Objectives: Endovascular aneurysm repair (EVAR) remains challenging in patients with bilateral iliac artery aneurysms. We evaluated the clinical outcomes of patients after EVAR in which the bilateral limbs extended into the external iliac arteries (EIAs), and after either revascularization of a unilateral internal iliac artery (IIA) or interruption of the bilateral IIAs. Methods: We retrospectively reviewed 21 patients with bilateral iliac aneurysms who underwent EVAR at our institution between June 1, 2008, and March 31, 2013. We basically reconstruct IIA on one side to treat aortoiliac aneurysms with bilateral iliac aneurysms. However, we sacrifice both IIAs if bilateral internal iliac artery aneurysms are evident or if the general condition of a patient is bad. Fourteen patients were treated by coil embolization to the unilateral IIA and a contralateral EIA-IIA bypass through the retroperitoneal approach and seven were treated by coil embolization to the bilateral IIAs. We compared hospital mortality, surgical duration, hospital stay, and ischemic complications between the two groups. Results: Mean surgical duration was shorter (p=0.01), and the mean amount of blood loss (p=0.04) as well as mean transfusion (p=0.03) were lower in the group with embolization to the bilateral IIAs than in the group that underwent IIA revascularization. Postoperative hospital stay, buttock pain, erectile dysfunction and ischemic colitis did not significantly differ between the two groups. However, one patient died of acute bowel ischemia. Conclusion: Coil embolization to the bilateral IIAs before EVAR is safe and acceptable for treating patients with bilateral iliac aneurysms. However, we recommend unilateral IIA revascularization unless patients are frail and have bilateral internal iliac aneurysms.

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We report a rare case of pseudoaneurysm of arteriovenous fistula which could be treated by patch-angioplasty using a PTFE graft wall. A 41-year-old woman on chronic hemodialysis was referred to our hospital complaining of an enlarged pulsatile mass with pain in the left upper arm. Ultrasonography revealed the presence of a 40-mm aneurysm of the vein of arteriovenous fistula. Considering the risk of aneurysmal rupture, we performed aneurysmectomy. After removing the pseudoaneurysm completely, a perforating hole, 30 mm in size, on the anterior wall of the shunt vein was identified. The venous wall around the hole appeared firm without any atherosclerotic changes or infectious sign, so we performed patch-closure with trimmed PTFE graft wall. Postoperative contrast computed tomography (CT) showed stenosis of the left subclavian vein, suggesting a cause associated with possible postoperative swelling of the left upper arm. After the patient underwent percutaneous angioplasty, swelling of the left upper arm was improved gradually. The patient has been doing well nine months after the treatments.

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Brachial artery aneurysms are relatively rare and are often caused by a trauma or a medical practice. We report a successful surgical treatment of focal dissecting brachial artery aneurysm. The 79-year-old woman without any traumas and medical histories was referred to our hospital with the painless mass in her right upper arm, which had gradually grown over two years period. Arterial duplex imaging demonstrated that the mass arising from her brachial artery was 21.7 mm in diameter. At surgery, the aneurysm was excised and reconstructed with end to end fashion under general anesthesia. She recovered uneventfully and the post operative computed tomography does not reveal any recurrences of aneurysm. The histological examination shows focal dissecting aneurysm with some tears and losses of elastin fiber. Neither atherosclerosic change nor laminar medial necrosis was found.

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In this report, we present a case of chronic aortic pseudo-aneurysm due to blunt trauma. The patient was an 81-year-old female who fell off a cliff three years ago. Recently, an aortic pseudo-aneurysm was found on computed tomography (CT). It was located on the proximal portion of the brachiocephalic artery, and had a maximum diameter of 57 mm. As the aortic wall did not have any other abnormalities on CT, we thought reconstruction of the aorta was not needed. However, it was difficult to repair the aorta and the brachiocephalic artery by cross-clamping at the origin of the brachiocephalic artery or side-clamping of the aorta due to the large aneurysm. Therefore, cardiopulmonary bypass with cerebral protection was required. A median sternotomy was performed with an extension to the right side of the neck. To establish extracorporeal circulation, 8-mm vascular prostheses were anastomosed bilaterally to the axillary arteries, and perfusion catheters were inserted bilaterally into the common carotid arteries using a cut-down approach. The right common carotid artery was exposed, and a perfusion catheter was inserted at the neck. The operation was performed under extracorporeal circulation using these four access sites for systemic and cerebral perfusion. Under hypothermic circulatory arrest, the aneurysm and brachiocephalic artery were resected. After side-clamping of the aorta around the defect, systemic perfusion from the left axillary artery was resumed with rewarming. A bifurcated prosthetic graft was anastomosed end-to-side to the aortic defect, and the two graft sections distal to the bifurcation were anastomosed end-to-end to the proximal right common carotid and subclavian arteries. Because of the ingenuity of the perfusion sites, the aorta was preserved and the influence of the extracorporeal circulation was reduced.

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We report a case of bypass grafting to a distal radial artery at wrist necessitated by severe upper limb ischemia. A 70-year-old man presented cyanosis, coldness, pain and hypesthesia in right hand, and was referred to us for necrosis of the right 4th finger. Angiography revealed occlusion of the radial and ulnar artery, and distal radial artery was visualized with collateral blood flow from interosseous artery. Because of expansion of necrosis, right brachial-distal radial artery bypass grafting with the great saphenous vein was performed for limb salvage. The patient was well without symptom 11 months after operation. There is a few reports related to forearm bypass grafting, but it is useful method in case of severe upper limb ischemia.

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Idiopathic pulmonary artery aneurysm is extremely rare and many aspects of its natural course remain to be elucidated. However, treatment is recommended as soon as possible after diagnosis, regardless of aneurysm etiology, size, or symptomatic status as rupture is potentially fatal. We encountered a woman in 60s in whom transcatheter arterial embolization (TAE) was identified during a routine health check 14 years previously. The aneurysm was 15×12 mm in size, with one feeding and two draining arteries. TAE of the feeding and draining arteries was completed using metallic coils with no apparent complications. TAE is less invasive and should thus be feasible of treatment options for idiopathic pulmonary artery aneurysm.

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The rupture of the artificial vascular graft is a rare complication. This report describes a case of disruption of a ringed ePTFE graft in the mid-point of a left axillofemoral bypass. A 62-year-old man stumbled on the road and bruised his abdomen knocking against the concrete. He had undergone a left axillofemoral bypass procedure using a ringed ePTFE graft, 8 mm in diameter, 14 years previously for the atherosclerotic obstruction of his left common iliac artery. He came to the emergency department and a physical examination revealed a large hematoma at the site of the ePTFE graft on his left lateral abdominal wall. The patient was hemodynamically stable, with a blood pressure of 143/76 mmHg, and pulse rate of 87 beats/min. CT showed the disruption of the ePTFE graft and a pseudoaneurysm 2 cm in diameter about 15 cm cranial side from the disrupted portion. The patient underwent emergent surgery under general anesthesia. Intravenous heparin was not used during the operation because he had been administered warfarin 2.5 mg/day and PT-INR was 3.24 when he came to our hospital. An incision was made on the hematoma and the graft was dissected free. The graft was clamped above and below the lesion using forceps. When the mass was entered, it was evident that the graft was completely divided. The cut edge was smooth and there was no need of trimming. Two rings were peeled off and end-to-end anastomosis was created with 5-0 Prolene sutures. Pseudoaneurysm was not repaired because it was not critical. Postoperative CT at 7 days revealed no extravasation. Convalescence was uneventful and the patient was discharged on the 14th postoperative day without leg pain or claudication. Not only the effects of external forces but also the deterioration of the graft seemed to be the cause of the disruption in this case. Our case report demonstrates the potential for disruption of the midportion of ringed ePTFE axillofemoral bypass graft with direct blunt trauma.

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We report a successful case of ruptured infected abdominal aortic aneurysm treated by endovascular repair and continuous irrigation of retroperitoneal abscess. A 77-year-old man, presenting with abdominal pain and loss of consciousness, was transferred under the diagnosis of ruptured abdominal aneurysm. High inflammatory reaction and thickened retroperitoneum was detected, and the diagnosis of ruptured infected abdominal aneurysm was made. We performed emergency surgery with endovascular treatment first, and drainage with irrigation of retroperitoneal space via subsequent laparotmy under same operation. Postoperatively infection was controlled by administration of the adequate antibiotics and continuous irrigation. However, postoperative CT showed a pseudoaneurysmal formation at proximal edge of stent graft, and additional endovascular repair was performed on the 21 postoperative day. The postoperative course was uneventful and no complication was detected during the 12 months follow up.

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A 42-year-old man who had chest pain suddenly during a conference and was diagnosed acute type A aortic dissection on CE-CT was referred to our hospital for operation. Ascending aortic replacement was emergently performed. On the first post-operative day (POD), he had left leg pain and was diagnosed malperfusion of left external iliac artery and femoral-femoral bypass was emergently performed. On the 2nd POD, he had abdominal pain and acidosis had been gradually progressing. On CE-CT, SMA was occluded just before it divided to right colonic artery. Visceral malperfusion was diagnosed and emergently SMA-illiac artery bypass was planed. However, inflow of the iliac artery was not enough, so SMA stent was implanted to the root of SMA. The gap between blood pressure of SMA and upper limb was about 20 mmHg. On IVUS, the true lumen of a part of the descending aorta was pressed by the false lumen and stenosis. TEVAR was performed to expand the true lumen of the descending aorta. After this operation, acidosis improved and finally recovered.

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An 82-year-old woman with Alzheimer’s dementia was suffered from aspiration pneumonia, and admitted to our hospital. During her treatment, she was not able to eat enough. Therefore, total parenteral nutrition was performed. A catheter was inserted through her right femoral vein because it was difficult to insert the CV Catheter to any other sites. Seven days after the insertion, she had a fever. Cholangitis was suspected by blood chemical examination. However, MRCP showed a multilocular liver abscess. The abscess did not affect for antibiotics. The abscess became larger during this period by CT scan. Furthermore, the tip of the catheter was seemed in the abscess. Therefore, percutaneous transhepatic abscess drainage was performed. Contrast medium injection through the catheter showed communication between the catheter and the abscess. The catheter was left and was used as a “drainage tube.” A week after drainage, her body temperature was down and laboratory tests were improved. Then, we removed the CVC. Three weeks after the procedure, drainage tube was removed and the abscess was cured.

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We report the first case of thoracic endovascular aortic repair (TEVAR) with a semi-custom made fenestrated thoracic stent graft for Stanford type B aortic dissection. 68-year-old man suddenly experienced severe back pain. He was taken to a hospital and was diagnosed with Stanford type B acute aortic dissection. The primary entry tear was located at the distal region of left subclavian artery. The aortic dissection extended to the right external iliac artery. He was transferred to our hospital. Despite medical management (decreasing blood pressures and bed rest), the diameter of the dissected aorta rapidly increased. The false lumen expanded and the true lumen became greatly compressed. Thoracoabdominal aortic replacement was too invasive for the patient because the length required to be replaced would be extending (Crawford type II thoracoabdominal aortic aneurysm). We therefore decided to perform primary entry closure with TEVAR. We selected Najuta thoracic stent graft system^®, which is a semi-custom made fenestrated stent graft system. We performed TEVAR two months after the onset of aortic dissection. The surgical procedure was completed successfully. Postoperative enhanced computed tomography showed closure of the primary entry tear and expasion of the true lumen. The patient was discharged 28 days after TEVAR.

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We have experienced 2 cases of proximal pseudoaneurysmal formation and re-dissection after replacement of ascending aorta or aortic arch for acute aortic dissection. The GRF glue was used at first operation in both cases. The first case was 61-year-old man who had undergone total aortic arch replacement 7 years ago due to acute Type A aortic dissection. He came to our outward claiming chest discomfort. A new dissection at Sinus of Valsalva was detected and the ascending aorta had enlarged to 63 mm. Ultrasound cardiogram revealed severe aortic valve insufficiency. Aortic re-implantation using Valsalva graft and CABG to RCA was performed. New intimal tear was found proximally at former suture line, two aortic valve commissures were detached from aortic wall. The second case was a 78-year-old man who had previously undergone replacement of ascending aorta using GRF glue for acute aortic dissection 4 years ago. A follow up computed tomography showed an aortic root pseudo-aneurysm. Also moderate aortic insufficiency was found on ultrasound cardiogram. Aortic root replacement was performed. In the pathological examination, the necrotic change of smooth muscle cells in the aortic media was revealed in both cases. Higher rate of long term complication especially re-dissection or pseudoaneurysm formation provided by the usage of GRF glue for repairing dissected aorta was described in previous reports. The toxic effect of excess formalin is known to be the cause of those complication. We have to observe the patients carefully who has been used GRF glue.

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