Objectives: To analyze early and mid-term results after hybrid aortic arch repair (HAR). Methods: Between December 2008 and May 2012, 56 patients were admitted to our hospital for intent-to-treat of aortic arch pathological conditions. There were 44 men and 12 women, with a mean age of 75 ± 9 years. Complete debranching was performed in 20 patients, partial debranching in 8 patients, and isolated left subclavian artery revascularization in 28 patients. Debranching and thoracic endovascular aortic repair (TEVAR) was performed in a staged fashion in 10 patients. HAR could not be completed in 1 patient because he died of acute myocardial infarction prior to staged TEVAR. The proximal landing zone was Z0 in 13 patients, Z1 in14 patients, and Z2 in 28 patients. Japan score was 15 ± 15%. Results: The 30-day mortality was 5% (3/56). Respiratory failure developed in 8 patients, stroke in 2 patients, spinal cord ischemia in 2 patients, and aortic perforation in 1 patient. Eighteen of 55 patients (33%) had endoleaks immediately after HAR. In 46 patients with a follow-up period of more or 6 months, there were 6 endoleaks (13%). Three patients required secondary TEVARs. Actuarial survival estimates at 1 year and 3 years were 83 ± 7% and 77 ± 17%, respectively. Event-free survival curve were 76 ± 7% at 1 year, 72 ± 7% at 2 years, and 50 ± 14% at 3 years. Conclusions: HAR was associated with an excellent morbidity and mortality. However, there was a substantial incidence of complications including endoleaks during follow up. Thus, continued vigilant surveillance of patients is needed.

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Objective: Major side effects after endovenous laser ablation (EVLA) are pain and bruising. The aim of this study was to compare outcome and side effects after EVLA for primary varicose veins with 1470 nm diode laser using bare-tip or radial fiber. Methods: From October 2007 to December 2010, 385 patients (453 limbs) with primary varicose veins treated with 1470 nm laser were studied. Bare-tip fiber was used in 215 patients (242 limbs) (BF group) and radial fiber (ELVES^TM Radial, Biolitec AG, Germany) was used in 177 patients (211 limbs) (RF group). This study is retrospective study and radial fiber was started for use from November 2008. Laser energy was administered at 6–12 W of power in BF group and 10 W of power in RF group with constant pullback of laser fiber under tumescent local anesthesia. The patients were assessed by clinical examination and venous duplex ultrasonography at 24–48 hours, one week, one month, 4 months and one year follow-up postoperatively. Results: Mean operating time, length of treated vein and linear endovenous laser energy of all cases were 42.6 minutes, 36.2 cm and 83.4 J/cm, respectively. Major complications such as deep vein thrombosis and skin burns were not seen. Bruising (1.9% vs. 19.4%) and pain (0.9% vs. 7.4%) were significantly lower in the RF group. Cumulative occlusion rates by Kaplan-Meier method were 100% at 32 months in RF group and 99.5% at 4 years in BF group. Conclusion: EVLA using 1470 nm laser with the radial fiber minimized adverse effects compared with bare-tip laser fiber.

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Objective: The basics of the treatment for Stanford type A acute aortic dissection are immediate surgical repair of ascending aorta, but emergency operation for the early thrombotic type is not necessarily required. Even if these patients do not have surgical treatment, they heal. In this study, we investigated the results of treatment for the cases of the early thrombotic type A acute aortic dissection, and clarified the validity and the problems of treatment strategies. Methods: Between January 2004 and September 2011, in 75 patients of acute type A aortic dissection that we treated for acute stage, we examined 21 patients in which the false lumen was thrombotic in early phase. Indications of emergency surgery are patients with an ascending aortic diameter of 50 mm or more with a narrowed true lumen. Except for the above patients, we chose conservative treatment. Results: There were 2 cases of emergency aortic surgery, on the other hand, the cases that chose conservative treatment were 19 cases. Pericardiotomy and pericardial drainage was performed in all 10 patients who were accompanied by cardiac tamponade in medical therapy group. All cases survived and were discharged. In the medical therapy group, 12 patients showed complete resolution of the false lumen in the ascending aorta, 4 patients showed decrease in the size of the false lumen, 1 patient showed decrease in the size of the false lumen but the diameter of the ascending aorta increased. One patient showed re-dissections during the follow-up period and the false lumen opened again. One patient dropped out. Conclusion: In patients with Stanford type A acute aortic dissection with the thrombotic false lumen, 2 patients underwent emergency surgical repair of the aorta and remaining 19 patients were treated medically. Because all cases survived, our therapeutic strategy for patients with thrombotic type A acute aortic dissection was suitable and removal of cardiac tamponade is effective lifesaving therapy.

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Objective: This study aimed to evaluate the surgical results of pararenal abdominal aortic aneurysm (AAA) repair using partial cardiopulmonary bypass. Methods: Between June 2009 and April 2012, we performed graft replacement in 10 patients with pararenal AAA using partial cardiopulmonary bypass. The median age was 74 years with 90% men. The etiologies of pararenal AAA were atherosclerotic aneurysm in 7 and pseudoaneurysm at the proximal anastomosis due to previous graft replacement of infrarenal AAA in the remaining 3 patients. Thoracoretroperitoneal incision was made through the 7th intercostal space. The diaphragm was incised circumferentially at the periphery from the line of incision around to the aortic hiatus. The abdominal viscera and left kidney were rotated medially, and the abdominal aorta was then exposed. After establishment of partial cardiopulmonary bypass via the femoral artery and vein, distal perfusion and selective visceral perfusion including the renal arteries were performed. Results: Beveled anastomosis at the proximal site was performed to preserve the celiac artery and inferior mesenteric artery in all patients. Reconstruction of the left renal artery was performed in 4 patients, right renal artery in 2, and bilateral renal arteries in 1. No renal revascularization was required in 2 patients. Mean cardiopulmonary bypass time, visceral artery perfusion time, and reconstructed renal artery perfusion time were 128±48 minutes, 60±33 minutes, and 116±22 minutes, respectively. There were no in-hospital deaths or postoperative complications, except for dysuria due to spinal cord ischemia in one patient. Discussion: Graft replacement using partial cardiopulmonary bypass for pararenal AAA is a safe and effective operation without causing visceral organ ischemia.

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Objective: The aim of this study was to evaluate the results of treatment for visceral artery aneurysms in our institution and examine the validity of therapeutic approaches. Subjects and Methods: This study included 43 patients with 48 aneurysms (17 renal artery aneurysms; RAAs, 20 splenic artery aneurysms; SAAs, 3 celiac artery aneurysms; CAAs, 6 superior mesenteric artery aneurysms; SMAAs, 1 inferior pancreaticoduodenal artery aneurysm; IPDA, and 1 hepatic artery aneurysm; HAA) treated between 2001 and June 2012. Aneurysms with a diameter ≥20 mm, symptomatic aneurysms, false aneurysms, and superior mesenteric artery branch aneurysms were treated, and other aneurysms were followed-up. As an exceptional measure, 2 RAAs and 1 SAA of 20 to 21 mm in diameter with an eggshell appearance were also followed-up. Endovascular treatment was chosen as the first-line treatment, and surgical treatment were performed when arterial reconstruction was necessary or endovascular treatment was anatomically impossible. Results: Of the 48 aneurysms, 17 required therapeutic intervention: 8 surgical treatments and 9 endovascular treatments. The surgical treatments performed were: resection and arterial reconstruction for 2 RAAs; aneurysmectomy, aneurysmectomy with arterial reconstruction, or aneurysmectomy with splenectomy for 3 SAAs; aneurysmectomy with arterial reconstruction for 2 SMAAs; and aneurysmectomy for 1 IPDA. Endovascular coil embolization was performed for 3 RAAs, 5 SAAs, and 1 HAA. None of the patients who underwent surgical or endovascular treatments developed late complications, but all of them returned to their social activities. The diameter of the 31 aneurysms that were followed-up for a mean period of 43±19 months did not significantly increase (13.1±3.3 mm at the first examination and 13.5±3.7 mm at the final examination, p=0.12), and none of the patients with these aneurysms developed aneurysm rupture or converted to surgery. The 5- and 8-year cumulative survival rates of patients treated by surgical or endovascular treatments were 100 and 75%, respectively. No patients died of aneurysm-related causes. Conclusion: The outcome of patients treated by surgical or endovascular treatments or followed-up was favorable, suggesting that our current therapeutic approaches are appropriate.

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Upper-extremity arterial aneurysms are uncommom lesions, and are usually pseudoaneurysms. Most pseudoaneurysm are associated with trauma. We report two cases of nontraumatic pseudoaneurysm of ulnar artery, which were treated successfully with excision of the aneurysm. Case 1: A 66-year-old male presented with a painless mass in his right forearm. Arterial duplex imaging demonstrated a 20-mm diameter mass arising from the ulnar artery. The excision of the aneurysm was performed, and postoperatively, he had no ischemic complications. Case 2: A 53-year-old woman presented with a painless mass in her left forearm. The laboratory findings revealed eosinophilia. Computed tomography showed a 30 mm diameter pseudoaneurysm of the ulnar artery. The aneurysm was totally resected, and diagnosed histologically as angiolymphoid hyperplasia with eosinophilia. Postoperatively, the eosinophilia gradually returned to within the normal range. The operative resection of pseudoaneurysm of upper extremity should be performed, and revascularization can be performed selectively.

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Pseudoaneurysm-enteric fistulas after graft replacement of abdominal aortic aneurysm (AAA) are relatively rare. An 83-year-old man who underwent graft replacement of AAA complained of melena during follow-up. Upper gastrointestinal scopy revealed a raised lesion that resembled a submucosal tumor at the distal third portion of the duodenum and adhesion of blood to the top. Computed tomography showed a high density area that suggested aortoduodenal fistula. Therefore, he underwent urgent exploratory laparotomy. On operative view, the proximal jejunum near the ligament of Treitz adhered tightly to the residual aneurismal wall and the wall formed a pseudoaneurysm-jejunal fistula. The pseudoaneurysm-jejunal fistula was resected en bloc. We irrigated the abdominal cavity with saline, performed omentopexy and wrapped the graft with the aneurysmal wall. The postoperative course was uneventful and he was discharged on the 17th postoperative day. Simple closure of fistula and omentopexy may be useful in cases of secondary aortoenteric fistulas that have no graft infection.

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We report a case of infradiaphragmatic abdominal aorta – infrarenal abdominal aorta bypass for mid-aortic syndrome, which is considered to be a rare disease with poor prognosis. A 29-year-old man with juvenile hypertension was found to have a stenosis of the abdominal aorta and the right renal artery by means of a CT scan. For the treatment of renovascular hypertension refractory to medication, we performed descending aorta-abdominal aorta bypass surgery and revascularization of the right renal artery. The blood pressure in the upper extremities decreased into the normal range and the ankle-brachial pressure index improved postoperatively. He was discharged on the 13th postoperative day.

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We report a rare case of endovascular graft infection due to aortic dissection and aortoesophageal fistula after thoracic endovascular aortic repair. An 80-year-old man had type B aortic dissection, 2 weeks after endoluminal stent graft placement for aneurysm of descending thoracic aorta. Because of his age, abdominal angina, and dilatation of false lumen, we selected endovascular repair. The patient suffered bacteremia with MSSA and type A aortic dissection with thrombotic false lumen, 25 days after re-endovascular repair. We performed ascending aorta replacement. However, the patient died from septic shock and multiple organ failure due to aortoesophageal fistula and secondary endovascular graft infection.

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Two abdominal aortic aneurysm (AAA) patients with severe neck angulation (SNA) were successfully repaired with Endurant stentgraft systems, which were recently introduced in Japan. Case 1 was an 85-year-old woman with 54 mm maximum AAA diameter. The proximal neck angle was 135 degree and length was 20 mm. Both external iliac artery diameters were 6.1 mm. A stiff guide wire was inserted into the aortic root and the angulated neck became straight. The delivery system of the main stent body could be inserted easily, probably owing to the hydrophilic-coated delivery system and its lower outer diameter (18 F). Thereafter the stiff guide wire was pushed in with a fulcrum at the aortic valve, resulted in the bowing of the stiff guide wire and the delivery system becoming parallel to the proximal neck (device modification technique). Main body could be deployed accurately and smoothly because of the controlled release system of Endurant. Contralateral leg cannulation was easy because the direction of the main body was set as cross leg position. Case 2 was an 84-year-old woman with 52 mm maximum AAA diameter. The proximal neck length was 18 mm. Neck angulation was 130 degree and there was 155 degree angulation distal to the proximal neck. The angulated neck and the distal aortic angulation became straight with stiff guide wire insertion (aortic modification technique). During the deployment of the main part of the bifurcated stent graft, we waited until the main part fitted spontaneously to the proximal neck by pulsatile aortic blood pressure. As in case 1, the insertion of the 18 F delivery system of main body was easy although the external iliac artery diameter was only 6.0 mm. In both cases, there was no type I nor III endoleak by postoperative contrast enhanced CT. More AAA patients with challenging anatomy might be repaired with Endurant, because Endurant has greater flexibility due to the wire-formed M-shaped stents, controlled release system of endografts and suprarenal stents for accurate and smooth delivery, suprarenal active fixation by supra renal stent and anchoring hooks, and hydrophilic coated system with lower outer diameter.

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We report a case of iliac artery occlusion caused by abdominal blunt trauma. An 80-year-old man had suffered abdominal contusion injury by a traffic accident. CT angiography revealed occlusion of the right common and external iliac artery. Emergency Femoro-femoral bypass using a ePTFE graft was performed 5 hours after the episode. He recovered soon. If patients showed signs and symptoms of acute arterial occlusion after blunt abdominal trauma, we should consider the traumatic arterial occlusion and treat the patients appropriately.

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Popliteal artery aneurysms represent the most frequently encountered aneurysm within the peripheral vasculature. We encountered a case of thrombosed popliteal artery aneurym with severe tibial arterial calcifications satisfactorily treated by femoro-paramalleolar bypass. A 58-year-old man presented with claudication of the right leg and coldness of the toes. Resection of the occluded popliteal aneurysm and femoro-paramalleolar bypasses were performed in sequential fashion. When severe calcifications of the tibial arteries exist, distal bypass should be performed if the arteries of the paramalleolar region are intact.

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A 71-year-old woman with a complete-type persistent sciatic artery aneurysm successfully underwent aneurysmectomy and femoro-popliteal below the knee bypass surgery utilizing in situ saphenous vein graft (SVG). She found pulsatile mass on her left buttock 1 year prior to the surgery, and the symptom disappeared. After that, she suffered from left sciatic neuralgia and coldness along her left leg. CT finding showed 4×3 cm sized left sciatic artery aneurysm with an almost thrombotic, sciatic artery along the lateral back side of her left upper leg. Her left superficial femoral artery did not connect to her popliteal artery below the knee. Aneurysmectomy was essential to release her from neuralgia by mass compression. Distal anastomosis was placed on the left popliteal artery below the knee less than 3 mm in diameter. So in situ SVG was chosen for bypass surgery. The result of the surgery was successful, and her symptoms disappeared.

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Thrombotic occlusion of an abdominal aortic aneurysm (AAA) is comparatively rare. We performed simultaneous operations of a patient who had a natural thrombotic occlusion of an AAA complicated by coronary artery disease. This patient was an 83-year-old woman with a chief compliant of bilateral limb pain. On the preoperative examination, the maximum diameter of AAA was 57 mm, and it was occluded from below the renal artery and both the external iliac artery and the femoral artery were patent. She also had coronary artery disease with severe stenosis of the left anterior descending artery, and complicated by moderate aortic valvular stenosis. Therefore we performed simultaneous operation of the minimally invasive direct coronary artery bypass and abdominal aorta to both external iliac artery bypass. She left hospital without the intermittent claudication on the 35th postoperative day.

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A 72-year-old man underwent infrarenal abdominal aortic aneurysm surgery with a retroperitoneal approach 15 years previously. The maximum AAA diameter proximal to the previous graft was 55 mm and the left renal artery (RA) arose from the aneurysm, so he was admitted with a diagnosis of pararenal abdominal aortic aneurysm (PRAAA). Operation was performed through median laparotomy. Soon after suprarenal aortic cross-clamp, perfusion from the right axillary artery to the left RA was performed for renal protection. The graft used for aneurysm repair was a knitted Dacron graft. Perfusing to the left RA, proximal anastomosis was performed and the left RA was reconstructed. The serum creatinine level was 1.7 mg/dl on postoperative day 1, it returned to the preoperative serum concentration in 4 days after surgery. Though intestinal obstruction was caused by surgery, there was no deterioration of renal function during his hospital stay. He was discharged 37 days after surgery. Thus, perfusing from the axillary artery to the RA proved safe and useful for protection of renal function in the surgical treatment of PRAAA.

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Heparin is the standard anticoagulant used for patients with cardiovascular disease because of several advantages including rapid onset of effect, ease of titration and monitoring, and rapid reversal with protamine. However, treatment with heparin can lead to severe complication, heparin-induced thrombocytopenia (HIT), the diagnosis and management of which are important. We present a case of HIT, wherein the patient underwent bypass surgery for critical limb ischemia using argatroban. An 83-year-old man with an arterial occlusion in the lower extremity underwent thrombectomy. After the operation, thrombocytopenia developed and arterial occlusions in the lower extremity were observed again. We suspected HIT and began argatroban therapy. Next, we performed left external iliac artery-posterior tibial artery bypass. Thrombosis did not recur and hemorrhagic complications did not develop perioperatively. We successfully managed HIT with critical limb ischemia during the perioperative period using argatroban.

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Graft infection is one of the most fatal complications after surgical treatment for arteriosclerosis obliterans. Both redo arterial revascularization for limb salvage and prevention of recurrent infection are necessary to deal with the infected prosthetic graft. Therefore, surgical strategy is extremely troublesome and challenging. We successfully performed redo axillo-superficial femoral bypass by tunneling above the iliac crest for graft infection in the groin. An 82-year-old woman was referred to our hospital for suffering from intermittent claudication. Computed tomography (CT) revealed occlusion in the bilateral external iliac arteries, and right axillo-bilateral common femoral bypass was performed. One year later, a lymphocele developed in the left groin, which required for re-treatment of the inguinal wound. However, wound infection was occurred 2 months after the treatment. Staphylococcus aureus was found from the wound swab. Although the infection involved the bypass graft, it was limited around the left groin. We performed left axillo-superficial femoral bypass using a knitted 8 mm Dacron graft, followed by excising the infected graft and left common femoral artery. The graft was tunneled above the iliac crest by scraping off the upper edge of the bone to avoid skin perforation, graft kinking or compression, and led to the mid superficial femoral artery for distal anastomosis. Postoperative 3-dimensional CT angiography showed the patent graft in a proper position. The postoperative course was uneventful. We concluded that this extra-anatomic bypass was a safe procedure and an excellent option for patients with infected vascular prosthetic graft in the groin after previous revascularization.

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