Objective: Patients with varicose veins of the lower extremity have various complaints, and not a few of them complain of edema, which is one of the reasons for their deteriorated quality of life. We investigated the clinical usefulness of goreisan, a kampo prescription to regulate water metabolism, in patients with varicose veins of the lower extremity accompanied by edema. Methods: Twenty-two patients with varicose veins of the lower extremity accompanied by a subjective and objectively obvious symptom of edema (C3 or severer according to CEAP classification) received goreisan for 12 weeks in combination with the use of elastic compression stockings. Circumferences of lower extremity (circumference above patella, maximum circumference of lower leg, and circumference at external malleolus), Visual Analogue Scale (VAS) scores of subjective symptoms (edema, pain, coldness, malaise, numbness, pruritus, and muscle cramp), severity of varicose veins, and laboratory parameters (coagulation system, inflammatory reaction, general items, and blood pressure) were evaluated before and after the administration of goreisan. Results: All the circumferences of lower extremity were significantly reduced after the administration of goreisan. Significant improvements were also recognized in the VAS scores of subjective symptoms and the severity of varicose veins. The laboratory parameters showed no change. Conclusion: The possibility was suggested that using goreisan together with elastic compression stockings improves edema and reduces complaints in patients in treatment of varicose veins of the lower extremity accompanied by edema.

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Objectives: It is considered that the infrainguinal vein bypasses for critical limb ischemia (CLI) are reliable treatment of vascular reconstruction. The aim of this study was to assess results of vein bypass surgery for CLI. Methods: A total of 42 critical ischemic limbs in 39 patients who underwent infrainguinal vein bypasses from December 2005 to September 2013 were reviewed. A total of 23 bypasses (55%) were performed with single saphenous vein grafts, 19 reconstructions (45%) using spliced vein grafts. Results: The cumulative primary and secondary patency rate was 66% and 90% at 4 years. The survival rate and cumulative limb salvage rate at 4 years was 72% and 92%. The primary patency rate at 4 years was 86% in the single vein grafts group versus 37% in the spliced vein grafts group and the secondary patency rate at 4 years was 91% in the single vein grafts group versus 89% in the spliced vein grafts group. Conclusion: Infrainguinal vein bypasses for CLI can be performed with favorable limb salvage and survival rate. Acceptable secondary patency can also be achieved with spliced vein grafts in adding appropriate revision due to early detection of disease.

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Cystic adventitial degeneration of the popliteal artery is a rare disease wherein cysts are formed within the adventitia of the popliteal artery, leading to narrowing of the arterial lumen and causing symptoms of lower limb ischemia. In the present report, we describe a case of cystic adventitial degeneration of the popliteal artery, which presumably occurred due to the formation of a fistula connecting the cyst with the knee joint. A 71-year-old man presented to our hospital with a chief complaint of intermittent claudication of the left lower limb. In the left lower limb,the ankle brachial pressure index was as low as 0.53, and magnetic resonance angiography indicated severe stenosis of the left popliteal artery above the knee. Arteriosclerosis was suspected, and a balloon dilation procedure was performed; however, early recurrence of symptoms and re-stenosis subsequently occurred. The findings of contrast-enhanced computed tomography suggested the presence of cyst formation. Thus, cystic adventitial degeneration of the popliteal artery was suspected, and surgical treatment was performed. Intraoperatively, we observed that a fistula had formed between the cyst and the knee joint. Therefore, the treatment consisted of ligation and resection of the fistula, resection of the popliteal artery and the cyst, and revascularization using the great saphenous vein. Since the causes of adventitial cysts are currently unknown, careful attention should be paid to the formation of fistulas that connect the cyst with joints, in order to prevent recurrence.

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A 71-year-old man suffered from a blunt thoracic aortic injury (BTAI) and bowel injury caused by a traffic accident. He did not exhibit any symptom, except for a severe abdominal pain. A computed tomography scan showed a pseudoaneurysm at the distal arch and a large amount of free air in the abdomen, which suggested peritonitis caused by bowel. Hence, an emergency abdominal operation was necessary. To avoid performing an emergency operation for the BTAI during the severe infection caused by peritonitis, we decided to perform a simultaneous operation for BTAI and bowel injury. First, after estimated a partial cardiopulmonary bypass through the femoral artery and femoral vein, we performed grafting of a pseudoaneurysm that was present around the distal arch through the left thoracotomy. The patients’ position was then changed, and the bowel injury site was repaired. After the operation, he was treated for various complications and needed a long rehabilitation period, but he was discharged from our hospital without any complication. It is difficult to determine the timing of the operation for BTAI in patients with multiple organ injuries. When bowel injury is present along with a BTAI, patients may develop severe infection, and we may not able to treat the BTAI. Therefore, some cases may require a simultaneous operation for BTAI and bowel injury.

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An 81-year-old man who was complicated with chronic renal failure to need dialysis was admitted with pneumonia. Enhanced computed tomography showed aneurysm of descending aorta which was complicated with aneurysms of bilateral common and internal iliac arteries (left-sided aneurysms were occluded). After pneumonia was improved, TEVAR and EVAR were performed in twice. At the first operation, to keep the blood stream of right internal iliac artery for preventing spinal cord ischemia, we for intention did not treat the patient for iliac artery aneurysms. We implanted two pieces of GORE TAG^® from left leg of Y-shaped vascular prosthesis with which bypass grafting from abdominal aorta (distal to IMA) to right external iliac artery and left common femoral artery was performed. About two months after the first operation, the second operation was performed. After the coil embolization of right internal iliac artery, we implanted iliac extender of EXCLUDER^® from right leg of Y-shaped vascular prosthesis to right external iliac artery. After these operations, paraplegia and ischemic colitis were not occurred and CT showed no endoleak and migration of stent grafts. In order to prevent postoperative paraplegia and ischemic colitis, it is important to make treatment strategy for the patient of thoracic aortic aneurysm which is complicated with abdominal aortic or iliac aneurysm.

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Ruptured external iliac artery aneurysm is very rare and hardly reported. We experienced the case of this disease for whom the operation due to save his life was performed. A 53-year-old man was carried to our hospital by an ambulance because of severe pain and numbness from left inguinal to femoral region. The rupture of left external iliac artery aneurysm 70 mm in diameter was detected on CT and so emergent aneurysmectomy and graft replacement was performed. The patient needed time for recovery of bowel movements and diet was started nine days after the operation. But the subsequent operation progress was favorable and he was discharged 16 days after the operation. The loss of the elastic fibers was accepted by Elastica-Masson’s stain in the histopathological views. We diagnosed that the cause of this disease is arteriosclelosis judging from family history, clinical examination findings, physical views and histopathological views. Emergent thrombectomy was performed for acute graft occlusion two years after the operation. The graft was patent and stenoses of both anastomotic sites were not detected on CT angiography three years after the operation.

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We experienced 2 cases of abdominal aortic aneurysm complicated by chronic consumption coagulopathy caused by thrombus formation in the aneurysm. The patient in Case 1 was a 78-year-old man who presented at the hospital with intramuscular hematoma in his right lower leg. We found an abdominal aortic aneurysm of 70 mm in size and a right common iliac artery aneurysm of 76 mm in size. The patient in Case 2 was a 76-year-old man in whom an abdominal aortic aneurysm of 76 mm in size was recognized that was accompanied by extensive subcutaneous hemorrhage of the thoracoabdominal area and left cerebellar hemorrhage. The two patients were diagnosed as having disseminated intravascular coagulation (DIC) caused by chronic consumption coagulopathy with decreased platelet count and abnormalities in coagulation and the fibrinolytic system, and anticoagulant therapies were started. The patient in Case 1 underwent Y-graft placement on hospital day 22, and his postoperative course was uneventful. The patient in Case 2 underwent endovascular stent-graft placement on hospital day 38. After the placement, however, consumptive coagulopathy possibly due to rapid thrombus formation in the aneurysm was observed, which hampered the treatment of his postoperative hemorrhage. When perioperative consumption coagulopathy is observed, postoperative coagulopathy might appear more intensely in endovascular stent-graft placement than in Y-graft placement. Therefore, we report these cases and consider other reports in the literature.

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Recently, there have been reports that endovascular aneurysm repair (EVAR) applied to ruptured abdominal aortic aneurysm (rAAA) brings about lower mortality and is more useful than open surgical graft replacement of AAA. In our hospital, emergency EVAR for rAAA is performed depending on the cases. We report one case of impending rupture of pseudoaneurysm during the late postoperative phase. Emergency EVAR for rAAA was performed on an 86-year-old man. There was no endoleak on postoperative computed tomography (CT). One year and nine months later, he was taken to our hospital by ambulance with the chief complaint of low back pain. Upon arrival, CT revealed rapid expansion of a pseudoaneurysm. An emergency open surgery was performed following the diagnosis of an impending rupture of the pseudoaneurysm. Findings showed no related infection. Due to active bleeding from 4th lumbar artery, ligation was done from the outside of the pseudoaneurysm. EVAR procedure for ruptured AAA is prone to develop a pseudoaneurysm because the adventitia of the blood vessel on the ruptured site is broken. Therefore, a deliberate follow-up is required.

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A 79-year-old woman underwent aortic arch replacement and the maze procedure for ascending and arch aneurysm, and atrial fibrillation, followed two years later by stent graft placement for a descending thoracic aortic aneurysm that had shown a tendency toward enlargement. Computed tomography (CT) after discharge showed type II endoleak thought to arise from the bronchial arteries with an associated increase in aneurysm diameter. Because obstruction caused by compression of the esophagus also became evident, the patient was thought to require treatment at as early a stage as possible. Invasive treatment was judged to be difficult due to the patient’s poor systemic condition, and embolization using direct puncture was selected for treatment. Embolization was performed under local anesthesia with CT-like imaging guidance using cone beam CT. The procedure was completed without complications, and the patient was discharged on postoperative day 18. CT at six months after discharge confirmed the disappearance of endoleak and a reduction in aneurysm size.

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A 93-year-old female with atrial fibrillation was referred to our hospital for sudden numbness, pain and weakness of the left upper limb. Enhanced CT revealed that an origin of a left subclavian artery was obstructed. Embolectomy using a Fogarty catheter was performed. The patient showed decreasing level of consciousness, immediately after the surgery. MRI showed pontine, cerebellar and bilateral thalamic infarction, and MRA revealed a contrast defect of basilar artery. The patient died about ten hours later. Embolectomy of subclavian artery is not recommended because it may have a high risk of cerebral infarction.

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A 47-year-old man was admitted to our institution complaining severe dyspnea. The ultrasound cardiograph showed marked dilatation of right ventricle, pulmonary hypertension estimated 56 mmHg and the floating thrombi of bilateral atrium. The enhanced CT revealed thrombosis of bilateral pulmonary artery. An emergency operation was performed. The right atrium was opened under cardiac arrest and a tubular thrombus trapped in the patent foramen ovale was removed. Also massive fresh thrombi were removed from the bilateral main pulmonary artery. The patient discharged without symptoms. Early surgical treatment is necessary for avoiding paradoxical embolisms.

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A 60-year-old male was emergently transported to our hospital because of severe chest and back pain. The CT scan showed DeBakey type III B aortic dissection. The superior mesenteric artery (SMA) received blood flow from the true lumen, but the initial segment was compressed by the pressurized false lumen. Due to the prolonged intestinal peristalsis and the critically worsening respiratory conditions, thoracic endovascular aortic repair was performed at 3 days after the admission. A stent-graft was deployed to seal the primary entry. The false lumen was sufficiently depressurized, so that the SMA flow was increased right after the treatment. Oral intake started at the 8th post operative day, and post operative recovery was not uncomplicated. Entry closure using stent grafts seemed feasible to deal with the critical organ circulation under these circumstances.

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The patient was a 76-year-old man who underwent endovascular aortic repair of abdominal aortic aneurysm six years earlier. He was admitted to our hospital, where bilateral common iliac arterial aneurysms were diagnosed. We first performed additional stent graft placement with coverage of the right internal iliac artery for right common iliac arterial aneurysm. Next, five months postoperatively, we performed additional stent graft replacement for the left common iliac arterial aneurysm and reconstruction of the left internal iliac artery to prevent ischemic colitis. In the future, complications of distal landing zone after endovascular aortic repair can be expected to increase. As treatment, prevention of ischemic colitis is important, and surgical procedures to prevent ischemic colitis will need to be considered.

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