Objectives: There are few reports which compare the different sealed woven types of vascular prosthesis in cases with total arch replacement (TAR). In this article, we compared various perioperative data in patients who underwent TAR using two types of sealed woven vascular prostheses, J graft SHIELD NEO^® or Gelweave^®. Methods: From January 2008 to December 2010, 25 consecutive patients underwent TAR using J graft SHIELD NEO^® (10 cases) or Gelweave^® (15 cases) for thoracic aortic aneurysm or dissecting aneurysm, performed by a single surgeon in our institution. We retrospectively compared various perioperative data statistically between the two groups. Results: There were no significant differences between the two groups in terms of preoperative condition, comorbidity, surgical procedure, mortality or morbidity. However, postoperative drain discharge from the pericardium (P=0.003) and CRP score on the postoperative 7th day (P=0.003) were significantly higher in the group receiving the J graft SHIELD NEO^®. Conclusion: We found significant differences between the two groups in terms of postoperative drain discharge or CRP score. However, there were no differences in the reoperation rates due to bleeding or surgical site infection including mediastinitis or any other inflammatory complication. We have to collect more data to identify whether the differences we identified in this study is meaningful or not.

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Aiming for improved long-term post-surgical outcomes, we adopted a simplified and safe descending aorta stent graft implant procedure (modified open stent graft technique; MOS) for use during circulatory arrest in hemi-arch replacement (HAR) and evaluated its effectiveness. We analyzed 76 consecutive HAR procedures conducted for acute type A dissection at our institution from April 2007 to March 2011. The C group consisted of 16 HAR cases conducted with the normal technique, and the S group consisting of 60 cases treated by HAR+MOS. In 36 cases used home-made stent grafts and the TALENT thoracic stent graft in 24 cases. The stent grafts were prepared for insertion using a braiding technique and were introduced through the opened proximal descending aorta and deployed under circulatory arrest. For evaluation, we used early and mid-term CT analysis, and analyzed the status of closure of the false lumen, as well as the diameter of the true and false lumens in the descending thoracic aorta and the abdominal aorta. There was no significant difference in patient backgrounds, in surgical time, aortic cross-clamp time, or lower body ischemic time. There were two surgery-related deaths in the C group (one case of left ventricular rupture, and one case of descending aortic rupture), and one in the S group (intestinal necrosis). There were no cases resulting in paraplegia or malperfusion. Early post-operative CT imaging was conducted on 14 cases in the C group (88%) and 53 cases in the S group (88%). Complete thrombosis of the false lumen in the descending aorta in the C group was found in 6 cases (43%), and in 31 cases (58%) in the S group. There were 7 cases (50%) in the C group which were true lumen dominant, compared with 44 cases (83%) in the S group, with the S group being significantly higher. Mid-term CT imaging was conducted on 12 cases (86%) in the C group, and on 30 cases (51%) of the S group. The false lumen in the descending aorta had shrunk or disappeared in 3 cases (25%) of the C group and in 15 cases (50%) of the S group. The proportion of cases in the descending aorta that had an increase in diameter in the C group was 6 cases (50%) and 4 cases (13%) in the S group, with the S group being significantly smaller, and the C group requiring one re-do surgery. MOS requires less than 3 minutes of stent graft implant time, has few peri-surgical or post-surgical complications, and can be conducted safely. Mid-term post-surgical shrinkage of the false lumen in the descending aorta, as well as the high closure rate for the S group compared with the C group, allows us to expect a decreased risk of re-do surgery and danger of rupture due to an increase in the size of the false lumen in the long-term.

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Objectives: We evaluated the clinical outcome of concomitant endovascular repair of abdominal and iliac artery aneurysm compared with two-stage repair. Methods: Between April in 2006 and January in 2011, a total of 34 patients received endovascular aneurysm repair (EVAR) and coil embolization of abdominal and iliac artery aneurysms in our hospital. Twenty three patients underwent concomitant EVAR and coil embolization (concomitant group), and 11 two-stage repair (two-stage group). We compared hospital mortality, operation time, hospital stay, amount of intravenous contrast, symptom and perioperative renal function between the two groups. Results: There was no hospital mortality. There was no significant difference in operation time, hospital stay, amount of intravenous contrast or buttock claudication between the two groups. The change of estimated GFR was significantly lower in the two-stage group than in the concomitant group (-1.8±1.5 vs. -3.9±4.2 ml/min/1.73 m², p=0.02). Conclusions: Two-stage endovascular aneurysm repair and coil embolization might be less invasive in patients with abdominal and iliac artery aneurysm compared to concomitant repair.

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Objectives: An increasing number of patients are receiving endovascular abdominal aortic aneurysm repair (EVAR) in an off-label situation. In light of the increasing complexity of EVAR cases, it is important to assess the impact of training residents on patient outcomes. Methods: Between May 2008 and August 2009, a total of 66 consecutive patients underwent EVAR, of which 33 patients received EVAR performed by a resident surgeon (RS). The surgical outcomes in the RS group were compared with those of the remaining 33 patients operated on by an attending surgeon (AS). The RS group included 15 patients with unsuitable anatomy defined in the instructions for use (IFU) of endografts, while the AS group had 14 non-IFU patients. Results: Patients in the RS group were significantly more likely to have a history of previous laparotomy. Regarding other baseline characteristics, there were no differences between the two groups. Endovascular stent-graft deployment was successful in all patients. Operative time was longer in the AS group (151±45 minutes vs. 127±32 minutes) but the difference was not statistically significant. Blood loss was also higher in the AS group (339±219 mL vs. 232±151 mL) but was also not statistically significant. Postoperative complications occurred in 6 patients in the AS group and 3 patients in the RS group (p=0.028). Early endoleak (within 1 week) was observed significantly more frequently in the AS group (n=11) than in the RS group (n=4) (p<0.05). However, this significant difference disappeared one month after EVAR because of complete resolution of endoleaks. Conclusion: Supervised RS can safely perform EVAR with reasonable early results even in the era of off-label indications.

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We report a right common iliac artery aneurysm in an 86-year-old man with congestive heart failure (CHF) syndrome resulting from arteriovenous fistula. A computed tomographic scan revealed a right common iliac artery aneurysm measuring 6.6 cm with an arteriovenous fistula and a left internal iliac artery aneurysm measuring 6 cm. He was admitted to our hospital due to CHF. After CHF resolved rapidly by medication, surgery was performed on an elective basis. An arteriovenous fistula with a 3 cm by 1 cm orifice was found between the right common iliac artery and the left common iliac vein. The fistula was directly closed from the inside of the aneurysm. The abdominal aorta and bilateral common iliac arteries were replaced with a Y-shaped prosthetic graft. His postoperative course was uneventful.

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A 61-year-old woman who had neck pain and back pain was admitted. An enhanced computed tomographic (CT) scan showed acute type A aortic dissection, and aortic dissection extended from the ascending aorta to the bilateral iliac artery. Although the celiac artery was occluded due to aortic dissection, blood flow to liver was maintained by collateral flow from the superior mesenteric artery. Therefore, she was hospitalized and received an ascending aortic replacement for acute type A aortic dissection. Although the patient had no symptom, laboratory examination showed significant elevation of serum liver enzyme levels on the third day of admission. An enhanced CT scan and angiography showed a significant decrease of blood flow to the liver because of a decrease in collateral flow. Because the patient had previously received gastrectomy, we avoided laparotomy. Thus, we chose endovascular treatment. We placed a 14.5×5 mm balloon expandable stent in the celiac trunk. The blood flow to the liver was significantly increased and serum liver enzyme level was decreased after the procedure. Her liver function recovered, and she was discharged 22 days after the procedure. We report a case of hepatic ischemia after occlusion of the celiac artery due to acute aortic dissection, and refer to the literature.

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Infected popliteal artery aneurysm is rare and Bacteroides infection in this site has not been previously reported. The patient was a 72-year-old Caucasian man and his chief complaint was swelling and pain of his right knee. He had undergone hemodialysis for one year and had intermittent claudication previously. Contrast-enhanced computed tomography demonstrated a 57 mm-diameter occluded, calcified popliteal artery pseudoaneurysm containing gas. An infected popliteal artery aneurysm was strongly suspected and emergency surgery was performed. Using a posterior approach, debridement and drainage of the infected aneurysm was performed and the popliteal artery was suture-closed proximal and distal to the aneurysm. Culture of the pus revealed Bacteroides infection. Pathological examination revealed secondary infection to the atherosclerotic pseudoaneurysm. He underwent right superficial femoral-tibioperoneal trunk arterial bypass using an accessory saphenous vein 5 months after the first operation. His postoperative course was uneventful.

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A 25-year-old man was admitted to our hospital with a diagnosis of residual coarctation of the aorta. He had undergone repair for coarctation of the aorta at the age of 2 and extra-anatomical bypass grafting at the age of 14. However, because he had repeated graft infection at the age of 24, he underwent graft removal and covering by an omentum flap. The size of the aortic arch and descending aorta was 10 mm, and the pressure gradient between the arms and legs was 60 mmHg. We performed a total arch replacement and descending aorta bypass graft for the residual coarctation. We used an aortic no touch technique under deep hypothermic circulatory arrest to avoid potential aortic injury. Furthermore, we devised an operation method from the viewpoint of spinal cord protection and minimized adhesion detachment using an aortic navigation system. The postoperative course was uneventful, and he did not suffer from paraplegia. He was discharged 20 days after surgery without medication. The strategy of our operation is a safe and effective option for residual coarctation.

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Children with an injured peripheral artery should undergo surgical reconstruction to prevent limb shortening if possible. We report the case of a child with initially ineffective treatment of an injured popliteal artery associated with blunt trauma. A 10-year-old boy received a hard kick on the knee while practicing karate. Three days later, he experienced intermittent claudication in his left lower extremity on exercise and was transported to our hospital. A computed tomographic angiogram of the left popliteal artery revealed 50% stenosis, and therefore we started medical therapy. After 1 month, he experienced pain and discomfort in his left lower extremity at rest and was admitted. Angiography revealed total occlusion of his left popliteal artery, the distal part of which developed collateral circulation. We immediately performed percutaneous transluminal angioplasty on the left popliteal artery. However, his symptoms did not improve, and ultrasonography showed that the obstruction in the left popliteal artery was caused by a thrombus. Despite undergoing a thrombectomy, his symptoms did not improve. Finally, we performed interposition with a reversed saphenous vein graft, with excellent postoperative outcome. Vascular injuries resulting from blunt trauma are rare in children, and the importance of ensuring normal limb growth patterns should be considered in the selection of surgical treatment.

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A case of an aortoesophageal fistula in a 61-year-old woman who underwent thoracic endovascular aortic repair and subtotal esophagectomy is presented. The patient had a history of left hemiplegia caused by a brain hemorrhage. She suddenly vomited blood at dinner and was taken to a local hospital. Though emergency endoscopic examination was performed, it revealed only mucosal erosion and constriction of the middle portion of the esophagus. The endoscopic fiber scope could not be inserted through the constriction. She was admitted to the hospital for further examination. Enhanced computed tomography (CT) showed a ruptured descending aortic aneurysm (maximal diameter, 40 mm) and aortoesophageal fistula. The middle portion of the esophagus was conpressed between the ascending aorta and descending aortic aneurysm. Just before leaving for our hospital, she vomited large amounts of blood. When she arrived at our hospital, she was intubated tracheally and transfused with large amounts of blood. Since open surgery entailed a high risk, endovascular surgery was performed to control the bleeding. Emergency thoracic endovascular aortic repair was performed, and a ready-made stentgraft (Gore TAG^®) was deployed at the ruptured site. Since there was concern about the perforated esophagus being a source of infection, subtotal esophagectomy and omental flap transposition were performed at a later date. Postoperative CT showed no endoleaks. Respiratory failure persisted, and a tracheotomy was performed. After surgery, an antibiotic (ceftazidime) was administered, and fosfluconazole was added later because Candida glabrata was detected from the tip of the thoracic drainage tube. No symptoms of infection appeared. She was transferred to a local hospital on postoperative day 42. Four months later, she was re-admitted, and a retrosternal gastric bypass operation was performed successfully.

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A 71-year-old man was referred to our hospital for surgical treatment of a right subclavian artery aneurysm. The mass was 34 × 39 mm in size and was located approximately 12 mm distal to the bifurcation of the right common carotid artery and the right subclavian artery. Reversed L-shaped partial sternotomy was performed from the second intercostal space and the skin incision was extended to the superior border of the clavicle. Proximal clamping was performed between the right common carotid artery and the subclavian artery aneurysm. Distal clamping was performed at the first part of the axillary artery. The aneurysm was incised and backflow of the vertebral artery was observed from the lumen. Preoperative cranial MRA showed a communication between the right and left vertebral arteries, and the right vertebral artery was occluded from outside of the aneurysm. The aneurysm was replaced by an ePTFE graft (7 mm), and reconstruction was performed by end-to-side anastomosis of the right vertebral artery and the graft. Histological examination of the mass revealed an arteriosclerotic true aneurysm. An upper partial sternotomy approach was very useful for intrathoracic subclavian artery aneurysm because this approach provided a good operative field and enabled surgery without transection of the clavicle.

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We report a rare case of an 88-year-old woman who had an abdominal aortic aneurysm (AAA) with left-side inferior vena cava (IVC). The preoperative enhanced CT revealed that the maximum diameter of the AAA was 58 mm and the left-side IVC crossed at the aneurysmal neck. At operation, a midline incision was made and the left-side IVC was dissected widely from the aneurysmal neck. The operative field was exposed by drawing the intestines in superior and inferior directions. After the retroperitoneum was opened at 2 places, the left upper site and the right lower site of the mesenteric root, bifurcated graft replacement was performed by retracting the IVC. The postoperative course was uneventful. Good exposure of the aneurysm was obtained through this approach and was useful for repair of the AAA.

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Critically ischemic limbs with extensive tissue loss may be candidates for major amputation. However, aggressive therapy, which was bypass surgery with free flap transfer, can reduce the need for major amputation. We report two cases of ischemic limb with tissue loss, which were treated successfully with bypass surgery, vacuum-assisted closure and free flap transfer. Case 1: A patient with tissue loss around left heel, firstly underwent bypass surgery and debridement of the heel. The heel wound was treated with vacuum-assisted closure therapy, accelerating granulation. After that, free flap transfer was performed with covering split-thickness skin graft. Case 2: A patient with right plantar tissue loss first underwent bypass surgery and debridement. The wound plantar was treated with vacuum-assisted closure therapy, accelerating granulation. After that, free flap transfer was performed with covering split-thickness skin graft. A multidisciplinary approach for ischemic limbs with tissue loss can provide excellent results, and this procedure should be considered in patients with extensive tissue loss before amputation is performed.

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