Objectives: In this article, we compared various perioperative data in patients who underwent replacement of abdominal aorta using with 4 types of impregnated woven vascular prostheses. Methods: From January 2002 to March 2012, 112 consecutive patients underwent replacement of abdominal aorta using with Intergard^® (56 cases), UBE SHIELD^® (13 cases), Gelweave^® (23 cases), and J Graft SHIELD NEO^® (J Graft; 20 cases) for abdominal aortic aneurysm. We retrospectively compared various perioperative data statistically among the four groups. Results: There were no significant differences among four groups in terms of preoperative condition, surgical procedure, mortality, and morbidity. There were the transient increased body temperature, WBC count, and C-reactivew protein (CRP) value reaching their peak within 2 days after operation. The body temperature and CRP value in J Graft were gone up again at about 7 to 10 days after operation, although these values were normalized within post operative day 7 in other grafts. In addition, the body temperature and CRP values in J Graft were significantly higher than those in other grafts. Conclusion: We found significant differences among the four groups in post operative inflammatory responses such as post operative body temperature or CRP value. However, there were no reoperation due to bleeding or any other inflammatory complication. We have to collect more data to identify whether the differences we identified in this study is meaningful or not.

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Objectives: Popliteal artery aneurysm (PAA) is the most common peripheral artery aneurysm. PAA has low mortality and high amputation rate in the patient. We analyzed the medical records of PAAs experienced at our departments to clarify operative strategy. Methods: The medical records of PAAs were retrospectively reviewed in Yamanashi University Hospital (1992–2011) and Tokyo Medical University Hachioji Medical Center (2005–2011). Results: PAAs were diagnosed in 29 legs in 21 patients (male 17, female 4, mean 73.6 years). Average size of PAAs was 33.9 mm (13–70). Twenty three PAAs (79.3%) were treated surgically (bypass 20, direct anastmosis 1, below-knee amputation 2). Average follow-up time after operation was 1364 days. Saphenous vein grafts (SVGs) in 10 legs and prothetic grafts in 10 legs were used in bypass surgery. The cumulative estimated 5-year patency of all grafts was 71.8%. Emergency operations were performed in 12 legs with symptomatic PAAs (bypass 11). The amputations were performed in 2 patients with small PAAs (15, 30 mm). The 5-year patency of elective and emergency operations were 100% and 44.3% (p=0.03). The 5-year patency of medial approach with SVG, with prosthetic graft, and posterior approach with prosthetic graft were 88.9%, 45.7%, and 100%, respectively. One patient in the medial approach group needed re-operation for re-expanded PAA from back flow. The 5-year patency of using SVG, prosthetic graft (≥8 mm), prosthetic graft (<8 mm) were 87.5%, 100%, and 31.3%, respectively. Conclusions: Our data demonstrated that the elective surgical treatment should be performed in patients of asymptomatic PAA. There is no difference between both approaches in the patency. The posterior approach might be more effective to avoid re-operation. The patency of prosthetic graft (≥8 mm) would be as good as SVG in surgical bypass of PAA.

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The patient was a 51-year-old woman with systemic lupus erythematosus and renal failure undergoing hemodialysis. She developed gangrene of the left leg and endovascular therapy to the anterior tibial artery and peroneal artery had been performed at a different hospital. However, the leg did not cured. It was suggested that she undergo below-knee amputation of the left leg. She hoped that she could be treated at a hospital near her home, so she visited our hospital. Preoperative angiogram showed that the anterior tibial artery was observed to be patent but the area of posterior tibial artery flow was very limited. The value of skin perfusion pressure was low in the plantar region. Left below-knee popliteal-posterior tibial artery bypass with reversed autovein graft and amputation of left metatarsal bones were performed. After the surgery, there was extensive formation of granulation tissue at the edge of the amputation area. To prevent the occlusion of the graft, we administered heparin by drip infusion, but the graft was occluded on the 7th postoperative day. We performed angiography on the 14th postoperative day, and found that the graft was occluded. We therefore used a multidisciplinary approach; endovascular therapy at the anterior tibial artery, vacuum-assisted closure therapy, and split thickness skin grafting, and we were able to avoid major amputation.

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Extracranial internal carotid artery aneurysm (ECICA) is uncommon, but represents a challenging treatment strategy. We experienced a large size of ECICA (7 cm) concomitant with a high-grade of internal carotid artery (ICA) tortuosity. A 71-year-old female presented with discomfort of the throat. She had subarachronoidal hemorrhage at the age of 68, but made a full recovery of daily activities, after clipping of the ipsilateral intracranial ICA aneurysm and ventriculo-peritoneal shunt. Contrasted computer tomography revealed the ECICA on the tortuous ICA. After resection of aneurysm, the curved ICA was stretched distally. The distal stump was directly anastomosed to the proximal end of ICA. Ischemic complications or cranial nerve injury was not recognized postoperatively. Aneurysmectomy with arterial reconstruction has been an ideal treatment for such ECICA. In similar cases, concerning tortuosity of the ICA and the lack in long-term results, endovascular methods, including (covered) stent implantation or coil embolization, should be considered secondarily.

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Inferior gluteal artery aneurysms are rare, and most reported cases involve posttraumatic symptomatic pseudoaneurysms that present with varied symptoms. We report a case of an inferior gluteal artery aneurysm without any history of trauma or symptoms, but was confirmed based on diagnostic imaging findings as a true aneurysm. A 26-mm aneurysm between the left gluteal muscles was detected by chance by CT in a 60-year-old man 5 years prior; however, he was asymptomatic and therefore underwent observational follow-up. The patient underwent treatment because of the enlargement of the aneurysm to 39 mm, which was 1.5 times its prior diameter, on CT examination for hepatocellular carcinoma. Percutaneous transarterial coil embolization was performed as our less-invasive treatment of choice considering that the patient had cancer. Postoperative course was not eventful, and 3 months after treatment, no blood flow was detected on the aneurysm. To our knowledge, this is the first case in which the patient was followed up for a gluteal artery aneurysm before treatment initiation.

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We reported a rare case of surgical treatment of recurrent femoral artery aneurysm with arteriomegaly. The patient was a 45-year-old man who was suffering from swelling of his left leg, and intermittent claudication. He had a past surgical history by forming the arteriovenous fistula and pseudoaneurysm on the left leg eleven years ago. Preoperative CT angiography revealed arteriomegaly from the left common iliac artery to the superficial femoral artery with occluded common and superficial artery aneurysms. We performed left iliac artery-popliteal artery bypass, exclusion of superficial artery aneurysm. The postoperative course was uneventful and postoperative CT angiography showed good bypass flow and thrombotic occlusion of residual superficial femoral artery.

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We report the endovascular repair of aortocaval fistula (ACF) with congestive heart failure (CHF) and hypotension caused by ruptured abdominal aortic aneurysm (AAA). An 83-year-old woman admitted our hospital for acute CHF and severe lumbago. Computed tomography showed an AAA measuring 7.8 cm with an ACF. We performed endovascular repair on the same day. The postoperative course was good and she discharged the hospital satisfactory. The report which endovascular repair of ACF associated ruptured AAA is rare. So we describe it with additional literatures.

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Ruptured abdominal aortic aneurysm (RAAA) is a condition with a high fatality rate, which requires emergency surgery. In cases where circulatory dynamics fail, the only way to ensure survival is to cross-clamp the aorta swiftly at the proximal aorta of the ruptured site. At our hospital, we have experienced three RAAA cases transferred from a remote island under cross-clamping the aorta. One case was a 68-year-old man. He was diagnosed with RAAA at a previous hospital and experienced acrotism while waiting to be transferred, at which point emergency cross-clamping of the aorta was administered and he was transported under emergency conditions. He survived as a result of emergency surgery. The second was a 58-year-old man. Similar to the first case, he was diagnosed with RAAA, and his symptoms had deteriorated suddenly while waiting for transfer, and therefore emergency cross-clamping of the aorta was performed and he was transported here under emergency conditions. He survived as a result of emergency surgery. The third case was a 70-year-old man. Subsequent to being diagnosed as RAAA, cross-clamping of the aorta was performed due to sudden deterioration of his symptoms, but the patient was unable to recover from a state of shock. When he was transferred to this hospital, his blood pressure was unmeasurable, and despite being subjected to further cross-clamping and continued cardio-pulmonary resuscitation in the operating theater, he did not survive. Our experiences suggest that in cases of RAAA in which shock is present, implementing aortic cross-clamping below the renal artery bifurcation before transferring the patient to a facility that offers surgery is effective.

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A 66-year-old man underwent an urgent operation of the ascending and arch replacement with the branched graft for early thrombosed Stanford type A acute aortic dissection. The regional saturation of oxygen (rSO₂) in the right cerebrum suddenly fell down under normothermia because of the redissecton of the innominate artery after discontinuing the extracorporeal circulation. The branched graft was immediately connected through a plastic connector to the graft anastomosed to the right axillary artery as the aortic perfusion. Then, the rSO₂ of the right cerebrum returned to the baseline value, and the patient recovered without any neurological deficits after all. The intraoperative malperfusion caused by the redissection is unpredictable, but one of lethal complications, especially in case of critical cerebral ischemia. The intraoperative measurement of rSO₂ in the cerebrum is very useful tool for early detection and procedures for preventing irreversible brain damage.

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After vascular procedures, lymphatic complications at groin sometimes may lead to devastating circumstance, such as prosthetic graft infection. Here, we report a case of early graft infection subsequent to lymphorrhea managed with vacuum-assisted closure (VAC) therapy and sartorius muscle flap coverage. A 78-year-old man had surgical repair of an abdominal aortic aneurysm via laparotomy and bilateral oblique femoral incisions. Seven days after the operation, he presented serous lymphatic fluid from right femoral incision followed by prosthetic graft infection with high fever. After initial wound debridement, the wound was treated by VAC therapy. His lymph leak ceased after 7 days of VAC therapy. Although the wound was clean and clear of infection, the dead space around the exposed prosthetic graft was too large. So we performed sartorius muscle flap coverage in order to eliminate the dead space and avoid prolonged hospital stays. The wound was healed completely and the lymph leak was not recurred. On postoperative day 58, he discharged from hospital in good condition. We recommend consideration of VAC therapy and sartorius muscle coverage for prosthetic graft infection complicated with groin lymphorrhea as an alternative to many modes of conventional treatment.

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We report a case of limb occlusion after endovascular repair of abdominal aortic aneurysm (EVAR) with Endurant^® AAA endovascular graft. A 64-year-old man underwent EVAR for abdominal aortic aneurysm (AAA) 54 mm in diameter demonstrated by computed tomography (CT). He was discharged 8 days after surgery without symptom. 20 days after the surgery, he got a cramp in his left leg suddenly, and he became aware of the intermittent claudication. However, he left the symptom. 28 days after the surgery, he consulted internal medicine and CT was performed because his left leg had a symptom of ischemia. The CT revealed limb occlusion of the left leg of endovascular graft. The occluded range was the left superficial femoral artery from the origin of the left leg. He was treated with right external iliac to left common femoral bypass (ePTFE graft 8 mm) after thrombectomy. The condition of his left leg improved after surgery.

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Lumbar sympathectomy (LS) is helpful to treat the ulceration and gangrene associated with Buerger disease. To evaluate the outcome of the treatment, the ankle-brachial pressure index (ABI), transcutaneous oxygen tension (tcPO₂) and thermography are widely available. We herein report a case in which the outcomes of LS were evaluated with a new method, indocyanine green fluorescence imaging (ICG-FI). The case was a 38-year-old male with Buerger disease. Because his ulceration of the right fifth toe was resistant to conservative treatment, we performed LS. After the procedure, the ABI and tcPO₂ were improved; however, his skin temperature, as measured by thermography, did not remarkably change. By ICG-FI, it was noted that the maximum intensity and the time to maximum intensity were improved in the dorsum and the distal region of the fifth metatarsal bone. The major advantage of ICG-FI is its ability to measure the regional perfusion without direct contact with the skin. ICG-FI may offer another optional test to evaluate the tissue perfusion.

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Endovascular aneurysm repair (EVAR) has become widely adopted as the primary treatment modality for abdominal aortic aneurysm(AAA) in the elective settings. Recently, it has been reported that EVAR for ruptured AAA (rAAA) is associated with acceptable mortality rates. In EVAR for rAAA, the persistency of endoleak might be countinous intra-abdominal bleeding, and unfavorable for success treatment of rAAA. A 56-year-old man was referred to our hospital for suffering from left abdominal pain with shock vital status. On arrival, his blood pressure was not be measurable. After endotracheal intubation in the emergency room, contrast enhanced computed tomography (CT) was performed, which revealed ruptured AAA with huge retroperitoneal hematoma. Length of the proxymal neck was 20 mm and EVAR appeared feasible. We decided to repair the rAAA by EVAR emergently. After deploying the stentgrafts, type II endoleak (EL) was detected. No additional procedure was necessary after the surgery, because his circulatory status was stable without much blood transufusion. Postoperative CT demonstrated that the size of AAA was remarkably decreased, although the type II EL was still exist, and the retroperitoneal hematoma were vanished 6 months after the sugery. Furthermore, the type II EL was reduced 12 months after the surgery without enlarging the aneurysm size. We reported a case of rAAA successfully treated by emergent EVAR. Although the type II EL persisted after EVAR, the patient has overcome the critical preoperative condition and got the uneventful postoperative course without any additional intervention. It is important to keep attention to endoleak and deliberate the necessity of additional intervention for susessful EVAR for rAAA.

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A 29-year-old man with Behçet disease was admitted to our hospital for right gastrocnemius muscle pain. Computed tomography demonstrated pseudoaneurysm of the right common femoral artery. After hospitalization, he suffered from right limb ischemia due to thromboembolism. Treatment of pseudoaneurysm and reconstruction of right common femoral artery were performed using Dacron grafts. The patient has been well and shown no evidence of pseudoaneurysm at the anastomosis sites for two years since the operation.

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A rare case of acute and blunt traumatic aortic dissection that extended through an atherosclerotic abdominal aortic aneurysm (AAA) to the left external iliac artery will be presented. A 67-year-old man sustained a traffic injury and was transported to the emergency department of our hospital. Angiographic computed tomography (CT) of the thoracoabdomen showed Stanford type B aortic dissection and AAA of maximum 52 mm diameter. Aortic dissection extended through AAA to the left external iliac artery. At 8th day after injury the patient suffered from an ischemia of right lower extremity. Angiographic CT showed compression of the true lumen due to the dilated false lumen with no aneurysmal dilatation. Urgent operation of aneurysmectomy with fenestration and bifurcated artificial grafting was performed. The pathological specimen of the AAA demonstrated acute change of dissection. At follow-up 4 years postoperative, no expanding false lumen was noted.

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Vascular access complications are serious problems in chronic hemodialysis patients. We report a case of subclavian vein occlusion in vascular access limb that was treated with subclavian-subclavian vein crossover bypass. Right upper limb swelling appeared in 75-year-old man with chronic hemodialysis. The angiography showed subclavian vein occlusion. Though endovascular therapy was tried, the guide wire could not be passed through the subclavian vein occlusion. Then subclavian-subclavian vein crossover bypass was carried out. The procedure resulted in rapid resolution of the associated limb swelling.

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Polycystic kidney disease (PKD) is primarily associated with renal failure and hypertension, but it can also cause systemic diseases such as cysts of other organs, cerebral arterial aneurysms, aortic aneurysms and aortic dissection. We describe a 53-year-old woman who was admitted to our hospital with cardiac tamponade, acute respiratory failure, hepatic failure and renal failure. Computed tomography (CT) findings indicated a diagnosis of PKD and acute type A aortic dissection. She was treated medically for three months and then the ascending aorta and total aortic arch were surgically replaced with an elephant trunk. Postoperative dialysis was required. The blood pressure of patients with PKD should be strictly controlled and the relationship between PKD and aortic dissection must be understood as mortality and morbidity rates can be high.

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A case of exacerbation of lower ischemic symptom after percutaneous catheter intervention for peripheral artery disease using arteriotomy closure device (Angioseal^®). Seventy-six year-old man referred our clinic due to acute exacerbated claudication after percutaneous angioplasty. Angiography revealed stenosis at common femoral artery puncture site. This stenosis was due to anchor of arteriotomy closure device in vascular lumen. Operative findings showed excentric atherosclerosis in common femoral artery and stenotic lumen was filled with soft lucid plaque originally from the device. A thrombo–endoarterectomy and patch closure with polytetrafluoroethylene patch was performed, resulting remission of claudication.

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