According to clinical guidelines, arteriovenous fistula (AVF) by basilic vein transposition (BVT) might be considered if radial-cephalic and brachial-cephalic AVF fail. We report initial experience and early outcome of AVF by one-stage BVT. Twenty-seven consecutive patients (male : female=8:19, age 46–91 years, mean 72 years) who underwent brachial-basilic vein AVF by BVT in our institute were enrolled retrospectively in this study. The basilic vein in the upper arm level was evaluated by preoperative venography in all patients. Surgery was performed under general anesthesia in 21 patients, intravenous anesthesia in 2, and under local anesthesia in 4. Basilic vein at the upper arm was dissected as long as possible initially, then it was transposed at the anterior side of the upper arm, and finally anastomosed to the brachial artery in end-to side fashion. Graft flow was measured by the transit time method just after anastomosis, the result was 94–785 ml/min, mean flow: 313.2 ml/min. Postoperative clinical course was generally uneventful, but one patient died due to respiratory failure prior to use of this vascular access. The BVT was immature in one patient and iatrogenic BVT injury occurred in one patient. Therefore, 24 BVT (88.9%) were successfully used for hemodialysis at 9–18 days, mean 13.3 days after surgery. Graft failure due to thrombosis in the early phase occurred in two patients, one was in the brachial artery 37 days after surgery, the other was severe stenosis of the transposed basilic vein 141 days after surgery that was finally improved by surgical thrombectomy and percutaneous transluminal angioplasty (PTA). Dialysis-associated steal syndrome which was successfully revised by surgical ligation to reduce blood flow of transposed basilic vein, was indicated in one patient about 4 months after creation of BVT. Primary graft patency at one-year was 70.0%, and assisted primary patency was 85.0%. These results suggested that brachial-basilic vein AVF by one-stage BVT could be a reliable option and an alternative of forearm arteriovenos grafts (AVG) and failed or infected AVF, with less complications than high flow AVF and AVG. Mandatory care is necessary in high-risk patients to improve long-term outcome.

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Objectives: Abdominal aortic aneurysm (AAA) in high risk patient could be repaired by endovascular aneurysm repair (EVAR) because of its less invasiveness. We evaluated the change of AAA patient’s characteristics before and after the introduction of EVAR.
Methods: We encountered 328 patients with AAA from January 2000 through December 2010. For 293 elective cases, we compared the patient’s characteristics such as age, frequency of coronary artery disease (CAD), stroke, and impaired daily activity (walking with a stick or worse) between patients before (pre group, n=180) and after (post group, n=113) the introduction of EVAR. In addition, post group was divided into open repair patients (post-open group, n=32) and EVAR patients (EVAR group, n=81). We also analyzed the proportion of cases of ruptured AAA during this period.
Results: Patient age did not differ between pre and post groups, however post group patients had a significantly higher incidence of CAD, stroke and impaired daily activity. Post-open group were younger than the EVAR group (p=0.005), with less risks for surgery. Mortality rate did not differ between three groups. Post operative admission period was significantly shorter in the EVAR (10.6 days) group than the pre (20.4 days) or post-open (18.1 days) groups (p<0.001). The proportion of ruptured AAA decreased during the study period, from 12% in the pre-EVAR period to 8% in the post-EVAR era, however the difference did not reach to statistical significance.
Conclusion: The mortality rate did not increase even the patient’s characteristics became high risk by the introduction of EVAR. Ruptured AAA might decrease with the wider applications of EVAR in the future.

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Objectives: Infection of an arteriovenous fistula (AVF) for hemodialysis is a relatively rare complication. When such an infection is localized without sepsis, it responds well to antibiotic treatment. However, if rupture and hemorrhage occur as a result of such an infection, an emergency operation is required. In the present study, we investigated the pathology of rupture of an infected AVF as well as treatment options in 6 cases of rupture secondary to AVF infection encountered at our institution.
Patients and methods: All patients were women with a mean age of 70.5 years. Five were referred to our hospital due to hemorrhage, while the other was admitted for an infected pseudoaneurysm.
Results: The duration from AVF formation to infection and rupture was an average of 25.0 months. Two of the 6 patients experienced rupture within 2 months after AVF creation, while all received emergency surgery. In the cases of open hemorrhage, they transferred to the operating room applying a tourniquet to their arm. Four had a rupture in the outflow vein or mid-AVF. In those cases, the infected portion was removed and the AVF was closed surgically. In 2 of those cases, the surgical wound was closed using a 1-step procedure and it was left as an open wound in the other 2. Anastomotic hemorrhage occurred in 2 patients. In 1 of those, the ruptured portion was first sutured in an attempt to preserve the AVF, though AVF closure was eventually necessary, as hemorrhage immediately recurred, while in the other the infected portion was removed, then the AVF was closed and the radial artery reconstructed using the autogenous vein. In that second case, the reconstructed graft collapsed as a result of relapsing infection, thus it was necessary to ligate the radial artery, which was only required in this case. Blood culture findings confirmed MRSA in 5 cases. Four of the 6 patients survived. One of the 2 who underwent 1-step wound closing died from sepsis induced by recurrent infection and the other death was from aggravation of general status caused by difficulties with hemodialysis treatment after surgery.
Conclusion: S. aureus is frequently found to be a causative bacterium of AVF infection. It is critical to control the hemorrhage of the ruptured AVF in the initial step of their treatment. For surgical treatment, it is generally considered necessary to open the infected wound, as 1-step wound closure has a risk of developing sepsis. In these cases, it is important to quickly design a therapeutic plan, including proper choice of antibiotics and operative procedure.

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We report two cases of diabetes mellitus with end-stage renal disease to which we performed additional distal bypass for intractable critical leg ischemia. Case 1 is 64-year-old man was admitted to our hospital with gangrene of the right heel and infection of the surround tissue. Arteries of the right leg and ankle were occluded on angiography while the arteries of the medial malleolus and the dorsal foot were visualized on duplex scanning. Popliteal-to-plantar artery bypass suggested the results of wound infection worsening and the ineffectiveness of debridement sustains ischemia and the hence necessity of reoperation for more blood supply. Thus a bypass was added to a branch of the dorsalis pedis artery. The postoperative course was uneventful and the wound healed. Case 2 was a 72-year-old man admitted with painful left hallux ulcers. On angiography the crural arteries were occluded while the paramalleolar arteries were patent. Popliteal-to-plantar artery bypass was performed but did not relieve ischemia of the foot. Therefore an additional bypass was performed to the dorsalis pedis artery bypass. The postoperative course was uneventful and the symptoms were relieved. Multiple anastomoses might reduce ischemia in intractable cases after distal artery bypass surgery.

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A 30-year-old woman of 30 weeks gestation was transferred to our hospital due to sudden onset backpain and dyspnea. Enhanced computed tomography and echocardiography revealed Stanford type A acute aortic dissection with aortic regurgitation. Marfan syndrome was suspected in this patient because her mother had died of aortic dissection following a diagnosis of Marfan syndrome before. Immediate operation of aortic repair was required. However, due to the risk of massive bleeding from her uterus and placental separation site due to cardiopulmonary bypass with heparin administration, emergency caesarian section was initially performed. Twelve hours later, graft replacement of the ascending aorta was performed secondarily. The postoperative courses of the mother and infant were uneventful.

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A 48-year-old woman underwent breast-conserving surgery with sentinel lymph node dissection for a right breast cancer one year ago. During the follow-up observation, computed tomography (CT) revealed an aneurysm of the right subclavian artery; hence, she was referred to our department. The previous surgery left no trace of a central venous catheter. The CT showed a 20×17 mm extrathoracic aneurysm of the right subclavian artery located closer to the cranium than the clavicle. The surgery was carried out via a supraclavicular approach in a supine position under general anesthesia. A 5-cm skin incision was made on the right supraclavicular fossa. After the sternocleidomastoid muscle, internal jugular vein, and phrenic nerve were retracted, and the subclavian artery and aneurysm were identified. After heparin administration, the proximal and distal sides of the aneurysm were clamped and then resection was performed. The subclavian artery was reconstructed by end-to-end anastomosis without a prosthetic graft because the artery was well preserved. The postoperative course was uneventful with no complication. This experience presents the feasibility of supraclavicular approach for surgical management of extrathoracic aneurysm of the subclavian artery. Thus, we report this case with a review of the literature.

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We report a case of infected pseudoaneurysm of left common iliac artery in a 67-year-old man whose past history was diabetes mellitus and angina pectoris. He presented abscess of the left thigh and high fever caused by Klebsiella pneumoniae. Infected pseudoaneurysm of the left common iliac artery, caused by prolonged sepsis, was found on computer tomography. So resection of aneurysm and in-situ replacement by a rifampicin-soaked Dacron graft was performed immediately after diagnosis of the infected pseudoaneurysm. He was followed up with intravenous infusion of antibiotic therapy after surgery, for 28 days, and has been doing well with no recurrence of infection, and with no oral antibiotics. He was followed for one year after the operation and had a good course without reinfection.

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A 76-year-old man was involved in a high speed motor vehicle accident, and brought to the emergency department. Computed tomography showed local type A aortic dissection with sternal fracture and splenic injury. We performed graft replacement of the ascending aorta 16 hours after admission under cardiopulmonary bypass with hypothermic circularory arrest. Intimal tear of the aorta was just above the aortic valve, and it involved the right lateral aortic wall. The postoperative course was uneventful.

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Cystic adventitial disease is rare and its etiology remains controversial. A 53-year-old man suddenly felt languidness and pain in his right calf while he was working. Since his symptoms worsened, he consulted a physician 4 days later. Ankle-brachial systolic pressure index (ABI) was lower than normal in the right leg. The physician consulted our center on the suspicion of artery occlusion. Since emergency was not indicated, we decided to perform delayed surgery in the chronic period. A computed tomography (CT) showed a 3-cm obstruction of the right popliteal artery. No atherosclerotic findings were seen in the artery, and 1 month later, the symptoms had almost disappeared except the calf pain after stepping up stairs. CT and magnetic resonance imaging (MRI) showed a cystic adventitial disease and operation was performed. Popliteal artery and adventitial cyst were resected and interposed with saphenous vein graft. After operation, symptoms totally disappeared, and ABI was normal. Pathological findings showed attachment between the inner and outer elastic band. Adventitial cystic disease might originate from microtrauma.

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A 75-year-old man presented with left hemiparesis, which had been preceded by recurrent left hand clumsiness that lasted for one hour. MRI detected multiple embolic lesions in his right cerebral hemisphere. He had a severe grade of right internal carotid stenosis (NASCET 80%). The cranial end of the lesion was located at the level of the second cervical vertebra. Carotid endoarterectomy partially left the plaque, which was confirmed by angiography in situ. The residual lesion was treated by transcervical filter-protected carotid stenting. During the initial passage of the filter device through the lesion, the arterial blood was aspirated transiently to collect the debris. Postoperative diffusion weighted MRI did not detect new embolic lesions and 10 days after the operation, the patient was discharged with a decrease of modified Rankin score from 4 to 0.

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A 77-year-old man presented with a 55-mm infrarenal aortic aneurysm associated with old myocardial infarction, severe diabetes mellitus, and an undiagnosed pleural tumor. Endovascular aortic repair (EVAR) via the femoral artery and thoracoscopic pleural biopsy was performed under general anesthesia. On EVAR, there were neither technical difficulties nor unstable circulatory dynamics such as hypotension during the procedure. After extubation in the intensive care unit, he developed paraplegia. Emergency cerebrospinal fluid drainage, steroid administration, and arterial pressure augmentation were ineffective. On postoperative computed tomography, aortic dissection and endoleak were not found but partial infarctions of the right kidney were revealed. Pathological diagnosis of pleural tumor was pleural dissemination of pulmonary large cell carcinoma.

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Coral reef aorta is a rare form of aortic stenosis characterized by localized intraluminal heavy calcification of the juxtarenal and suprarenal aorta. Its main symptoms are hypertension, renal dysfunction, visceral ischemia, and intermittent claudication caused by hypoperfusion. We report 2 cases of extra-anatomical bypass for coral reef aorta. A 73-year-old woman was admitted after presenting with dyspnea and oliguria. Thoracoabdominal computed tomography (CT) showed subtotal occlusion of the heavily calcified aorta at the level of the celiac artery. A right axillo-femoral bypass was performed, which successfully improved her cardiac and renal function, but she still had intermittent claudication that required an additional left axillo-femoral bypass. After the second operation, her symptoms disappeared completely. Another 73-year-old woman was admitted complaining of intermittent claudication. Thoracoabdominal CT demonstrated a densely calcified occlusive lesion of the infrarenal abdominal aorta. A right axillo-bifemoral bypass was performed, and her condition improved. Surgical options for coral reef aorta include thromboendarterectomy, graft replacement, extra-anatomical bypass, and endovascular stent-graft. For patients in poor clinical condition, extra-anatomical bypass may be more efficient than a radical surgical procedure.

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This report describes a case of a giant superior mesenteric artery (SMA) aneurysm. A 21-year-old man was admitted to our hospital because of progressive intermittent backache. He was given a diagnosis of a giant aneurysm of the SMA by enhanced computed tomography, with a diameter up to 80 mm. Angiography showed adequate collateral flow from the inferior mesenteric artery to the distal small bowel and the right half of the colon. We extirpated the giant SMA aneurysm as thoroughly as possible, and closed the trunk of SMA with sutures. We resected a small daughter aneurysm and reconstructed one of the major collateral arteries by end-to-end anastomosis. The postoperative course was uneventful without any abdominal complications. Pathological examination of the aneurismal wall proved to be associated with fibromuscular dysplasia (FMD).

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We report 2 cases of patch reconstruction of the inferior vena cava (IVC) by the great saphenous vein (GSV). To make a large patch, a GSV was opened longitudinally and then divided into two equal parts, which were set out in parallel to make a “two-sheets patch” graft. Case 1: A 28-year-old man with leiomyosarcoma infiltrating to the IVC underwent tumor excision and IVC reconstruction. The resected portion of the cava wall was 50 mm long and 30 mm wide. Blood flow was normal for 33 months after surgery. Case 2: A 59-year-old man with leiomyosarcoma, located in the retroperitonium between the IVC and right kidney. The tumor and right kidney were removed and IVC was reconstructed. His IVC was problem-free and anticoagulant therapy was unnecessary. However, he died of systemic metastasis 22 months later. In both cases, we had to resect large portions of the IVC, which usually requires replacement by vascular prosthesis. However we elected a “two-sheets patch” graft repair with the aim of avoiding prosthesis. In doing so, patients face a low risk of venous thrombosis and do not need anticoagulant therapy.

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A 55-year-old woman with a history of von Recklinghausen’s disease felt right chest pain while taking her dog for a walk. Chest computed tomography showed right hemothorax. Furthermore, angiography detected bleeding from the right subclavian artery. An emergency operation was performed by median sternotomy, we recognized massive bleeding from right thoracic cavity. We found intrathoracic artery separated from right subclavian artery, which we repaired by some sutures. It was not easy to repair the vessel due to the fragility and thin wall. We did not detect any tumor around the vessel. Though the vascular complication of von Recklinghausen disease is rare, it can lead to severe results. It is crucial to diagnose as quickly as possible, and start management.

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Endovascular aneurysm repair (EVAR) is a minimally invasive therapeutic method. Iodine contrast medium is necessary and is contraindicated in cases of renal dysfunction or iodine allergy. We encountered a case of ruptured abdominal aortic aneurysm (AAA) treated with EVAR using carbon dioxide (CO2) angiography. An 84-year-old woman was brought to our hospital as a diagnosis of ruptured AAA. Because she had anamnesis of ileus and renal dysfunction, EVAR was performed. Angiography was performed using medical CO2. However, it was impossible to perform EVAR, only using CO2 angiography. CO2 angiography is useful and safe method for patients with renal dysfunction and can increase operative indications of EVAR.

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A 47-year-old man visited his local hospital complaining of numbness in his left arm. Computed tomography revealed a left subclavian artery aneurysm for which he was referred to our hospital for surgery. However, because of arterial embolism of the left upper extremity and retrograde cerebral thrombosis arising from a mural thrombus of the aneurysm developed preoperatively and surgery was performed by supraclavicular and infraclavicular incisions. The aneurysm was excluded and the left subclavian artery was reconstructed with an artificial graft. Aggressive surgical management is necessary for subclavian artery aneurysms, because they may be complicated with not only arterial embolisms of the arm but also cerebral infarction.

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A 72-year-old man who had a slight fever for three months presented, because he also started to have low backpains and left lower limb. Computed tomography showed a 40-mm diameter left buttock mass which might have an inflammation. It was diagnosed as left thrombosed persistent sciatic artery (PSA) aneurysm with inflammation. He was treated surgically only by mass reduction of thrombotic PSA aneurysm without a bypass procedure, because we thought his pains came from compression of the sciatic nerve and there was strong adhesion with the aneurysm and the sciatic nerve. After that, his symptoms disappeared, and he was discharged on 7 POD. It is important to preserve the sciatic nerve in terms of the anatomical features. If the patients have pain of the lower limbs, we should assess whether the cause is ischemia or compression of the nerve.

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