Objectives: Isolated spontaneous dissection of the superior mesenteric artery (SMA) is very rare among of the visceral artery dissection and its treatment is not established. In this paper we present our experiences and consider the treatment of isolated SMA dissection. Methods: A retrospective review of our cases from 2005 was performed. Clinical symptoms, radiologic findings and results were evaluated. There were 14 cases of visceral artery dissection, in which all cases were with SMA dissection. There were 12 males and 2 females with a mean age of 57 years (range 41–78 years). Results: We categorized SMA dissection into the 6 types according to the Sakamoto’s and Zerbib’s classification. One patient with type VI underwent emergent endovascular surgery with stent. One patient with type VI received thrombectomy and intimectomy with open surgery. One patient with type II underwent anurysmectomy due to enlarged dissected SMA 3 months later from onset. The other 9 patients were managed conservatively. At follow-up, the diameter of SMA did not enlarged and the length of the dissection significantly decreased to 20.7±15.7 mm from 38.0±15.1 mm at onset (p<0.01). After treatment, imaging indicated the following changes in classification: type I, one patient; type II, 4 patients; type IV, 4 patients; complete remodeling, one patient, all without any event during the follow-up period of 5–82 months. Conclusion: Most patients with isolated visceral artery dissection occurred in superior mesenteric artery and can be treated conservatively; however, endovascular or surgical procedures including laparotomy are indicated when there is suspicion of severe mesenteric ischemia. Because the dissection configuration will change, long term follow-up is necessary.

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Objectives: Inflammatory abdominal aneurysms (IAAAs) have traditionally been treated using open repair; however, the operative mortality involved is higher than that for atherosclerotic aneurysm repair due to intraoperative technical difficulties associated with periaortic inflammation and dense adhesion to the surrounding organs. Therefore, endovascular repair is a potentially better option for IAAA repair as it does not involve laparotomy and dissection. Methods: We examined 172 patients who underwent endovascular repair for abdominal aortic aneurysms and/or common iliac aneurysms between June 2006 and November 2011. IAAAs were suspected in 9 of these 172 cases (5.2%). Diagnoses were made using patient symptoms and computed tomography (CT) findings. Results: Aneurysm exclusion using stent grafts was performed successfully in all cases. No perioperative deaths or complications were noted. A single case of late death was noted due to advancement of pancreatic cancer. In most cases, significant reduction in aneurysm diameter occurred more quickly following endovascular repair of IAAAs than that noted following atherosclerotic aneurysm repair. No cases converted to open repair in the follow-up period. Although the inflammation persisted and extended to the iliopsoas muscle and vertebral body in 2 cases, it was eventually resolved through conservative treatment. In another case, inflammation recurred 3 years postoperatively around the site of the original inflammatory aneurysm in the common iliac artery; steroid therapy was initiated in this case. Conclusion: Thus, we believe that endovascular repair for IAAAs is a safe and useful option. However, careful follow-up is essential as the long-term results for this treatment and the mechanism of abdominal wall inflammation remain unknown.

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Without surgical treatment, the life expectancy of patients with Marfan’s syndrome is reduced by the associated cardiovascular lesions. In this study, we reviewed our experiences of the patients with Marfan’s syndrome who required multiple surgical procedures to identify the optimal treatment for these patients. Twenty-two patients with Marfan’s syndrome were operated on at our division of cardiovascular surgery. Among them, 9 patients (41.0%) underwent multiple surgical procedures. There was a mean age of 45.4±12.3 years at initial surgery. The causes of additional procedures were new dissection in 7, progression of aortic valve regurgitation (AR) in 2, coronary false aneurysm in 1, progression of annulo aortic ectasia + AR + mitral valve regurgitation + new dissection in 1, enlargement of residual thoracoabdominal aortic aneurysm in 1. Among them, 2 patients were operated on multiple additional procedures (three to four times), and were finally total aortic replacements. Additional procedures of the remaining 7 patients were total arch or hemiarch replacement + Bentall’s procedures in 2, Bentall’s procedures in 2, aortic valve replacement in 1, descending aortic replacement in 1, total arch replacement in 1. There was one early death (11.1%) due to graft infection. In 9 patients, both ascending and descending aorta were replacement. Among them, 5 patients ultimately underwent total arch replacement. The observed 10- year survival rate was 64.3% and freedom from reoperation was 37.5%. In conclusion, total arch replacement with an elephant trunk at the initial operation should be performed in order to minimize the future risk of vascular events and to eliminate the need for extensive replacement in a reoperation. Although a strategy of this procedure which is associated with a high level of risk, we believe that these extensive procedures will be decreased in a reoperation. It is anticipated that further improvement in freedom from reoperation of patients with Marfan’s syndrome will be observed in late results.

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Objective: This study was conducted to determine whether to perform endovascular intervention or bypass surgery as a treatment option for critical limb ischemia (CLI) with lesions in the popliteal artery or below. Subjects and Methods: A total of 150 patients (164 limbs) with CLI underwent endovascular intervention or bypass surgery for lesions in the popliteal artery or below at our department between May 1995 and June 2011. Therapeutic outcomes were examined by surgical technique. An indication for endovascular intervention was established with the combination of 1) poor general condition, and 2) a stenotic or occlusive lesion ≤ 5 cm. Results: The bypass group (group B) comprised 119 patients (99 males, 20 females) with 131 affected limbs at 46 to 89 years of age (mean: 70 years). The endovascular intervention group (group E) comprised 31 patients (25 males, 6 females) with 33 affected limbs at 47 to 89 years of age (mean: 72 years). There was no significant difference in patient demography between the two groups. Regarding preoperative complications, hypertension was observed in 54% and 61% of the subjects in groups B and E, respectively, diabetes in 36% and 55%, renal dysfunction in 29% and 58%, ischemic heart disease in 27% and 32%, and cerebrovascular disorder in 18% and 23%; renal dysfunction accounted for a significantly higher percentage in group E. As for early postoperative complications, subjects in group B experienced wound infections (6 patients), hemorrhage (2), thrombosis (2), pneumonia (1), and another complication (1), and those in group E experienced wound infections (1) and another complication (1). The hospital mortality rate was 0.8% (1 patient) for group B and 0% for group E. The 3-year cumulative primary patency rate was 72% for group B and 54% for group E; the rate was significantly higher for group B. The 3-year secondary patency rate was 82% for group B and 60% for group E. The 3-year limb salvage rate was 86% for group B and 82% for group E; there was no significant difference between the two groups. The 5-year survival rate was 57% for group B and 42% for group E; the survival rate was significantly lower for group E. Conclusion: For the study population of CLI patients with lesions in the popliteal artery or below, the patency rate was higher for the bypass group than for the endovascular intervention group, whereas there was no difference in the limb salvage rate. Based on the findings in prognosis for survival, the indication for endovascular intervention at our department is believed to be appropriate.

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Objectives: The aim of this study is to show the advantages and disadvantages of InvisiGrip vein stripper, new device for stripping of great saphenous vein comparing with conventional used stripping wire. Method: From June 2009 to March 2012, 51 patients with 68 limbs underwent great saphenous vein stripping by InvisiGrip vein stripper (group I). Duration of operation, bleeding amount during operation, subcutaneous hemorrhage and limb pain at 6 days after surgery was compared with those of 38 patients with 50 limbs from April 2007 to May 2009 (group C). Results: Duration of operation per limb of group I was significantly shorter than that of group C (76.8 ± 28.0 minutes vs. 42.3 ± 15.8 minutes, p<0.0001). Bleeding amount during operation of group I was not significantly different from that of group C (9.3 ± 13.9 ml vs 11.2 ± 17.1 ml). Subcutaneous hemorrhage was seen on 47 limbs (69.1%) of group I and 25 limbs (50.0%) of group C. On the contrary, limb pain was seen on 12 limbs (17.6%) of group I and 24 limbs (48.0%) of group C. Success rate of great saphenous vein stripping by InvisiGrip vein stripper was 93.2%. Conclusion: InvisiGrip vein stripper, as a safe and smart device for stripping of great saphnous vein by only one and small incision, may be the new alternative for operation of patients with varicose veins.

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Celiac artery aneurysm (CAA) is rare in the visceral artery aneurysms. We report a case of isolated CAA successfully treated with aneurysm repair and concomitant bypass grafting. A 68-year-old man was admitted to our department due to loss of appetite. The patient had no abdominal oppression nor pain. Computer tomography revealed a large saccular isolated CAA (40 mm). Both the gastroduodenal artery and the common hepatic artery were not sufficiently recognized by selective visceral arterial angiography, therefore the vein bypass to the common hepatic artery was performed. The postoperative course was uneventful, and the patient was discharged on the 24th postoperative day.

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Upper-extremity arterial aneurysms are uncommom lesions, and are most commonly pseudoaneurysm. Most pseudoaneurysm are associated with trauma. We report a case of nontraumatic pseudoaneurysm of brachial artery, which were treated successfully with excision of the aneurysm, and reconstruction. Case: A 46-year-old male presented with a painless mass in his right upper arm. Arterial duplex imaging demonstrated 40 mm diameter mass arising from the brachial artery. The excision of the aneurysm with reconstruction was performed, and postoperatively, he had no ischemic complications. The operative resection of pseudoaneurysm of upper extremity should be performed, and revascularization can be performed selectively.

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We report a case of peroneal artery aneurysm complicated with Marfan syndrome. A 39-year-old woman had undergone whole aorta replacement in 5 consecutive operations over 7 years. She felt a pulsating mass in the left inner calf of her leg and was admitted to our hospital. Computed tomography demonstrated peroneal artery aneurysm with a maximum transverse diameter of 33 mm. Aneurysmorrhaphy and surgical ligation via a medial approach was performed. Pathological results showed Marfan syndrome. The patient made good progress following surgery without any complications. Peroneal artery aneurysm is very rare. In this case, however, follow up is important because aneurysm may have been progressed in another site.

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A computed tomography examination of a 71-year-old female with chest pain showed acute type A dissection that we treated by total arch replacement. Thereafter, levels of liver enzymes and CPK remarkably increased and intraperitoneal vessel obstruction was suspected. Transesophageal echocardiography (TEE) revealed a celiac artery obstruction that required an emergency right external iliac artery-common hepatic artery bypass. Levels of liver enzymes and CPK sharply decreased thereafter and the patient was discharged without complications. TEE detected the obstruction of an intraperitoneal vessel.

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Visceral artery reconstruction and extended endovascular aortic repair (EVAR) for thoraco-abdominal aortic aneurysm (TAAA) has been reported as less invasive therapy for TAAA. Perigraft seroma after this procedure is rare; however open repair for this complication is difficult. We repaired perigraft seroma by endovascular procedure with a handmade covered stent successfully. A 74-year-old female underwent ascending, arch and descending aortic aneurysmectomy at another institution in 2007. She developed pseudoaneurysm at the distal anastomosis and was referred to our hospital in 2011. She also had thoracoabdominal aneurysm with maximal diameter of 47 mm. Because of the previous thoracic surgery, a hybrid procedure was selected instead of open repair. Under general anesthesia, the terminal aorta, bilateral renal arteries (RAs), a superior mesenteric artery (SMA) and a celiac artery (CA) were exposed. Bypass graft between the terminal aorta and the SMA was constructed with a 12-mm Hemashield graft (MAQUET Cardiovascular LLC, NJ). Blood flow from the Hemashield graft to RAs and CA were constructed with polytetrafluoroethylene (PTFE) graft (W. L. Gore, Flagstaff, AZ). TAG stent grafts (W. L. Gore, Flagstaff, AZ) were deployed to seal the pseudoaneurysm and thoracoabdominal aortic aneurysm. Postoperative course was uneventful. However, three months after the procedure, she developed a perigraft seroma and it was drained by re-laparotomy. Three months after the second laparotomy, the seroma re-expanded to 52 mm diameter around the PTFE graft anastomosed to right renal artery. The seroma compressed the 3rd portion of duodenum and the Hemashield graft. Exchange the grafts responsible for the seroma would be very difficult because of previous operative findings, therefore endovascular treatment was planned. Prior to the procedure, unmounted Express^TM vascular LD stent (7 × 37 mm, Boston Scientific Corp., Natick, MA) was covered with great saphenous vein (GSV) and they were fixed with 4 of 6–0 prolene interrupted sutures. The covered stent remounted an Wanda^TM balloon catheter (5 × 40 mm, Boston Scientific Corp., Natick, MA). To prevent the covered stent slip drop from the balloon catheter during delivery, both ends of the balloon were slightly dilated and the covered stent was attached to the balloon firmly. A KTI sheath (18 F × 65 cm, Cook Medical Inc., Bloomington, Indiana) was used because of the enough length to reach the PTFE graft from common femoral artery, and the silicone pinch valve to minimalize blood loss. Under general anesthesia, covered stent was deployed in the PTFE graft to right RA. The perigraft seroma shrunk rapidly and the compression on both duodenum and Hemashield graft disappeared. Oral intake could be started 4 weeks after the procedure and she became well and discharged. The endovascular treatment seemed to be feasible and effective for perigraft seroma in high risk patients.

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This report describes a 61-year-old man with the spinal cord symptom and intermittent claudication. Computed tomography (CT) revealed aortic coarctation with development of many collateral arteries caused an anterior spinal artery steal syndrome. Surgical repair was performed by extra-anatomic bypass. Furthermore, it did not process the collateral arteries with the danger. The postoperative CT revealed that the retrograde bloodstream from spinal cord wasdecreases and the aneurysms of the collateral vessels wave shrinked. Intermittent claudication was completely disappeared, but the spinal cord symptom of the upper extremitieswas still remained.

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We present a rare surgical case of chronic contained rupture of an infected iliac aneurysm with pyogenic spondylitis. A 68-year-old man was referred to our hospital because of fever, lumbago and pain at rest in both lower extremities. Contrast-enhanced CT and MRI showed aneurysm formation in the common iliac artery on both sides and destruction of the L4/5, L5/S1 intervertebral disks and L4, 5 vertebral bodies. Aortography showed a lobulated aneurysm. A diagnosis of infected iliac aneurysm and pyogenic spondylitis was made. After establishment of an axillo-bifemoral bypass, a laparotomy was performed. The posterior wall of the right iliac aneurysm was not detected and an organized retroperitoneal hematoma was noted. The aorta was occluded proximal and distal to the aneurysm. Debridement of the eroded bony tissue was performed. Culture of the hematoma fluid yielded growth of Pseudomonas aeruginosa.

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We report a case of an aortic injury during a lumbar disc surgery. A 75-year-old female with lumbar spinal canal stenosis was operated with L2–5 stabilisation procedure in prone position. During L3–4 discectomy by rongeur, her blood pressure dropped from 80 to 30 mmHg, soon followed by bleeding from the disc space. The bleeding was stopped in a few minutes. After the blood pressure was recovered and stabilized by rapid infusion of fluids and blood transfusion, the operation was finished. Four hours after the surgery, her blood pressure suddenly dropped again and an immediate computed tomography scan revealed a large retroperitoneal haematoma, so an urgent laparotomy was performed. A laceration on the posterior aspect of the terminal aorta was revealed and repaired. After the surgery, her clinical course was uneventful.

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A 61-year-old man underwent endovascular aneurysm repair(EVAR) for abdominal aortic aneurysm with maximum diameter of 88 mm.Type II endoleak from lumbar artery without no significant aneurysmal enlargement appeared at 6 month after the procedure. However, redilatation of aneurysm with persistent type II endoleak was observed in the next 6 months. Open conversion was successfully performed with infrarenal aortic clamping and preservation of the distal part of the endograft. In Japan, there have been a few case-reports of open conversion after EVAR with persistent type II endoleak. Because large aneurysmal diameter before EVAR is one the risk factors for the reoperation, open surgery is preferable for good risk patients with significantly large aneurysm.

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This case pertains to a 64-year-old male. Thoracic aorta arch vessel bypass surgery and surgery to insert a stent graft into the descending aorta were performed on the distal arch aortic aneurysm, and the patient was hospitalized in the 7th year for therapeutic purposes, so as to expand the distal aortic arch aneurysm. The aortic aneurysm of the distal arch had expanded to a diameter of 76 mm, and the stent graft that has been indwelling in the descending aorta had become exceedingly crooked and had also migrated inside the expanded aortic aneurysm. A comparison was made with the computed tomography (CT) from after the last surgery, and it is believed that the crimping of the distal side of the stent-graft came off due to the expansion of the descending aorta, and the stent thus became crooked inside the expanded aneurysm. We selected re-operation as a treatment for this case, total arch replacement, and the crooked stent-graft was removed with aortic aneurysm. An open stent graft from a median sternotomy for distal arch aortic aneurysm, is a method that is minimally invasive and effective. The results after surgery are good, and the reduction and/or disappearance of the aneurysm can be expected. However, there is a report that re-operations required as a result of endoleaks due to the expansion of an aneurysm. In this case also, it is inferred that this situation occurred because endoleak developed after indwelling, and the stent-graft was therefore thrust up due to the expansion of the aneurysm. For follow-up observations of stent-grafts after indwelling, it is therefore considered necessary to strictly track the presence of endoleaks using enhanced CT, rather than just using plain CT to track the diameter of the aortic aneurysm.

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We reported three cases of endovascular aneurysm repair (EVAR) for ruptured aortic aneurysm with severe complications preoperatively. Stent-grafts were successfully inserted in ruptured aneurysms under local anesthesia in all cases. EVAR can be a less invasive and safe treatment for ruptured aortic aneurysm with severe complications. Further examination make it possible to treat more patients with ruptured aortic aneurysm.

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We report a rare case of contained rupture of abdominal aorta which was not dilated. The patient was successfully treated by replacement of ruptured aorta with a straight graft. A 64-year-old man with previous history of coronary artery disease and lung cancer was referred to our department for rapidly progressed abdominal aortic dilatation. Contrast computed tomography (CT) of the abdomen showed dilatation of infrarenal abdominal aorta, suggesting a pseudoaneurysm associated with possible contained rupture of the aorta. These findings were not seen in the CT performed two months prior to the admission. Patient underwent urgent repair of the aortic aneurysm. Intraoperative findings included severe adhesion around the abdominal aorta and a punched-out defect in the posterior wall of the incised aneurysm. Therefore, we diagnosed chronic contained rupture of abdominal aorta. Subsequently, the aneurysm was replaced with a straight graft. Postoperative course was unremarkable and the patient has been doing well one year after the operation.

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A 63-year-old man transferred to our hospital because of hemodiarrhea with anemia and low blood pressure. He had a history of two surgeries. One was graft replacement of the abdominal aorta, and another was take-down of aortic graft because of graft infection. The infection caused graft-enteric fistula, so duodenojejunostomy, graft removal, and axillo-bifemoral bypass was performed at the second operation. Computed tomography after emergent administration showed adhesion of aortic blind end and transvers colon, and contrast leakage from aorta to colon. Coronoscopy showed penetrated suture and bleeding. We performed debridement, re-closure of the arotic blind end and colorectomy. Aortic blind end was packed with thrombosis and the aortic wall was defective. The aortic blind end was re-closed in two layers of 4-0 continuous suture with bovine pericardium strip. The colon was reconstructed by end-to-end anastomosis.

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