Objectives: The treatment outcome of ruptured abdominal aortic aneurysm (RAAA) remains poor. On the other hand, there is a serious doctor shortage in the provinces in Japan. The objective of this study was to analyze RAAA cases in Ibaraki Prefectural Central Hospital (IPCH), which is a local base provincial hospital, and to propose a strategy to improve the results of RAAA treatment. Methods: A retrospective analysis of 15 patients who underwent operation for RAAA at IPCH between July 2007 and September 2012 was undertaken. These patients were divided into two groups according to whether the referring physician had diagnosed RAAA (Group D) or not (Group N). Non-operative cases diagnosed as RAAA during the same period were also identified from the IPCH medical records. Results: Five patients (4 male and 1 female) aged 70.1±12.4 years in Group D and 10 patients (9 male and 1 female) aged 77.1±10.0 years in Group N were investigated. Group D had a significantly higher prevalence of hypotension (systolic blood pressure <100 mmHg) on arrival than did Group N. There was no significant difference in operative duration and blood loss between the two groups. In-hospital mortality was 0% and 30% for Group D and Group N, respectively. Hospital stay after operation tended to be longer in Group N than in Group D. Ten patients with a diagnosis of RAAA did not undergo surgery at IPCH; one female and one male patient were transferred to other hospitals and successfully treated surgically, and the other eight patients (4 male and 4 female) died in IPCH. Non-operative cases were significantly older and tended to be female compared with operative cases. Overall mortality including non-operative cases was 44%. Conclusion: The surgical outcome for patients with a prehospital diagnosis was better than for those without. The proposed agenda for RAAA treatment in the provinces is improvement of diagnostic ability at first-line medical institutions, cooperation and transportation between first-line and local base hospitals, and a system for efficient use of limited medical resources at local base hospitals.

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Objective: Outcomes of open surgery (OS) and endovascular repair (EVAR) for abdominal aortic aneurysm were analyzed, after commercialized devices for EVAR has introduced. Patient and method: A total of 383 patients (OS: 244, EVAR: 139) were treated at Tenri hospital from January 2008 to April 2012. Results: Variation of yearly patient number was not seen among 4 years from 2008 to 2011. Patient number decreased in the OS and increased in the EVAR from 2008 to 2009, but no change has in both groups from 2010 to 2011. ASA classification was no significant change in both groups. Average of risk factors was 2.0±1.0 in OS group and 2.2±1.0 in EVAR group. Extra-indication factors in instruction for use (IFU) were no significant change between two groups. In hospital morbidity and mortality were 15% and 3% in OS group, and 13% and 0% in EVAR group. Conclusion: EVAR is useful in 1st choice treatment for abdominal aortic aneurysm. However, open repair has important role for unsuitable case in IFU and emergent case.

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A patient was 84-year-old female, presenting mild abdominal pain. Vital signs were normal; however, the enhanced computed tomography showed juxtarenal aortic aneurysm (JAA) measured 80 mm. Because the size was huge, and the patient had mild symptoms, emergency operation was performed. The endovascular treatment was attempted due to her age and some medical histories. The right renal artery was managed with snorkel technique, and the left renal artery with endowedge technique to achieve additional sealing zone and to maintain the distal perfusion. Complete angiography showed patent bilateral renal arteries without endoleaks or enhancement of aneurysm. Postoperative computed tomography showed the patent of stent graft, bilateral renal arteries, and there was no endoleaks. Endovascular aneurysm repair (EVAR) has gained widespread acceptance as the procedure for patients with elective infrarenal abdominal aortic aneurysms. However, the management of JAA with EVAR remains challenging. These techniques, including endowedge and snorkel, achieve additional proximal aortic seal, and may allow for safe and effective endovascular treatment of aneurysms with proximal short aortic necks.

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Isolated iliac artery aneurysms are rare, comprising only 7% of abdominal aortic aneurysms (AAAs). Open repair of isolated iliac aneurysms is technically challenging and associated with considerable morbidity and mortality, especially in the high risk patients. Recently, endovascular repair of isolated common iliac aneurysms has emerged as an alternative to open repair. We described a novel technique using back table manipulation of a commercially available stent graft to accommodate a challenging anatomical scenario. A 67-year-old male with a history of open low anterior resection for rectal cancer was referred to our hospital for the expanding right isolated common iliac aneurysm. The aneurysm was 37 mm in diameter adjacent to the internal iliac artery. The diameter of the proximal sealing zone was 17 mm, larger than that of the distal sealing zone, 14 mm. A reversed tapered device was needed. We described the off label use of the Gore Excluder contralateral leg endoprosthesis in a reversed configuration to accommodated this diameter mismatch. The procedure was minimally invasively completed without any complications and the aneurysm was totally excluded postoperatively without endoleaks and expansion.

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Mycotic visceral artery aneurysms are rare diseases. Once ruptured, the outcomes are fatal. We report the case of a 56-year-old man who presented with mycotic celiac artery aneurysm caused by methicillin-resistant Staphylococcus aureus infection of the catheter, which was placed for regional infusion therapy for severe acute pancreatitis. Because the presence of intense adhesion of the retroperitoneum due to pancreatitis made it difficult to perform a conventional graft replacement, we performed a thoracic endovascular aneurysm repair with a saphenous vein graft bypass to superior mesenteric artery (SMA). During the operation, the right common iliac artery and SMA were bypassed using a saphenous vein graft through a median laparotomy. After grafting the stent-graft was deployed covering the celiac axis and SMA ostium. He was discharged on the 50th post-operative day. He remains well without recurrence of the infection.

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Recently, nonanastomotic rupture of vascular grafts is hardly reported. We experienced a very rare case of giant nonanastomotic aortic pseudoaneurysm of Hemasield woven double velour graft, 1 year and 4 months after Bentall’s procedure and hemi-arch replacement. The patient was a 27-year-old male with Marfan’s syndrome who had funnel chest. The rupture site was found on the intact surface of Hemasield graft. Constant friction between a sternal wire and the graft was highly suspected as the cause of rupture. In such cases, to avoid a friction between the sternum and the graft, using a thick artificial pericardium covering the anterior mediastinum, or closing the sternum without metal wires should be considered, and periodical follow-up computed tomography is necessary for long-term.

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We report three elderly patients with deep vein thrombosis (DVT) who responded well to subcutaneous administration of fondaparinux as the initial treatment, along with a brief review of the relevant literature. All three patients were women, aged 89 years 11 months, 89 years 6 months, and 76 years old. After lower limb DVT complicated by pulmonary arterial embolism was diagnosed by computed tomography (CT), the patients were started on treatment with subcutaneous injections of fondaparinux. At the same time, oral warfarin treatment was also started. The fondaparinux treatment was discontinued when satisfactory increase of the prothrombin time-international normalized ratio was confirmed. Two patients also required a temporary inferior vena cava filter. The duration of fondaparinux treatment was 10 days, 8 days and 10 days in the three patients. CT performed 1 week after the start of treatment revealed resolution of the pulmonary embolism and lower limb DVT in all three patients, along with improvement of the lower limb symptoms. Moreover, there were no complications such as hemorrhage, and all of the patients were discharged from the hospital in good general condition. In general, urokinase infusion and warfarin are used for the treatment of DVT. However, in patients with a high risk of hemorrhage, such as elderly patients, and in those with relatively mild deep vein thrombosis, subcutaneous administration of fondaparinux also appears to be effective for obtaining improvement of the subjective symptoms and radiological resolution or reduction of the thrombosis, allowing early ambulation and prevention of other clinical complications specific to elderly patients.

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When a 76-year-old woman was taken to a hospital by ambulance, she had a fever, was feeling fatigued and in dyspnea. She has a previous history of old myocardial infarct, ischemic cardiomyopathy, mitral valve replacement, tricuspid annuloplasty, MAZE operation, severe pulmonary hypertension, chronic congestive cardiac failure, and congestive liver. She was also undergoing a treatment for miliary tuberculosis using domiciliary oxygen therapy. Her chronic cardiac failure got worse, and congestive liver and jaundice also got worse. Thoroughly examining her condition, we found that she had an approximately 6 cm saccular aneurysm in her left external iliac artery. From the fact that a previous CT examination a year before didn't detect any arterial aneurysm, we assumed her aneurysm was an infected external iliac artery aneurysm. She has been physically weakened and debilitated before the surgery. We first performed an extra-anatomic revascularization by bypassing the right external iliac artery to the left common femoral artery. And then, we performed a percutaneous arterial embolization with coils for the infected external iliac artery aneurysm. After the surgery, she recovered well and left the hospital. A year has passed now after the surgery, the left external iliac artery aneurysm remains occluded and no infection is seen. This surgery is one of the effective options for a patient who is physically weakened and debilitated with an infected iliac artery aneurysm.

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Acute abdominal aortic occlusion is a rare vascular emergency. We treated a patient whose life and limbs were saved by successful treatment with catheter-directed thrombolysis (C-DT). A 69-year-old man came to our emergency department with a sudden onset of loss of sensory and motor function in both legs. Neurogenic shock was suspected and he was referred to the Department of Vascular Surgery the next morning, where CT angiography findings revealed an occlusion in the terminal abdominal aorta. Since more than 12 hours had passed since the initial manifestation and the level of creatine phosphokinase (CPK) was high at 4667 IU/L, we considered the patient to be at high risk for development of postoperative myonephropathic metabolic syndrome (MNMS). C-DT therapy using a pulse spray technique restored blood flow in the bilateral lower extremities. Following treatment, CPK was elevated to 6656 IU/L and renal function deteriorated, which then resolved without development of MNMS. We considered that C-DT might act advantageously to alleviate reperfusion injury, as this treatment is known to have a low risk of vascular endothelial injury and reperfusion under low pressure.

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Aortic thrombosis without an atherosclerotic lesion is a rare disease that occasionally follows fatal embolism. We report the case of a 43-year-old man with acute myocardial infarction caused by right coronary artery ostial occlusion due to a large mobile thrombus in the ascending aorta. The patient was referred to our department with sudden chest pain during steroid replacement therapy after Hardy procedures. Angiography and contrast-enhanced computed tomography detected a large mass or flap in the ascending aorta. His coagulation tests were almost normal without D-dimer. We performed emergent surgery to remove a 5.6×1.8×0.8-cm thrombus from the right coronary cusp without an atherosclerotic lesion or calcification. Anticoagulant therapy with warfarin was subsequently initiated. No recurrent thrombosis has been observed for a year. Thus, early removal of a thrombus in the ascending aorta is considered a useful treatment strategy.

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Aortoduodenal syndrome is a rare entity and its main etiology is duodenal obstruction caused by compression of the third portion of the duodenum between the abdominal aortic aneurysm (AAA) and the abdominal wall or the superior mesenteric artery. The case is an 88-year-old woman who visited us with complaints of epigastric pain and vomiting. The infrarenal AAA (maximum diameter 6.7 cm) and obstruction at the third portion of the duodenum were found on the computed tomography (CT). These findings led us to the diagnosis of aortoduodenal syndrome. On admission, she was treated with gastric decompression, fluid administration and correction of electryolyte disturbance for 10 days. On hospital day 11, she underwent AAA repair with open surgery. She had uneventful postoperative course and was discharged on the 26th day after surgery. There was no obstruction of the third portion of the duodenum and the repaired AAA was shrinked on the CT at the 3 months after surgery.

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We report a 71-year-old man with a sudden onset severe back and abdominal pain who had a Stanford type B acute aortic dissection extending through a preexisting 78 mm abdominal aortic aneurysm that was diagnosed by computed tomography scan in a prior hospital. He was transferred to our hospital by an ambulance. There was no evidence of aortic rupture, but a continuous abdominal pain. Though the patient was diagnosed an impending rupture of an abdominal aortic aneurysm, he was strictly treated with antihypertensive medication waiting to stabilize intimal flap prior to a repair of the abdominal aortic aneurysm. Open fenestration and bifurcated graft replacement were performed at 10th day from the onset. Proximal side of the graft was anastomosed to both true and false lumina what was called double barrel anastomosis. It was thought to be an inflammatory aneurysm through the clinical course and the pathological findings. There were no postoperative complications. The patient was discharged with ambulatory state at 19th postoperative day.

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We report a case of rupture of pararenal abdominal aneurysm after endovascular abdominal aneurysm repair (EVAR), using the covered bi-renal stent and fenestrated Zenith stent graft. A 74-year-old man, had polycystic kidney disease, complained the sudden abdominal pain and shock in ambulance to our hospital. Computed tomography showed a type III endoleak between the covered stent inserted in right renal artery and main body of fenestrated stent graft, and aneurysm ruptured. The patient was treated by secondary endovascular stent grafting with obstruction for bilateral renal artery. After EVAR, the blood dialysis required. If the new appearance of type III endoleak is seen after EVAR, surgical treatment should be considered for the endoleak immediately.

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A 75-year-old man was referred because of back pain. Enhanced computed tomography showed bilateral iliac artery aneuryms and urine extravasation. After emergent percutaneous nephrostomy, elective endovascular repair (EVAR) for aneurysms was performed. After EVAR, hydronephrosis was gradually improved and finally the percutanous nephrostomy cathetel was extracted. Iliac artery aneurysm with urine extravasation is very rare and that strongly suggests inflammatory aneurysm. The patient was successfully treated by percutaneous nephrostomy followed by staged endovasclurar repair.

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We present a patient of a 68-year-old man with a thoracoabdominal aortic aneurysm, which make us difficult to have a diagnosis of inflammatory or infected. The rapid expansion of the aneurysm was detected on computed tomography despite steroid or antibiotic therapy. Severe adhesion was seen on the distal site of the aneurysm, but we successfully underwent graft replacement of thoracoabdominal aorta with reconstruction of visceral artery. His postoperative course was uneventful. Pathological findings showed not infected but inflammatory changes.

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This report presents a case of angioleiomyoma that originated from the short saphenous vein. A 40-year-old male presented with a tender subcutaneous nodule in the right calf. Ultrasonography demonstrated a localized varicose vein of the short saphenous vein; however, a histopathological examination of the excised tumor confirmed the diagnosis of angioleiomyoma. Angioleiomyoma is a relatively rare, benign, vascular soft tissue tumor originating from the tunica media of a vein. It tends to occur in the lower extremities and often causes localized pain. A definitive diagnosis is difficult without a histopathological examination. Therefore, angioleiomyoma should be considered in a patient presenting with a painful small tumor in a lower extremity.

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