Objectives: We considered the management how to avoid complications related to the femoral access after interventional radiology (IVR). Patients and Treatment: Between September 2009 and September 2011, local neurosurgeons referred to us 6 patients (4 males and 2 females) with a mean age of 67.5 years ranged from 15 to 87 due to the troubles at the femoral access after IVR for cerebral and cervical vessel lesions. Five patients underwent carotid artery stenting (CAS) and coil embolization for intracranial arteriovenous malformation was done in one patient. Pseudoaneurysms occurred with superficial femoral artery (SFA) puncture in 4 patients. Limb ischemia occurred in 2 patients. Their common femoral arteries were filled with thrombus and the vascular closure devices (Angio-Seal^TM SJM). Emergency operations were performed for these 6 patients including direct suture of puncture site in 3, angioplasty using autovein patch were done in 2 patients, and common femoral artery bypass using autovein graft was done in one patient. One patient suffered from fibral nerve palsy postoperatively. Conclusion: To avoid complications related to the femoral access, we must take care of the selection of the puncture site and the hemostasis as well as the endovascular catheter technique. Pre-operation mapping using ultrasonography and CT is useful to detect the accurate puncture site. Following catheter withdrawal, the manual compression required sustained pressure over the puncture site for at least 10–15 minutes. Vascular closure device (Angio-Seal^TM SJM) is restricted to the patient with proper indication. According to the individual cases, not only the percutaneus puncture but also the incisional open puncture might be considered.

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Objectives: The effect of statin on the inflammatory response and postoperative course after endovascular abdominal aortic repair (EVAR) was investigated. Methods: During April 2008 and March 2012, 151 abdominal aortic aneurysm patients underwent EVAR in our hospital. Among these 151 patients, 66 patients did not take any kinds of statin. For 32 patients, strong statin was prescribed and other type of statin was prescribed for 11 patients. The postoperative body temperature, white blood cell count (WBC), serum C-reactive protein (CRP, mg/dl), postoperative hospital stay period and postoperative complications after EVAR were compared among 3 groups. Results: The period of maximal body temperature higher than 37.5 degree or 38.0 degree did not differ among 3 groups. The WBC on the postoperative day (POD) 1, 3 and 6 did not differ among 3 groups. The CRP on POD 1 and 3 were significantly lower in the strong statin group than no statin group (POD 1: strong statin group 2.5 ± 1.4, no statin group 4.1 ± 1.9, p=0.0002, POD 3: strong statin group 8.2 ± 3.1, no statin group 10.5 ± 4.4, p=0.039). There was no significant difference between no statin group and other type statin group on POD 1, 3. In the no statin group, postoperative stay period prolonged in 6 patients because of postoperative complications, however no postoperative complication occurred in the statin groups. Conclusion: Strong statin attenuated postoperative inflammatory reaction early after EVAR procedure and statin might prevent postoperative complication. These effect of statin depend on the intensity of statin.

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Objective: The distal external iliac, common femoral, profunda femoral and proximal superficial femoral arteries are often affected by arteriosclerosis obliterans, particularly in patients complicated with diabetes or during dialysis. We performed endovascular surgery for arteries in the inguinal region in 20 patients. Patients: We performed an operation for 23 legs in 20 patients. The surgical procedures consisted of longitudinal incision of the occlusive artery, endarterectomy and artificial graft pathing to dilate stenosis. Results: The longest follow-up term for these cases was 8 years and patency was confirmed in the latest examination in all patients. postoperatively. Conclusion: For intricate arteriosclerotic obstruction, endovascular surgery is favorable to intravascular dilatation with a catheters in regard to reduced complications and side effects, while treated patients show excellent long term outcomes.

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Case: A 77-year-old dialysis patient. Debranching TEVAR (Thoracic endovascular aortic repair, fenestrated stent grafting 42 mm, 38 mm) of the left common carotid artery and left subclavian artery was performed for an approximately 7×8.5 cm saccular aneurysm. After surgery, due to enlargement of the aortic aneurysm by a type III endoleakage, dissection of the ascending aorta and a bypass occlusion of the left common carotid artery, reoperation was performed. The proximal stent graft was removed and the distal stent graft was left in place because no type Ib endoleakage was found and therefore, a total replacement of the aortic arch and reconstruction of the left common carotid artery were done. TEVAR was less invasive and dramatically improved surgical mortality. However, due to additional treatments for endoleakages, semipermanent imaging monitoring is necessary. Thus, it seems to be important to think that treatment must be performed with consideration of the fact that mortality increases once a reoperation is decided.

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We describe a 59-year-old woman with cerebral infarction and acute aortic dissection who underwent cerebral decompression followed by elective arch replacement. The patient was admitted to a nearby hospital with minimal tongue movement and suspected right brain infarction. Chest CT on the following day confirmed acute type A aortic dissection and a right common carotid artery which occluded. Depressed consciousness and anisocoria became evident at two days after onset, when she was transferred to our hospital. At that time, Brain CT showed a midline shift and pressure on the brainstem. Emergency right front temporal craniectomy with internal and external decompression at three days after onset was followed by arch replacement for the Type A aortic dissection at 46 days after onset. Left hemiplegia that was evident before arch replacement did not improve, but the right half of the body recovered. The patient was transferred to another hospital to undergo rehabilitation at 118 days after onset.

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A 75-year-old woman was referred to our department due to groin prosthetic graft infection. She was a hemodialysis patient and had undergone bilateral external iliac-superficial femoral bypass with Dacron graft in our department 4 years ago. Methicillin-resistant Staphylococcus aureus (MRSA) was isolated from the left groin. Bilateral grafts were patent and we chose graft preservation as management because of poor nutrition, lowered activity with dementia and heart disease. Debridement and direct wound closure was performed with initiation of Vancomycin therapy, but the wound did not heal. After culture from the wounds had become negative, we performed Sartorius myocutaneous flap coverage which was followed by the wound healing. This strategy is a plausible choice for graft preservation in the presence of groin prosthetic infection even in MRSA-positive patients.

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Traumatic injury to major vessels is rare, but results in critical conditions. Here, we report a case of successful surgical treatment of the transected right subclavian artery caused by accidental blunt trauma. An 80-year-old man met with a traffic accident. Three-dimensional computed tomography showed complete transection of the right subclavian artery. During surgery, we first conducted a full sternotomy to encircle and clamp the brachiocephalic artery and proximal right subclavian artery to control bleeding. We then exposed the right subclavian artery and axillary artery to apply clamp through a subclavian skin incision and repaired the transection by direct suture. This patient was discharged 13 days after the operation. Patency of the right subclavian artery was confirmed by enhanced computed tomography.

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A 69-year-old man with diabetes developed a pseudoaneurysm in the right groin 3 years after bilateral femoro-popliteal bypasses with PTFE grafts. There were no local signs of infection and the pseudoaneurysm was repaired by re-suturing. Wound healing was prolonged and debridement was necessary before discharge. Two months after the operation, a pseudoaneurysm recurred. Although no signs of infection at the onset and during recurrence were observed, we resected the pseudoaneurysm and interposed a new graft from the external iliac artery to the distal graft detouring outside the groin, because of suspected occult infection. The pseudoaneurysms developed on the side which we anastomosed after endarterectomy at the original operation. The main cause of the pseudoaneurysms appears to be the degeneration of the host artery, but occult infection cannot be excluded as the patient had tinea pedis, administered insulin self-injection, and had prolonged wound healing. Interposition grafting would appear to be the method of choice for the repair of pseudoaneurysms, rather than simple re-suturing.

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We report a case of axillary artery pseudoaneurysm secondary to displaced proximal humeral fracture. An 83-year-old woman presented to the emergency room complaining of right shoulder pain after accidental fall. There were no signs of ischemia or neurological deficit. Roentograms revealed right proximal humeral fracture. She underwent open reduction and fixation 3 days after. Thirty two days after operation, her shoulder pain and swelling were persisting, and the right brachial, radial pulses were unpalpable. Emergent enhanced computed tomography and angiography showed right axillary artery pseudoaneurysm. She underwent axillary exploration and direct repair. The postoperative course was uneventful, and she was discharged.

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We report here a case of acute aortic dissection (Stanford Type A) with severe aortic regurgitation (AR) successfully treated by postoperative ECMO (extracorporeal membrane oxygenation). The patient was a 52-year-old man who was transferred to our hospital after complaining of chest-back pain. An emergent operation was performed after diagnosis of a type A acute aortic dissection with severe AR. We performed ascending aortic replacement under hypothermia arrest and retrograde cerebral perfusion. ECMO became necessary, because of postoperative acute respiratory failure. We used axillary artery cannulation with a graft anastomosis for inflow perfusion in ECMO because of central support with antegrade flow and excellent upper body oxygenation. During ECMO, anticoagulation with nafamostat mesilate was used to control bleeding complications. Postoperative bleeding decreased gradually and the patient was successfully weaned from ECMO 65 hours after the operation with no neurological complications. The recovery was uneventful, and at discharge the patient was able to walk out of the hospital without assistance. In this case, V-A ECMO with axillary arterial perfusion was performed successfully after acute aortic dissection, with no cerebral complications. Moreover, we reported that nafamostat mesilate was effective in preventing bleeding during ECMO.

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Persistent sciatic artery aneurysm is so rare that the sciatic artery which mainly feed lower limbs in the embryonal development after birth form an aneurysm and sometimes cause limb ischemia. We present a case of a 56-year-old, obese woman who complained of right buttock pain and intermittent claudication with right persistent sciatic aneurysm and obstructive right poplitial artery. We treated it successfully by hybrid treatment with transcatheter embolization and revascularizaion.

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We successfully treated the patient who had a right internal iliac artery aneurysm and a left common iliac artery aneurysm without an abdominal aortic aneurysm using bilateral internal iliac coil embolization followed by the insertion of the bilateral Excluder contralateral legs as kissing stent grafts from the distal abdominal aorta to the bilateral external iliac artery so as to preserve the inferior mesenteric artery. A 93-year-old man on the medication therapy for multiple myeloma revealed to have a right internal iliac artery aneurysm 30 mm in diameter and a left common iliac artery aneurysm 62 mm in diameter. Both distal and proximal necks of the huge left common iliac artery were short, which precluded the simple stent graft insertion only in the left common iliac artery. We underwent bilateral coil embolization of the internal iliac arteries followed by the bilateral iliac leg stent grafts insertion. The proximal ends of the stent grafts were positioned at the abdominal aorta distal to the inferior mesenteric artery so as to prevent the pelvic ischemia and were deployed with a kissing stentgraft technique, while the distal ends being situated at the external iliac arteries on both sides. No endoleak was observed and he was discharged without any complication.

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An 81-year-old man with chronic kidney disease on hemodialysis with a history of graft replacement for abdominal aortic aneurysm 8 years previously was transferred to our hospital because of non-anastomotic aneurysm of Dacron graft with abdominal pain and pulsatile abdominal mass. Computed tomography (CT) revealed extravasation from the previously replaced Dacron graft. Endovascular aneurysm repair was indicated anatomically and performed with Gore Excluder. Postoperative CT at 12 months revealed shrinkage of the aneurysm without extravasation. Non-anastomotic false aneurysm was rare and endovascular aneurysm was effective and minimally invasive, especially for high risk patients.

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Isolated dissection of the abdominal visceral artery is rare disease. It is difficult to diagnose without enhanced CT. Conservative therapy, such as blood pressure control, anticoagulation therapy is done generally, but sometimes revascularization such as surgery, EVT (endovascular therapy) may be done. We experienced four cases of isolated dissection of the abdominal visceral artery. It is important to choose proper treatment.

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Adventitial cystic disease of the popliteal artery is a rare condition that cause localized arterial stenosis or obstruction. We report a case of adventitial cystic disease of popliteal artery. A 55-years-old woman presenting left-sided intermitted claudication was diagnosed adventitial cystic disease and underwent endovascular therapy with balloon angioplasty in another hospital. She was referred to our hospital for reccurent symptom at one month after balloon angioplasty. The leftsided ankle brachial pressure index (ABI) was 0.59. From MRI findings and clinical course, we made diagnosis of restenosis of left popliteal artery caused by compression of adventitial cyst after balloon angioplasty, and then popliteal artery and adventitial cyst were resected and interposed with saphenous vein graft. Postoperatively the left-sided ABI improved to 1.04, and her symptom disappeared. The postoperative course was uneventful and she has been without reccurence for 24 months after surgery. In treatment for adventitial cystic disease, endovascular treatment by balloon angioplasty leads to early restenosis and early reccurence of symptom. Balloon angioplasty is not a durable treatment option for adventitial cystic disease. We think the best treatment is surgical treatment including cyst excision, resection of arterial segment and graft replacement.

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We used a temporary AV shunt with a sieving device for perprocedural embolic protection in a thoracic endovascular aortic repair (TEVAR) for shaggy aorta. A 76-year-old man diagnosed as having an acute aortic dissection (DeBakey type IIIa) with intramural hematoma and severe atherosclerotic changes had been under a strict anti-hypertensive therapy. Two weeks after the onset, the diameter of dissecting aortic aneurysm increased to 58 mm. Considering the risk factors, such as past history of cerebral infarction, chronic obstructive lung disease, and renal dysfunction, TEVAR was performed 4 weeks after the onset. During the procedure, the side port of the 24-Fr introducer sheath was connected to a 12-Fr sheath inserted into the femoral vein. A filter with a pore size of 100 microns was placed between the sheaths, to filtrate the collected arterial blood. High amount of visible debris was caught by the filter. He had an uneventful postoperative course with no embolic events.

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A 63-year-old man was admitted to our hospital because of severe back pain. A diagnosis of ruptured infected thoracoabdominal aortic aneurysm with thoracic empyema was made by computed tomography imaging, marked inflammation, and evidence with positive bacteriological culture of hemothorax. The infected thoracoabdominal aortic aneurysm and tissue were resected completely and replaced by an in situ dacron graft with Vancomycin. The graft was covered with a pedicled omental flap and omentoplasty for thoracic empyema was performed. Staphylococus aureus was isolated from a culture of the aortic wall. After subsequent intravenous antibiotic therapy for 6 weeks, the patient was discharged without any evidence of remaining infection. There has been no sign of recurrent infection.

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