Objective: We have experienced 132 open repairs for ruptured abdominal aortic aneurysms (RAAA) and iliac artery aneurysms over the past 20 years. Methods: Our case mixture is as follows: 10 cases of F-1 (Fitzgerald, type1), 17 cases of F-2, 84 cases of F-3, and 21 cases of F-4. Because F-1 cases are equal to non-ruptured aneurysms as regards to preoperative stable vital conditions and good prognosis, we excluded F-1 cases, and divided the remaining 122 RAAAs into two groups: A-group (49 cases) with onset–admission time (O–A time) less than or equal to 180 minutes, and B-group (73 cases) with O–A time of more than 180 minutes. The A-group consisted of 7 cases of F-2, 37 cases of F-3, and 5 cases of F-4, whereas the B-group consisted of 10 cases of F-2, 47 cases of F-3, and 16 cases of F-4. The distribution of Fitzgerald’s classification was not significantly different between the two groups (p=0.238). Results: Preoperative data analyses revealed that the A-group was significantly older (76.2 yo vs. 72.8 yo: p=0.034), included more shock cases (89.8% vs. 75.3%: 0.036), and un-diagnosed cases (69.4% vs. 37.0%: p=0.0004) as compared to the B-group. More cases deteriorated preoperatively in the A-group than the B-group, although the difference was not significant (18.4% vs. 8.2%: p=0.094). Intraoperative data revealed that admission-operation time (100 min vs. 108 min), aorta clamp time (63 min vs. 68 min), the amount of estimated blood loss (2,105 ml vs. 1,894 ml), and transfusion volume (2,652 ml vs. 2,035 ml) were the same between the two groups. Although a statistically significant difference was noted in the operation-aorta clamp time (14.2 min vs. 20.1 min: p=0.035), it was not noted in the 91 shock cases without previous laparotomy (12.8 min vs. 14.0 min: p=0.587). Though postoperative course measures, such as extubation (3.9 POD vs. 3.5 POD), ICU stay (6.0 days vs. 5.5 days), first walk (5.3 POD vs. 5.7 POD), first diet (7.0 POD vs. 7.6 POD), and postoperative length of stay (20.4 days vs. 15.9 days) were the same in both groups, nevertheless, hospital mortality was significantly higher in the A-group than the B-group (34.7% vs. 17.8%: p=0.034). Conclusion: Even with comparable technical skill of vascular surgeons and postoperative data, the A-group had a poorer prognosis than the B-group. Many older patients with severe shock presented directly to our hospital soon after rupture, but tended to be seriously ill with poor prognosis. In conclusion: the RAAA patients directly admitted to a local stem hospital within 180 minutes may be in seriously worse condition and have a poorer prognosis than those who came later than 180 minutes.

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Background and Objectives: In patients with peripheral arterial diseases (PADs) due to infra-popliteal (below-the-knee; BTK) lesions, we often encounter situations requiring the immediate selection of either of two revascularization methods, namely bypass surgery or endovascular therapy (EVT). However, the question of whether endovascular or surgical revascularization should be performed initially for critical limb ischemia (CLI) patients with BTK lesions has not been clarified. To assess the efficacy and durability of EVT or bypass as a first approach, we evaluated the short- and mid-term outcomes of the first revascularizations achieved using EVT (EVT First Group; EVT-first) compared with bypass (Bypass First Group; Bypass-first). To verify the validity of each initial revascularization, we explored factors influencing overall survival (OS) rates using multivariate analyses. Methods: A total of 169 consecutive BTK revascularization procedures (150 patients) for CLI conducted at our facility between November 2006 and July 2012 were analyzed. Patients undergoing revascularization were divided into two groups (EVT-first or Bypass-first), with 102 patients undergoing endovascular therapy first (EVT-first) and 51 undergoing bypass surgery first (Bypass-first). No statistically significant differences were noted between the two groups with respect to preoperative background including age, gender, and cardiovascular risk factors (hypertension, diabetes, hyperlipidemia, coronary arterial disease (CAD), chronic heart failure (CHF), cerebrovascular disease, and hemodialysis). Technical success was defined as a single straight-line flow to the ankle after completion angiography of the first revascularization method. Hemodynamic success was defined as a postoperative skin perfusion pressure of the foot exceeding 40 mmHg. Results: The average age of patients was 76.0 years (range, 46–98 years; 65 men and 37 women) and 72.3 years (range, 43–93 years; 35 men and 13 women) in the EVT-first and Bypass-first groups, respectively. Patient follow-up ranged from 1 to 50 months (mean, 15 months). Respective technical and hemodynamic success rates were 96.2% and 66.7% for EVT-first and 100% and 94% for Bypass-first, respectively. Treatment was required an average of 1.5 times for EVT-first and 1.2 times for Bypass-first. Respective rates for other factors examined in the EVT-first and the Bypass-first groups were: major amputation rates 30 days post-procedure, 5.9%, and 3.9%; mortality rates 30 days post-procedure, 3.9%, and 0%; one-year AFS rates, 71.7%, and 79.5%; OS rates, 73.5% and 83.9%; and limb salvage rates, 88.8%, and 91.0%. Multivariate-analysis of all subjects in the two groups revealed that the OS rates was affected by four risk factors as follows: 1) age greater than 80 years, 2) CAD, 3) CHF, and 4) a non-ambulatory limb. Conclusion: For patients with CLI due to BTK lesions and whose saphenous veins are in poor condition or are in poor general condition having two or more of the four severe risk factors, the EVT-First procedure is effective and provides durable results. Overall survival in patients with CLI due to BTK lesions is worse when patients have more than two severe risk factors, which is non-ambulatory limb, aged less than 81 years, with CAD or with CHF.

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Abdominal compartment syndrome can occur after abdominal trauma, liver transplants, postoperative intraabdominal haemorrhage, tense ascites, acute pancreatitis, ileus, intestinal obstruction and ruptured abdominal aortic aneurysm. In the case of ruptured abdominal aortic aneurysm, it is thought to arise because of retroperitoneal haematoma, coagulopathy and interstitial and retroperitoneal edema during the perioperative period. A 71-year-old man was given a diagnosis of ruptured infrarenal abdominal aortic aneurysm. Emergency aneurysmectomy and graft replacement was performed. And temporary abdominal closure was performed in order to prevent the development of acute abdominal compartment syndrome after operation. He discharged from hospital on postoperative day 30 and was doing well without any morbidity. Temporary abdominal closure is a good method to prevent acute abdominal compartment syndrome after ruptured abdominal aortic aneurysm.

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Double aortic arch who needs surgical treatment in adulthood is rare. A 23-year-old woman admitted to our hospital with complaint of dyspnea and dysphagia. Chest X-ray showed an abnormality of thoracic aorta and computed tomography revealed double aortic arch. Both right and left arches showed similar size. Trachea and esophagus were compressed by the complete vascular ring. We performed division of the right aortic arch and reconstruction of the right subclavian artery through a right intercostal thoracotomy under partial cardiopulmonary bypass. Common associated anomalies in vascular ring, such as tracheomalacia or vulnerable vascular wall (Kommerell diverticulum) were not found in our case. The postoperative course was uneventful and her symptoms disappeared.

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Vascular infections in the groin require both infection control and arterial revascularization for limb salvage. We treated two cases of arterial bleeding caused by vascular infections in the groin by debridement with extra-anatomical bypass. Case 1 was a 74-year-old woman with a history of right inguinal lymph node metastasis of pudendum carcinoma. She underwent exclusion of the right inguinal lymph nodes and right femoral vein. A femoral wound infection with arterial bleeding occurred 2 months later. We performed extra-anatomical bypass (right external iliac artery-right femoral artery bypass) and ligation of the right external iliac artery, and right superficial and deep femoral arteries. Case 2 was a 73-year-old woman who underwent coronary angioplasty for acute myocardial infarction. Post catheterization, an inguinal hematoma occurred and a groin infection with arterial bleeding developed 1 month later. We performed extra-anatomical bypass (right axillary-right popliteal artery bypass) and ligation of the right femoral artery. Femoral arterial re-bleeding occurred 3 months later. We performed coil embolism of the right external iliac artery and right deep femoral artery, and ligated right superficial femoral artery proximally. In both cases, the infections were controlled and blood flow to the leg was maintained. Extra-anatomical bypass is a good option for vascular infections in the groin.

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A 71-year-old female presenting cyanosis of the left 1st and 2nd toe was admitted to our hospital by diagnosis of left anterior and posterior tibial arterial occlusion. Enhanced CT examination showed that a persistent sciatic artery aneurysm (PSA) with 3 cm of the maximum diameter existed in the left gluteal region, and that popliteal and the distal arteries toward lower limb was enhanced from the internal iliac artery through PSA. Emergent angiographic examination presented that significant stenosis was observed at anterior tibial artery, the proximal site of posterior tibial artery and the ostium of peroneal artery, and that thromboembolic occlusion was also found in the anterior and posterior tibial arteries. Emergent thrombectomy and angioplasty was performed in these 3 vessels. After that, sufficient blood flow was observed through the 3 vessels into lower limb. Thirty seven days after the catheter intervention, the patient underwent left common femoro-popleteal bypass surgery using ePTFE graft, as well as coil embolization for PSA by catheter intervention. Eighteen months after the series of treatments, the patient was asymptomatic, and no abnormal findings were detected by enhanced CT and vascular ultrasonography. In this case of PSA with symptomatic limb ischemia due to arterial occlusion, staged interventional procedure which was reconstructive surgery combined with coil embolization for PSA following release from ischemia by emergent catheter intervention was effective. In addition, for the treatment of PSA, hybrid treatments by surgical and catheter intervention was an efficient and less-invasive procedure.

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We treated a patient with an aortoenteric fistula (AEF), and report this case. A 67-year-old man with hematemesis and melena was admitted to our hospital. Gastroduodenal fiberscopic examinations could not reveal a bleeding focus. Computed tomography (CT) showed an abodominal aortic aneurysm (AAA) measuring 45 mm in diameter. We suspected AEF and planned the semi-emergency operation. However, since he fell into the shock state, the emergency surgery was required. Intraoperatively, we confirmed an AEF between an AAA and the duodenum. We performed the abdominal aorta replacement and the duodenal repair. In order to reduce the risk of infectious complications such as a graft infection, a pedicled omentum was used to cover the prosthetic graft. Though he was complicated with catheter-associated bacteremia, he was discharged 74 days later.

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Aorto-caval fistula is a rare complication of abdominal aortic aneurysms that results in extremely high pressure in the venous bloodstream and congestive heart failure. We describe a 79-year-old woman who presented in a state of shock with an abdominal aortic aneurysm rupturing into the inferior vena cava, low back pain, syncope and chest discomfort. She was transferred to our hospital where we discovered low blood pressure, leg edema and a pulsating abdominal mass. Abdominal computed tomography revealed aneurysms of the abdominal aorta and bilateral common and bilateral internal iliac arteries as well as an aortocaval fistula of the abdominal aortic aneurysm. Emergency surgical repair of the fistula and an aorto-bifemoral arterial bypass resulted in a good postoperative course.

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We report a case with postoperative superior mesenteric arteriovenous fistula. A 64-year-old-woman who had undergone ileocecal resection for ileocecal invagination 2 years previously was admitted to the other hospital with diarrhea. Abdominal examination revealed a bruit in the right lower quadrant with a postoperative scar in the lower midline. Computed tomography demonstrated dilated superior mesenteric artery. Selective superior mesenteric arteriography revealed dilated superior mesenteric artery leading to an arteriovenous fistula with rapid filling of the superior mesenteric vein and resection of the fistula was performed. Iatrogenic mesenteric arteriovenous fistula is uncommon and surgery performed before the development of associated portal hypertension. A review of the literature follows the report of this case.

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A 65-year-old man underwent endovascular repair for infrarenal aortic aneurysm with the Zenith stent-graft. The postoperative course was good and he discharged hospital satisfactory. Fourteen months after the procedure, he complained the numbness of the right leg. However, he didn’t consult our hospital. Eighteen months after the procedure, he admitted complaining of sudden onset of bilateral foot coldness and numbness. Enhanced computed tomography showed complete occlusion of the entire endoprosthesis to the level of the renal arteries. Emergency graft replacement was performed. The report which complication of the ready-made stent graft complete occlusion due to developing graft thrombosis is rare. So we describe it.

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We report the case of a 92-year-old man who was referred to our hospital, with a rapidly expanding painful mass in his left thigh. Contrast enhanced computed tomography revealed a 9 cm atherosclerotic aneurysm in the middle portion of the left superficial femoral artery with evidence of rupture into the surrounding soft tissue. The distal superficial femoral artery and popliteal artery were already occluded, and the peroneal artery, the distal portion of the posterior tibial artery and the planter artery were detected through the collateral vessels. Using a contralateral approach, 0.035-inch coils were used to embolize the artery both proximal and distal to the aneurysm. The aneurysm was fully thrombosed, which gradually shrink. The patient’s post-procedural course was uneventful, and the limb was viable at discharge.

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Right aortic arches are associated with an aberrant left subclavian artery, the dilated root of which is known as Kommerell’s diverticulum (KD). Such anomalies have been treated with open surgical resections and replacements, but recently, endovascular treatments for KD have been reported. We herein report a case of a hybrid endovascular treatment of KD, and the use of N-Butyl-2-Cyanoacrylate (NBCA) embolization for postoperative type 2 endoleaks. A 79-year-old male, who had been followed for hepatocellular carcinoma was diagnosed to have Kommerell’s diverticulum with a right aortic arch (Edwards IIIB type), and was admitted for surgery. A CT scan showed the KD with a maximum diameter of 40 mm. A biaxillary cross-bypass, a thoracic endovascular aortic repair and coil embolization of the left subclavian artery were performed. CT images taken seven days after the surgery showed a type II endoleak from a left subclavian artery, and the one-month postoperative CT images showed an enlarged KD. Therefore, a second operation was performed, wherein an NBCA-lipiodol mixture was injected into the KD cavity, and additional coil embolization was performed. CT images taken two-months after the second operation showed remaining endoleaks, and an intraoperative angiogram of the third operation suggested the KD had an intercourse with an intercostal artery. NBCA and coil embolization were performed again. One year has passed since the third operation, and there is still a slight blood flow into the KD, but there has been no evidence of enlargement of the KD. Thus, we believe that hybrid repair for KD is a safe and useful procedure, and our findings confirmed the usefulness of NBCA embolization for endoleaks in the thoracic region.

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A unique machine sandwiched and injured the knee of 31-year-old male. CT scan revealed the occlusion of popliteal artery. Revascularization was performed on electively. Dissected intima and thrombus in the popliteal artery was removed. Prosthesis or vein graft were not used. Popliteal artery occlusion with blunt trauma is rare. Though usually revascularization needs prosthesis or vein graft, they were not used in this case. But careful follow-up will be necessary hereafter.

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The patient was a 75-year-old man with a past history of total laryngectomy and permanent tracheostomy for laryngeal cancer and Hartmann’s operation and colostomy for rectal cancer. He was emergently hospitalized with pyrexia, general malaise, and loss of appetite. Detailed investigation revealed an infected thoracic aortic aneurysm secondary to Escherichia coli infection. He was initially treated with intravenous antibiotics, and subsequently underwent resection of the infected portion of the thoracic aorta and synthetic graft replacement of the ascending, arch, and descending portions of the aorta via an intercostal thoracotomy with cardiopulmonary bypass use. Postoperatively, intrathoracic lavage and drainage procedures were continued for 16 days and intravenous antibiotics for 6 weeks, successfully controlling the infection. No signs of recurrent infection have been observed for 2 years, to date. Although this patient’s condition was initially difficult to manage, especially in terms of selecting the optimal surgical method, he was successfully treated and a favorable outcome was obtained.

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Although myelodysplastic syndrome patient rarely shows thrombophilia, this patient developed repetitive thromboembolism on lower extremities. After 6th revascularization, severe anticoagulant therapy was effective. Careful follow-up is required from the point of views of vascular and blood diseases.

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