptable results in the current procedures for the preservation of renal function.

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Objectives and methods: We performed graft replacement of the entire descending thoracic aorta using the pull-through technique in patients with high mortality and morbidity who were unsuitable for endovascular repair. The purpose of this study was to determine the surgical outcomes, feasibility and problems concerning this method. Results: A total of 4 patients (1 man and 3 women, mean age, 72 years) with extensive thoracic aortic aneurysm underwent surgical repair using the long elephant trunk (LET) via a median sternotomy, but without an additional left thoracotomy. Two patients who had previously undergone total arch replacement for aortic dissection showed enlargement of the false lumen of the entire downstream descending aorta. One patient presented with rupture of a dissecting aneurysm of the descending aorta and another had an extensive atherosclerotic thoracic aortic aneurysm. The current technique was employed because of the difficulty in performing a left thoracotomy, due to abdominal vessels arising from the false lumen but without significant fenestration, and an unfavorable anchoring site of the endovascular stent graft. The distal end of the LET was fixed at the abdominal aorta just proximal to the celiac artery in 1 patient and the descending aorta in 3 patients. Distal anastomosis was performed in 2 patients in a double-barrel fashion. Subsequent distal anastomosis was not required in the other 2 patients. Complete aneurysmal thrombosis around the LET was achieved in all patients and no further procedures were required. Although the intercostal artery was not reconstructed in any case, paraplegia was not observed. The postoperative courses were uneventful except for 1 patient who died of gastrointestinal bleeding. In 1 case with a highly elongated aorta, we sutured the lesser curvature of the LET in order to fix its length and prevent over-stretching when the LET was pulled to the downstream aorta. However, if the size discrepancy between the proximal and distal aorta was too large, a composite LET which consisted of 2 different sizes of graft was pulled through the descending aorta. Conclusion: We recommend the pull-through technique as a less invasive alternative to a conventional left thoracotomy and endovascular aortic repair in selected high-risk patients.

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We report two cases of inflammatory abdominal aortic aneurysm (IAAA). Case 1: Computed tomography (CT) demonstrated an IAAA 54 mm in diameter and bilateral hydronephrosis. After insertion of ureteral stents, we planned open surgery but as severe adhesion was observed on the distal site of the aneurysm we chose to perform stent graft replacement rather than open surgery, which was successful. Case 2: A CT scan demonstrated an IAAA 70 mm in diameter. We successfully performed open surgery by dissecting the severe adhesion noted in the duodenum and aneurysmal wall. The appropriate treatment of an IAAA should be determined according to the location of the adhesion.

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Extensive atheromatous ulcerations in a non-aneurysmal aorta sometimes result in disseminated cholesterol microembolization such as peripheral or visceral embolization, which is known as “shaggy aorta syndrome”. Although it is fatal, the optimal therapy has not yet been clarified for this. We encountered a case in which abdominal aortic replacement was effective for infrarenal shaggy aorta. A 77-year-old man was referred for pain and discoloration of the left toes, and was given a diagnosis of blue toe syndrome. Contrast-enhanced computed tomography showed an infrarenal shaggy aorta, but no evidence of atheroma in the thoracic or pararenal aorta was observed. Moreover, laboratory tests did not reveal any visceral dysfunction. Although we administered antiplatelet agents, his left toes were amputated due to the recurrence of blue toe syndrome. We then performed abdominal aortic replacement of the shaggy aorta in order to prevent the recurrence of the embolism. Postoperative computed tomography showed no evidence of irregularities on the intimal surface of the aorta.

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It is considered rare for blunt injury to cause multiple arteriovenous fistulae and pseudoaneurysms of the anterior tibial artery. We present a case of blunt trauma to the left leg resulting in multiple arteriovenous fistulae and pseudoaneurysms of the anterior tibial artery 1 year and 10 months after the injury. The leg had a pulsatile mass with gradual onset of pain. The diagnosis was made by angiography. We performed surgery of direct closure of the orifice of the pseudoaneurysm, and then endovascular therapy of coil embolization of the multiple arteriovenous fistulae.

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A 77-year-old man was admitted to our hospital complaining of pain in pulsating masses in bilateral inguinal regions. He had undergone bilateral graft implantation using a Y-shaped Cooley Dacron graft 16 years previously for arteriosclerotic obliteration. Angiography demonstrated bilateral femoral pseudoaneurysms. The graft aneurysms were partially resected and replaced with Hemashield knitted Dacron grafts. The pathological diagnosis was rupture of bilateral non-anastomotic aneurysms. Gliding and force were considered to be the causes of the aneurysm. Careful long-term follow up is necessary for patients who have undergone Dacron graft implantation.

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A 64-year-old man was admitted to our hospital for acute congestive heart failure. Computed tomography (CT) images revealed an aortic arch aneurysm and a fistula between the arch aneurysm and pulmonary artery. Doppler echocardiography demonstrated aortopulmonary shunting with a Qp/Qs of 3.1. After the patient’s renal and liver dysfunction were treated with dehydration, his aortic arch was replaced with a Hemashield graft and the aortopulomonary fistula was directly sutured using 4-0 polypropylene interrupted sutures and pledget reinforcement under cardiopulmonary bypass, with deep hypothermic circulatory arrest and antegrade selective cerebral perfusion. Postoperative CT images showed that the aortic arch replacement was successful, and the LR shunt had disappeared. The patient was discharged on postoperative day 30.

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A 30-year-old man with previous diagnoses of Buerger disease (thromboangiitis obliterans; TAO), bronchial asthma, eosinophilia and a history of heavy smoking was referred to our hospital because of pain at resting in his bilateral fingers and dactyli. The resting pain was successfully treated conservatively after lumbar sympathectomy and thoracic sympathectomy, but his ulcer became worse. A granuloma in the right lung, bilateral coronary aneurysms and an edematous papule with pigmentation on the left leg were observed during follow-up. Allergic granulomatous angiitis was diagnosed based on the pathological findings of the edematous papule. However, this papule healed and his eosinophil level decreased to within the normal range following the administration of steroids and methotrexate, but the ulcer on his left leg became worse. A below-knee amputation was performed. However, the pathological findings did not reveal any eosinophilic infiltration in the crural artery. The pathological findings of the obstructive artery and skin lesions can be useful in patients with TAO and eosinophilia, when the diagnosis is in doubt. However, care must be taken to achieve a definitive diagnosis in patients with TAO-like symptoms and eosinophilia.

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A 56-year-old man noticed varicosis on the back of his left knee several years previously. One month before presenting at our department, he experienced severe pain in the gastrocnemius area with left knee joint swelling. Echovenography detected severe venous regurgitation at the saphenopopliteal junction. Computed tomography (CT) angiographic findings revealed multiple venous areas of bulging in the popliteal venous area. We ligated and divided all the venous branches from the small saphenous vein. Postoperatively, the patient reported muscle pain relief in the gastrocnemius region, but his knee joint incompetence persisted. The patient was given an elastic compression stocking and knee joint supporters, and flexibility of his knee joint gradually returned. In the current case, venous reflux from the saphenopopliteal junction to the small saphenous vein caused strain around the area of the knee joint.

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A 41-year-old woman with aortitis syndrome underwent total arch replacement for an aneurysm of the ascending aorta and aortic arch in February 2010. Her postoperative course was good, but approximately 7 months later a false aneurysm was detected at the site of the proximal and distal graft anastomoses. Echocardiography showed dilation of the Valsalva sinus and severe aortic valve regurgitation. Therefore, we performed reoperation with the Bentall procedure for the false aneurysm of the ascending aorta where the proximal anastomosis was located, and for her aortic regurgitation. We subsequently added thoracic endovascular aortic repair (TEVAR) for the distal false aneurysm where the distal anastomosis was located. Her second postoperative course was good. We report a successful hybrid operation in two stages with a Bentall reoperation and TEVAR.

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