Objectives: In the endovascular treatment of aortic aneurysm, type 2 endoleaks remain an issue. We created a hypothesis that type 2 endoleaks are associated with postoperative blood coagulation abnormalities. Intravascular coagulation and fibrinolysis are accelerated by the rapid progression of coagulation in the postoperative state after aortic aneurysm. We treated the patient via the chronic administration of oral tranexamic acid and assessed the efficacy of tranexamic acid in the suppression of fibrinolysis and type 2 endoleaks. Methods: Eighty-nine patients were included (51 EVAR and 38 TEVAR). Forty-eight patients were treated with tranexamic acid (Group T), and 41 patients were treated as controls (Group N). Patients took 750 mg oral tranexamic acid thrice daily as soon as possible after their operations. Plasma fibrinogen and Fibrinogen Degenerative Products (FDP) were measured during the perioperative period (POD 1, 2, 3, 5, 7 and 9), and type 2 endoleaks were assessed by using computed tomography at one week and six months after the operation. Results: During the perioperative period, the plasma fibrinogen levels of group T were significantly higher than those of group N (559.5±172.7 vs. 444.2±151.9 mg/dl: p = 0.013). FDP levels in group T were significantly lower than those in group N (18.3±17.1 vs. 43.8±36.6 μg/ml: p = 0.004). One week after the operation, type 2 endoleaks were significantly less prevalent in group T than in group N (6.3 vs. 22.0%: p = 0.031), and the number of type 2 endoleak patients in group T was significantly reduced by postoperative month 6 (0.0 vs. 27.2%: p = 0.005). There were only two patients in group N who experienced Major Adverse Cardiovascular and Cerebrovascular Events (MACCE), which included one death and one unstable angina. Conclusions: This study showed that tranexamic acid may suppress the acceleration of fibrinolysis after endovascular treatment for aortic aneurysm and that this effect may contribute to the prevention and reduction of type 2 endoleaks.

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Objectives: Arterial reconstruction of the lower extremity with an in situ greater saphenous vein is an important method for limb salvage surgery. In this procedure, multiple skip incisions along the saphenous vein are usually necessary for side branch occlusion. This procedure is fraught with hazards for wound complications and cosmetic problems. In this study, we used endoscopic vein harvest equipment to minimize these complications. Methods: We performed femoral to infragenicular artery in situ bypass with an endoscopic-assisted technique. Only two small skin incisions for arterial access were needed. Through these incisions, an endoscopic vein harvest system was inserted subcutaneously along the saphenous vein to locate and seal all of its side branches. After completion of the proximal anastmosis, the valves were lysed through the distal end of the saphenous vein with a flexible valvulotomy cutter. Then distal anastmosis was completed. Results: From August 2008 through June 2012, five patients were operated on using this method. All the patients were male, with ages ranging from 44–72 years (62.8±11.4). In all cases, intermittent claudication disappeared after the operation. In one case, emergent thrombectomy was needed on the same day after the operation. There were no wound complications (infection, hematoma, cellulitis, pain, etc). In two cases, swelling of the lower extremity after reperfusion resulted in a long hospital stay. One in situ bypass was occluded three years after the operation with rich collateral pathways without ischemic symptoms. The other in situ bypasses have remained patent during follow-up periods ranging from 11–57 months. Conclusion: Endoscopically assisted in situ greater saphenous vein side branch occlusion provides safe and effective results without wound complications.

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It is widely accepted that primary management for uncomplicated acute type B dissection is medication. Consequently, emergency surgical treatment has been limited for complicated acute type B dissection, including aortic rupture or clinical organ malperfusion caused by aortic branch compromise. The optimal treatment for complicated acute aortic dissection, however, remains controversial. We treated 132 patients of type B aortic dissection for 25 years in our institution. Twenty-one patients (15.9%) required emergency operation for complication. Hospital mortality rate of emergency operation for complicated type B aortic dissection was 33.3%. Sixty-seven patients (59.8%) required operation during follow-up period. Overall operative mortality rate of operation at chronic stage was 6.0%. It is important to improve surgical outcomes for complicated acute type B aortic dissection. Thoracic endovascular aneurysm repair could be reducing the invasive damage, especially in acute rupture cases. Visceral ischemia is a rare but severe complication of an aortic dissection, unusually due to obliteration of visceral arteries by the intimal flap. We believe that rapid revascularization is the best way to treat visceral malperfusion syndrome.

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Objectives: To compare the clinical outcomes of total debranching (TD) vs partial debranching (PD) for hybrid aortic arch repair. Methods: From May 2008 to April 2013, 77 patients underwent hybrid aortic arch repair for a variety of aortic pathologies. Total debranching was performed in 24 patients and partial debranching in 53 patients. Staged thoracic endovascular aortic repair (TEVAR) was carried out in 9 patients (TD group) and 13 patients (PD group). The length of proximal neck was 39±17 mm in TD patients and 29±9 mm in PD patients (p<0.05). Results: The early mortality rate was 4% (1/24) in the TD group and 2% (1/53) in the PD group. Respiratory failure developed in 25% (6/24) of TD patients and 4% (2/53) of PD patients (p<0.01). As for debranching and simultaneous TEVAR, hospital stay averaged 33±29 days in the TD group and 16±10 days in the PD group (p<0.001). Within 7 days, 3 patients (13%) undergoing TD had endoleak, while 18 patients (34%) undergoing PD experienced endoleak. Three patients of the PD group underwent endovascular revisions for endoleak. No patients of the TD group required surgical reintervention. Actual 2-year survival of the TD and PD cohort was 69±10% and 84±6%, respectively. Event-free survival of the TD and PD group was 59±11% and 73±6%, respectively. Conclusion: Although TD technique is more invasive than PD technique, the former allows a better landing zone.

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This case had previously received endovascular treatment for peripheral arterial disease. However, the left lower limb ischemia had worsened and the toe was necrotic with severe pain. Preoperative computed tomography revealed that the left iliac stent was completely occluded, additionally left common femoral artery and superficial femoral artery and deep femoral artery were occluded. Further, the stent was placed in the right common femoral artery, which made it even more difficult to perform the additional treatment. We successfully treated the critical limb ischemia by extraanatomical bypass (from right femoral artery to left below the knee popliteal artery) with autogenous vein. And the right common femoral stent was removed and patch angioplasty with autogenous vein was performed before the bypass.

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A 58-year-old male with neurofibromatosis type 1 (NF 1) was transferred to our hospital in pre-shock condition with severe abdominal pain of sudden onset. A CT scan demonstrated a large retroperitoneal hematoma and active bleeding from the infrarenal abdominal aorta. Emergency open surgical repair was performed under diagnosis of aortic rupture. Intricate thick fibrous tissue around the aorta made aortic exposure confusing and time-consuming. Suture ligation to control bleeding from lumbar arteries was also found troublesome due to tissue fragility. Although the abdomen needed two staged closure because of large retroperitoneal hematoma and bowel edema, his subsequent postoperative course was uneventful. Pathological exam revealed that observed thick fibrous tissue was plexiform neurofibroma which is highly characteristic to NF 1. Rupture of large vessels in NF 1 patients is a very rare and challenging complication. According to published reports, the possibility of unusual fragility of vascular wall and/or easy bleeding of neurogenic tumors around the vessel should be taken into consideration when you make strategies for treatment.

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Here we report a 70-year-old man who underwent surgery for a dissecting thoracic aortic aneurysm and an infected left femoral artery aneurysm. The patient underwent ascending aortic replacement for type A acute aortic dissection 1 year earlier. He experienced unexpected chest pain and pyrexia. Additionally, a left inguinal reddish swelling, which had been previously diagnosed as a femoral artery aneurysm, had rapidly grown in size. A computed tomography scan revealed a new dissecting thoracic arch aortic aneurysm and a rapidly growing left femoral artery aneurysm; therefore, the patient was diagnosed with a dissecting thoracic aortic aneurysm and an infected left femoral artery aneurysm. During surgery, the left femoral artery aneurysm was excised prior to resternotomy. One lateral branch of a Y-graft was used for femoral artery reconstruction, and the other was used for inflow in cardio-pulmonary bypass; following this, total arch replacement was performed uneventfully. Excision of the infected aneurysm, usage of a rifampicin-soaked vascular prosthesis, and intravenous antibiotic administration for 4 weeks after surgery were effective in the treatment of the infected femoral artery aneurysm.

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A 43-year-old woman had intermittent claudication in the left leg one month prior to visiting the hospital. The ankle brachial index was lower than normal. Computed tomography showed an obstruction of the left external iliac artery. Intravascular ultrasound showed an extravascular cystic lesion. The cystic lesion was removed surgically with the external iliac artery involved, which was replaced by an artificial graft. The histopathological diagnosis was adventitial cystic disease. Postoperatively, her symptom disappeared and the left ABI was normalized. Adventitial cystic disease is an unusual cause of intermittent claudication. The popliteal artery is most commonly affected. The external iliac artery is reported to be rarely involved with this disease. The exact cause of this disease has not been revealed and various theories have been proposed for its etiology. In this case, the cyst was considered to be connected to the hip joint bursa. This finding supports the developmental theory that the bursal cyst and the adventitial cyst have the same mesenchymal origin.

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Two patients who complain chronic pelvic pain and atypical varicose vein underwent coil embolization of ovarian vein based on the diagnosis of pelvic congestion syndrome. Both patients had varicose veins of the vulva, buttocks and back of thigh. Pelvic congestion syndrome was suspected from the symptom and clinical findings, and CT with contrast demonstrated dilated left ovarian vein with pelvic varicosities in both cases. To confirm the diagnosis and treat, venography was performed. Only the left ovarian vein showed significant reflux and dilatation in both cases. Coil embolization was performed for those veins. There was no complication and both patients showed significant symptom relief. Pelvic congestion syndrome is treatable, so the pathophysiology and treatment must be recognized by not only gynecologist but vascular surgeon.

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A 73-year-old man was admitted with severe back pain. Enhanced computed tomography (CT) showed a lobular dilatation of thoracic abdominal aorta, which eroded into anterior part of the adjacent vertebral bodies at T12 and L1. T1 weighted MR image revealed a hypo-intensity signal at the T12/L1. The diagnosis was infected thoracic abdominal aortic aneurysm (TAAA) associated with a pyogenic spondylitis. Following to antibiotic therapy for 3 weeks, the patient was underwent the operation. Terminal aorta was reconstructed with blood vessel prosthesis, bypass grafts were constructed to perfuse the visceral and renal arteries. Thoracic endovascular stent grafts were deployed to seal the pseudoaneurysm (hybrid-procedure). Postoperative CT revealed no endoleak in the TAAA. Thereafter, the patient was underwent spinal surgery, anterior reconstruction of the thoracolumbar spine and posterior spinal fixation. Postoperatively, the patient had significant reduction in pain, and there were no perioperative complications. Hybridprocedure may be an alternative to standard open procedures in high-risk cases.

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Aneurysm of the dorsalis pedis artery are rare vascular entities, producing a focal soft tissue mass in the dorsal foot. A case of dorsalis pedis artery pseudoaneurysm is reported. The patient was a 69-year-old woman. She had noticed a tumor on the dorsum on the right foot 4 years previouly and consulted our hospital complaining of pulsatile mass with uncomfortableness. We diagnosed this tumor as aneurysm at dorsalis pedis artery by duplex doppler ultrasound and CTA. It was thought that the etiology of the dorsalis pedis artery pseudoaneurysm was traumatic or iatrogenic (cannulation of a dorsal vein of foot, during the previous operation of cerebral aneurysm). The postoperative course was uneventful. The patient was discharged on 7th day after the operation. A review of literature in Japan is also presented.

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A retrievable inferior vena cava (IVC) filter is often used for acute pulmonary embolism (PE). Although only the temporary use of IVC filters has been recommended, it has been used as permanent treatment in some cases and has resulted in late complications. A 41-year-old man with deep vein thrombosis (DVT) and acute PE underwent implantation with a retrievable IVC filter at a hospital. Then, anticoagulant therapy with warfarin was administered, and no DVT recurrence was noted. One year and six months after IVC filter implantation, a foreign body was found in the duodenum during routine upper gastrointestinal endoscopy. A computed tomographic scan revealed that the strut of the IVC filter penetrated the duodenum. The patient had no gastrointestinal bleeding or abdominal pain; however, life-threatening bleeding could occur. Therefore, the IVC filter was removed surgically. To avoid late complications such as penetration, a temporary retrievable IVC filter should be used.

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We report a complicated case of the pancreaticoduodenal aneurysm with celiac axis stenosis due to compression of the median arcuate ligament. A 63-year-old woman consulted a local doctor with a chief complaint of acute epigastralgia. The patient was referred to our hospital because of mild anemia and hypotension. On admission her vital signs were relatively stable. Abdominal CT scan showed the dilated pancreaticoduodenal arcade with surrounding hematoma, the pancreaticoduodenal aneurysm (PDAA), celiac axis stenosis and poststenotic dilatation of the celiac artery. Therefore, we concluded that the PDAA was due to celiac axis compression syndrome (CACS) and rupture of the dilated pancreaticoduodenal arcade occurred. Transarterial embolization of the dilated pancreaticoduodenal arcade using a micro-coil was performed to prevent rerupture. We considered it is hard to dilate the celiac axis using a stent. We performed release of the median arcuate ligament under laparotomy in order to prevent the recurrence of the PDAA. We thought that an intraoperative ultrasonic flow measurement of the hepatic artery was very useful to check the release of stenosis. One month after the surgical procedure, coil embolization of the PDAA was performed because the PDAA showed no sign of shrinkage. One year after the hybrid therapy, CT showed no evidence of new development of the PDAA. In tandem with the technological advance and device improvement, total transarterial embolization and simultaneous stenting of the stenotic celiac trunk using self-expandable stents is likely to become less invasive and more suitable procedure for PDAA complicated with CACS.

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Aspects of bypass grafting for abdominal angina, including bypass graft used, bypass route, and selection of the bypassed artery, are controversial. We describe two cases of successful surgical revascularization for abdominal angina. In each case, antegrade bypass using a saphenous vein graft was performed with proximal anastomosis of the aorta cranial to the celiac artery. The first patient was a 61-year-old male complaining of both abdominal pain after meals and emaciation. His preoperative CT angiogram revealed obstructions of the celiac and superior mesenteric arteries. Bypass grafting using a composite saphenous vein graft was performed to the common hepatic artery and superior mesenteric artery. Parenteral hyper-alimentation was needed due to leakage of pancreatic juice for 3 months after surgery; thereafter, his recovery was good and his symptoms disappeared. Postoperative CT angiogram showed good patency of the composite vein graft. The second patient was a 65-year-old male complaining of intermittent abdominal pain and watery diarrhea. CT angiogram demonstrated obstructions of the celiac and superior mesenteric arteries and severe ostial stenosis of the inferior mesenteric artery complicated by an infra-renal aortic aneurysm. Saphenous vein bypass grafting was performed between the aorta and common hepatic artery as well as artificial graft replacement of the infrarenal aorta combined with revascularization of the inferior mesenteric artery. Postoperative angiogram showed a patent saphenous vein graft and good collateral flow from the inferior mesenteric artery to the superior mesenteric artery, and his symptoms had disappeared.

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Primary pulmonary sarcoma is a very rare tumor. The prognosis of primary pulmonary sarcoma is extremely poor and it is reported as 1.5 months without treatment. Here we report our experience of surgical treatment of primary pulmonary sarcoma. A 62-year old woman with a diagnosis of pulmonary sarcoma by chest CT scan was seen in the university of Tsukuba Hospital because of cough and hemosputum. A large tumor was arising from the left pulmonary artery and extending into the right pulmonary artery and the main pulmonary trunk. An emergent surgery was planned to eliminate the risk of sudden death. Upon induction of anesthesia, her circulatory condition was rapidly collapsed and her heart was arrested. The emergent sternotomy was performed and she was placed on extracorporeal bypass. The main pulmonary artery and the right pulmonary artery were opened. The tumor stacking in the right pulmonary artery was removed and resected with the main pulmonary artery wall. The defect was repaired with a bovine pericardial patch. After extracorporeal bypass termination, the left pneumonectomy was completed. Pathologically, the tumor was diagnosed as an intimal sarcoma of the pulmonary artery. The surgical margin was negative. An adjuvant therapy was not admitted. At 36 months after surgery, she is doing well without any evidence of recurrence. In conclusion, intimal pulmonary sarcoma was successfully treated with the complete resection of the tumor by the resection of the main pulmonary artery and the left pneumonectomy. Aggressive surgical resection would be the most effective treatment to prolong survival for this malignant disease.

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A 52-year-old man presented with swelling and pain in the left popliteal fossa, and transferred from previous hospital on the basis of the diagnosis of left popliteal aneurysm. On admission, he had fever and marked swelling, redness and tenderness in the left poplieal fossa. Blood examination showed high inflammatory reaction. Enhanced CT showed left popliteal aneurysm and fluid collection around the aneurysm. We diagnosed impending rupture of infected popliteal aneurysm and performed emergency operation. First we removed aneurysm and performed debridement of infected tissue via posterior approach, and wound was closed. Second revascularization was done via medial approach. Culture of the aneurismal wall and pus revealed Staphylococcus aureus infection. Postoperatively infectious signs showed rapid improvement by the adequate antibiotic therapy and any complication was not detected.

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