Background: The management of patients with abdominal aortic aneurysm (AAA) and concurrent malignant disease is controversial, and few reports are available on the result of endovascular aortic repair (EVAR) for such challenging cases. We have routinely performed EVAR as a first line therapy for the patients of AAA complicated with malignant diseases. To confirm the validity of our management, a retrospective review of concomitant AAA and malignant disease was undertaken.
Methods: A total of 159 patients who underwent EVAR for AAA from April 2007 to April 2011 were reviewed. Among these, 22 patients (13.8%) who had concomitant malignant disease were defined as the “M group”, and the other 137 patients (86.2%) without malignant disease were the “N group”. The mean follow-up was 15.0±2.1 months (range, 1.9 to 37.3 months) in the M group and 16.3±1.0 months (range, 0.3 to 45.4 months) in the N group. We performed a comparison of mid-term outcomes between the M and N group including mortality, aneurysm-related mortality, reintervention, development or resolution of endoleaks, and other complications.
Results: Twenty-one patients expired (M: 7 patients, N: 14 patients) during this study period, and the causes of death were malignant disease in 9 patients. In the M group, 6 of 7 patients (85.7%, Stage II: 1 patient, III: 4 patients, IV: 1 patient) died because of the concurrent malignant disease. No aneurysm-related deaths occurred. In the M group, no patient died perioperatively; in the N group, one patient died perioperatively (0.7%; P=NS). Postoperative complications occurred in 4 patients in the M group and in 26 patients in the N group for a morbidity rate, respectively, of 18.1% and 19.0% (P=NS). At 1 and 3 years, survival rates were 77.4±10.2% and 50.8±14.3% in the M group and 93.7±2.3% and 72.3±9.4% in the N group (log-rank P=0.012).
Conclusion: EVAR is a safe technique and could be a first line therapy for the treatment of AAA with malignant disease. However, in cases of advanced malignant disease ≥ Stage III, because the patients cannot be expected to achieve long-term survival, our indications for EVAR are limited to life-threatening conditions (rupture or impending rupture, for example).

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Case report: Computer tomography revealed type B acute aortic dissection with a distal aortic arch aneurysm 64 mm in a diameter in a 66-year-old man. He was treated conservatively according to the guidelines of the AHA, and later we performed total arch replacement using the elephant trunk method. One year later, dilation of the false lumen in the proximal descending aorta increased. For entry closure, thoracic endovascular aortic repair (TEVAR) was performed. Matsui-Kitamura (MK) stent-graft was used for protection of distal tunica intima. We used a Gore TAG covered elephant trunk and MK stent-graft. Postoperative computer tomography showed the false lumen was closed in the descending aorta and no endoleaks. Hybrid treatment of complicated multiple aortic lesions by combined open surgery and TEVAR can be effective.

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Isolated dissection of a splanchnic artery, including the celiac artery or superior mesenteric artery (SMA) is relatively rare. The cause, natural history, gender relationship, and prognosis are unknown.
In addition to the 165 patients already reported in Japan already, treated in our department were added and we reviewed all cases to survey demographic data, the location of dissection, and the length of dissection, symptoms, diagnostic modalities, treatments, and prognosis.
The overall mean age was 55.0 years old (from 31 to 89). There were 157 men (91.3%), and only 15 women (8.7%). There were 128 patients with acute abdominal pain (94.8%). 68.8% of chronic patients did not have any symptoms and were found by chance. In all cases, the most common of the beginning of the dissection were within 3 cm (94.6%) from the ostium, and the mean value was 1.8 cm. The mean length of dissection was 5.3 cm. Conservative therapy was performed for 74.4% of patients, and 25.6% underwent surgical and/or catheter intervention. Only 3 fatalities have been reported. There was no significant difference incases with or without antithrombotic therapy in terms of the radiological patency of false lumen.
Of the 7 cases of splanchnic arterial dissection treated at our facility, 6 had successful outcomes. In many cases, the clinical course of splanchnic artery dissection was benign. However, it is important to not miss the signs of severe bowel ischemia. Antithrombotic therapy does not appear to affect the patency of the false lumen.

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Aortobronchial fistula can be a fatal complication following thoracic aortic surgery. We report a successful surgically treated case of Aortobronchial fistulas. A 62-year-old man complained of hemoptysis. Computed tomography (CT) showed air around his stent graft. We treated conservatively by antibiotics. Since he did not improve, we therefore performed surgery. Using a partial cardiopulmonary bypass under mild hypothermia, we clamped thoracic aorta and removed the stent graft, then we replaced it with a prosthesis soaked in rifampicin, and an omental flap was transplanted around the prosthesis. The patient was discharged on the 62nd postoperative day without any complications. Stent grafting can be a very effective therapy for aortobronchial fistula. However, for some reasons such as infection or foreign bodies, open surgery is necessary. In such cases, Stent grafting and second-stage open surgery could be effective to prevent massive bleeding.

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We report a case of renal artery stenting with a new catheter access technique for severe stenosis of the renal artery caused by endovascular aneurysm repair (EVAR). An 82-year-old man who had an abdominal aortic aneurysm with a short and reverse-tapered proximal neck was received EVAR with a Zenith Flex stentgraft. We confirmed bilateral renal artery angiogram before finishing the operation. The patient status indicated poor postoperative urinary output and increasing serum BUN and Cr. Duplex scan revealed bilateral renal artery stenosis. We decided to salvage the bilateral renal arteries by stenting. In the first attempt, we inserted a delivery catheter by a brachial approach and were able to place a stent on the right renal artery, but we could not put stent into the left renal artery, because of the catheter could not be pushed through the severe stenosis of the left renal artery orifice. On our second attempt, we tried to insert Amplatz gooseneck snare catheter by a femoral approach in order to pinch the top part of the delivery catheter by a brachial approach, then the delivery catheter was able to be pulled through into the left renal artery orifice with additional traction by the snare catheter. Finally, we succeeded in placing the stent in the left renal artery.

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Aneurysms of the deep femoral artery are very rare because of their anatomical features and the characteristics of the arterial wall. Most patients with a deep femoral artery aneurysm have few symptoms until it expands, and once this happens rapid enlargement is noted. They have a high rate of rupture in comparison with other peripheral arterial aneurysms, local pressure symptoms caused by the aneurysm could precipitate nerve and vein compression and thrombosis in some cases. We report a deep femoral artery aneurysm with a diameter of 100 mm. A 72-year-old man was admitted with swelling of the right lower limb. His symptom began 6 months previously. However, the swelling had recently enlarged rapidly, with pain. Enhanced computed tomography showed a ruptured deep femoral artery aneurysm, measuring approximately 100 mm. We diagnosed ruptured deep femoral artery aneurysm, and performed an urgent operation. A preoperative imaging study showed no ischemic site, so we performed only resection of the aneurysm and no re-vascularization of the deep femoral artery. The postoperative course was good, with no ischemic change of the lower limb.

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Arterial prosthetic graft infection in the groin is rare but has a high morbidity and mortality rate. The standard treatment includes removal of the infected prosthetic graft and replacement by autologous conduit or extra-anatomic bypass. We report a case of a prosthetic graft infection in the groin, in which the graft was preserved using a vascularised muscle flap transposition. An 83-year-old man who had previously undergone a femoro-femoral crossover bypass using a Dacron graft was re-admitted with pus discharge in the groin. Wound culture findings were positive for methicillin-resistant Staphylococcus epidermidis. We treated promptly with debridement, rinsing and administration of antibiotics. After the wound culture was found negative and the infection was controlled locally, we performed the sartorius muscle flap transposition using the “twist” technique to cover the infected prosthetic graft. The graft was successfully preserved and wound healing was accomplished. We found that the sartorius muscle flap was a beneficial therapeutic option for an infected graft in the groin.

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Critical organ perfusion abnormalities (malperfusion) are main causes of acute mortality and complications in acute aortic dissection. Entry closure in most cases of Stanford type A aortic dissection can provide reperfusion, while there is no established method in Stanford type B aortic dissection, thus we are required to perform individualized treatment. We present good results in 2 cases of abdominal aortic fenestration and bypass grafting between the aorta and superior mesenteric artery in type B acute aortic dissection with intestinal ischemia along with a review of the literature.

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We report a case of tuberculous abdominal aortic aneurysm after intravesical instillations of bacillus Calmette-Guérin (BCG) therapy for bladder cancer. A 69-year-old man was referred to our hospital with a 5-month history of low back pain and 2-month history of relapsing fevers. One year previously he was treated for bladder cancer with transurethral resection, followed by adjuvant BCG therapy lasting 6 months. Computed tomography scanning demonstrated a pseudoaneurysm and perianeurysmal inflammatory changes in the region of the infrarenal aorta. An emergency operation was performed under a diagnosis of impending rupture of the tuberculous abdominal aortic aneurysm. The infrarenal aorta was successfully replaced with an in situ graft and the greater omentum was used to wrap the prosthetic graft. His postoperative course was uneventful and he was discharged on postoperative day 16 without any complications. Pathological findings revealed abdominal aortic wall with atheromatous disease and tuberculoid granuloma comprised of caseation necrosis, but acid-fast bacilli were not detected. We report a rare case of tuberculous aneurysm after BCG therapy with a review of the literature.

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Hybrid treatment combined with the elephant trunk procedure and thoracic endovascular aortic repair (TEVAR) for aortic arch and descending thoracic aneurysm have been occasionally reported. In these cases tortuosity of the elephant trunk procedure can cause failure to deploy, difficulty in guiding and migration. We report two cases of hybrid second-stage repair, who underwent TEVAR for descending thoracic aneurysm after open stent surgery for thoracic aortic arch aneurysms. The postoperative courses were uneventful. The stented elephant trunk procedure may be more functional in terms of the landing zone for hybrid TEVAR than the conventional elephant trunk procedure.

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We report a case of a 56-year-old woman suffering iatrogenic arteriovenous fistula after cardiac catheterization. Ultrasonography, computed tomography and angiography revealed an arteriovenous fistula in the brachial artery. Because simple observation for two months and compression therapy of the arteriovenous fistula were not effective, direct closure of the arteriovenous fistula was performed. Postoperative course was uneventful, and she was discharged without any complications.

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Long placement of a central venous port may cause infection and thrombus in the superior vena cava (SVC). We report a case in which the central venous port and thrombus were removed with SVC clamping. Right hemi-colectomy and chemotherapy with a central venous port inserted from the right subclavian vein were performed for colon cancer in a 76-year-old man. After that, CT revealed SVC thrombus. Catheter infection also occurred. Since conservative therapy was not effective, the central venous catheter and thrombus were surgically removed with simple SVC clamping. His postoperative course was good. Though short-time SVC clamping may not be problematic, it is important to take countermeasures against hemodynamic instability and brain edema.

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In situ bypass procedure is very often used for distal bypass especially in cases associated with critical limb ischemia. We experienced a case of in situ saphenous vein bypass graft aneurysm following an in situ femoro-peroneal bypass operation. An 85-year-old woman presented with a complaint of pain of the right leg at rest. CT angiography revealed superficial femoral and popliteal artery occlusion with atherosclerostic changes. In situ femoro-peroneal bypass was uneventfully performed. Soon after discharge she noticed a pulsating mass of the knee portion of the graft and it was gradually increased. Graft aneurysm was diagnosed by CT scan And 14 weeks later we performed aneurysm resection and repair by the contralateral great saphenous vein. Injury of the graft wall by a valvulotome might have been the cause. Gentle and careful manipulation is mandatory while using the valvulotome in in situ bypass procedures.

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Superior mesenteric artery (SMA) embolism can be a fatal disease causing intestinal necrosis. We cured a patient with SMA embolism who was treated for chronic idiopathic thrombocytopenic purpura (ITP). A 67-year-old man was diagnosed with ITP suffered from purpura in his lower limbs and decreased platelet count. He improved after taking steroids for a month, he had sudden stomachache. His enhanced abdominal CT showed SMA embolism. Transperitoneal operation did not show intestinal necrosis, so we started anticoagulant therapy. He left the hospital on postoperative day 47. Although platelet count decreases in patients with ITP, platelet aggregation may increase. We must be aware of the possibility of the occurrence of embolisms.

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In an 84-year-old man, CT demonstrated a 60 mm abdominal aortic aneurysm and the right pelvic kidney. The right renal artery originated from the aorto-iliac bifurcation. We performed trifurcated graft replacement and an anastomosis of the right renal artery reconstruction. For renal preservation, the right renal artery was perfused with cold Ringer’s solution using a rapid infusion pump and coronary perfusion cannula. Postoperatively he had an uneventful course without renal dysfunction. In a surgery of an abdominal aortic aneurysm with congenital renal anomaly, continuous perfusion of the renal artery with cold Ringer’s solution is simple and appropriate for renal protection.

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Treatment of infection of vascular prostheses implanted during redo axillo-bifemoral bypass is very difficult, especially in compromised patients, because an alternative bypass route has to be made and the infected prosthesis has to be removed completely. We present the case of a 79-year-old man with diabetes mellitus and chronic renal failure who was on hemodialysis, and who underwent a redo axillo-bifemoral bypass 3 months before presentation: Sepsis due to vascular prosthesis infection was diagnosed. Through median sternotomy an extra-anatomic bypass between the ascending aorta and both femoral arteries were performed, and most of the infected vascular prosthesis was removed. We used vacuum-assisted closure therapy on the infected wound. Sixty-seven days after the operation, the infected wound healed completely. Our experience confirms the safety and effectiveness of this treatment option, especially for redo operations in compromised patients.

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Crawford type V thoracoabdominal aortic aneurysm (TAAA) was detected in a 76-year-old male. His metastatic liver tumor had been treated by chemotherapy. The maximum dimension of the aneurysm was 67 mm. The distance from the distal end of the TAAA to celiac axis (CA) was only 5 mm. Preserving blood flow of the CA, TEVAR was performed with the sandwich technique. The postoperative course was uneventful. No symptoms of splanchnic ischemia were observed. Postoperative CT showed no endoleak. The blood flow of CA was maintained. Although the long-term prognosis has not been well documented, this could be a minimally invasive and feasible treatment for TAAA.

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A 57-year-old man had undergone two thoracic endovascular aneurysmal repair (TEVAR) procedures using a handmade stent graft to treat an enlarged ulcer-like projection due to type B acute aortic dissection and complications (type I endoleakage and migration) after an initial TEVAR. This report describes an infrarenal abdominal aortic aneurysm (maximum size, 60 mm) accompanied by a type III endoleakage and a dilated descending thoracic aorta (48 mm) revealed by chest computed tomography. A strategy to treat both aortic pathologies was considered because multilevel aortic disease is associated with a high mortality rate. We believed that replacing the thoracic descending aorta would treat the endoleakage after TEVAR and that endovascular aneurysmal repair (EVAR) would treat the AAA. The patient underwent EVAR followed by thoracic descending aorta replacement two months later without any complications, such as paraplegia.

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