Objective: To assess the outcomes of endovascular treatment for isolated iliac artery aneurysms by using Excluder leg. Methods: Between October 2009 and April 2004, 24 patients with isolated iliac artery aneurysms underwent endovascular treatment by using Gore Excluder contralateral leg or iliac extension at our institute. The medical records of these patients including baseline characteristics, procedure and follow-up data were retrospectively reviewed. Results: Solitary iliac aneurysms included 13 of common iliac artery aneurysm (CIAA) and 11 of internal iliac artery aneurysm (IIAA). Nine cases (5 of CIAA and 4 of IIAA) who had previous bifurcated graft replacement for AAA were also included. Mean diameter of CIAA at treatment was 38 mm, and that of IIAA was 47 mm. The operative procedure of CIAA was stentgraft placement from CIA to EIA with/without embolization of IIA and that of IIAA was stentgraft placement as well with embolization of the branches of IIAA. The technical success rate was 100%, and there were no major post-operative complications. The mean follow up period of CIAA was 25.3 months, and that of IIAA was 19.9 months. No graft occlusions have been seen during the period. All the patients except for one of IIAA showed aneurysm shrinkage. Only one patient of IIAA showed aneurysm sac expansion and needed secondary treatment. The cause of expansion was type 2 endoleak from branches of IIAA, and this was due to inadequate embolization at the first treatment. Conclusion: The outcomes of endovascular treatment for isolated iliac artery aneurysms by using Excluder leg was thought to be less invasive procedure and it showed good mid-term results.

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Objective and Methods: From October 2003 to October 2013, 42 popliteal artery aneurysms (PAA) in 30 patients presented at our hospital. The mean age of the patients was 69 years; 24 were male and 6 were female. Results: Mean PAA size was 32 mm. At initial visit 72% of the patients presented ischemic symptoms; 56% of the patients with aneurysm occlusion and 16% of peripheral embolization. Aneurism occlusion or intramural thrombosis tend to increase in relation to aneurismal size, however in these cases we observed this increase in patients with aneurysms of less than 2 cm. Twenty eight PAAs were treated surgically; three patients required leg amputation and in three grafts were occluded. These cases had poor vessel runoff due to occlusion of all three vessels. Conclusion: Popliteal artery aneurysm greatly increases the risk of ischemic event due to thrombosis, and surgical outcome may be affected by peripheral embolism. It is therefore important to consider not only PAA size, but also intra-mural thrombosis in determining surgical indications in the course of treatment to prevent increased risk of an acute ischemic event even in patients with small aneurisms.

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Case 1: an 85-year-old male had abdominal aneurysm ruptured case with retroperitoneal Hematoma (Fitzgerald III type), and the emergency graft replacement was carried on. Case 2: a 76-year-old man had a ruptured abdominal aneurysm (Fitzgerald IV type) in a shock status, and the emergency graft replacement was done. In both cases, IABO catheter was used through left brachial artery for the aortic clamping. Almost no bleeding from the proximal site was seen, and the graft replacement was made by inclusion method. They were discharged without any complication. Inflation of Rescue Balloon through the brachial artery for aortic clamping was useful in stable of hemodynamics and ensuring a good and easier surgical anastomosis. After the blood pressure was stable and there was no bleeding at the proximal site, the graft anastomosis by inclusion technique was done safely and precisely.

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The patient was a 64-year-old man treated by endovascular aortic repair (EVAR) for abdominal aortic aneurysm. Four years after EVAR, the patient revisited the previous hospital complaining abdominal pain and loss of consciousness. Ruptured abdominal aortic aneurysm was suspected and the patient was transferred to our institution. Hemodynamics was stable relatively. CT showed the retroperitoneal hematoma and migration of stent graft. Ruptured abdominal aortic aneurysm after EVAR was diagnosed, and we performed re-endovascular repair to the proximal side of the aneurysm emergently. Postoperative course was uneventful and he discharged without any morbidity.

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Persistent sciatic artery (PSA) is a rare congenital vascular anomaly that occurs in about 0.01 to 0.06% of the population. A 62-year-old woman consulted another doctor for a 2-day history of intermittent claudication following acute-onset right leg pain. She was referred to our hospital with a diagnosis of acute ischemia of the right lower limb. Physical examination revealed an absence of pulsation of the right popliteal artery. The ankle brachial index (ABI) was 0.62, and computed tomography (CT) showed a right PSA that was occluded in the obturator foramen. She became able to walk about 300 m with conservative medical treatment. However, because of intermittent claudication, thrombectomy and femoropopliteal above-knee bypass were performed 13 days after the onset. The result of the surgery was successful, and her symptoms disappeared. Postoperative CT showed no residual thrombus, and her ABI improved to 1.07.

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Limb trouble after endovascular repair (EVAR) of abdominal aortic aneurysm (AAA) is one of the major complications. We report a case of bilateral limb trouble after EVAR of AAA with Endurant^® stent graft system. A 75-year-old man with AAA (maximum diameter 50 mm) underwent EVAR without any troubles. Four months later of the surgery, intermittent claudication was occurred just after work with squatting posture. About 20 days after claudication occurred, this patient visited our department and computed tomography (CT) revealed the occlusion of the left limb. Bypass surgery between bilateral external iliac arteries (EIA) was performed and intermittent claudication was improved. Three months later of the second operation, ankle/brachial index (ABI) examination revealed malperfusion of bilateral lower extremities and CT revealed the stenosis at the distal edge of right limb. The percutaneous angioplasty with Epic^TM Vascular Self-Expanding Stent System was performed successfully. In our case, bilateral distal stent limb of EVAR were deployed in each EIA. But this maneuver is reported to be a cause of limb trouble. Considering other case reports, there may be a relationship between the distal deployment site, especially in EIA, and squatting posture. After EVAR of AAA, not only the image examination for endoleak but ABI examination should be performed to detect of limb trouble in early stage.

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A 67-year-old man who had a saccular abdominal aortic aneurysm (AAA) with narrow terminal aorta was underwent endovascular aortic aneurysm repair (EVAR) by Endologix Powerlink^®. He complained ischemic right leg pain, one year after EVAR. The computed tomography showed stenosis of Powerlink^® right limb. The right limb was compressed by the left limb of Powerlink^® at narrow terminal aorta. We performed re-intervention to dilate narrow terminal aorta with Palmatz XL stent^® (Cordis) and bilateral limbs with kissing stenting of Express Vascular LD^® (Boston Scientific). After operation his ankle brachial pressure index arise from 0.66 to 1.19. Powerlink^® is said that hard to complicate limb stenosis even if narrow terminal aorta case due to its sit on the bifurcation of aorta system. Even through, careful observation is needed at quit narrow terminal aorta cases, which may happen not to sit on stentgraft main body at terminal aorta.

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A 65-year-old man who suffered from dyspnea with sudden onset was referred to our hospital by an ambulance. Pulmonary thromboembolism was suspected from his symptoms, echocardiographic findings and high FDP and D-dimer levels. However, enhanced CT scan revealed aortocaval fistula (ACF) due to ruptured abdominal aortic aneurysm, and pulmonary thromboembolism was denied. Emergent operation was performed successfully. It might be very important to distinguish ACF from pulmonary thromboembolism in the early phase of diagnosis because of its similarity of symptoms and laboratory findings due to high pulmonary pressure. Precise diagnosis is mandatory to rescue patients with ACF.

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The patient was a 25-year-old primiparous woman complicated with deep vein thrombosis (DVT) of the left iliac vein. Despite conservative therapy for DVT, the thrombus did not disappear completely. A temporary inferior vena cava (IVC) filter (Gunther Tulip filter^TM) was placed to prevent pulmonary thromboembolism, and she uneventfully delivered a baby. Two weeks after childbirth, computed tomography revealed that the leg of the IVC filter had penetrated the inferior vena cava and the tip of it was located in the pancreas head. The IVC filter was removed under laparotomy, and the patient was discharged on eighth post-operative day without further trouble. In pregnant women, there must be particular concerns in IVC filter insertion such as type of the filter to be used and removal method of the device.

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A 73-year-old man, who had underwent coronary artery bypass, aortic valve replacement and debranching thoracic endovascular aortic repair for arch aneurysm, had abdominal aortic aneurysm (AAA, fusiform type, 46 × 44 mm in diameter) with multiple focal aortic dissections involving visceral/abdominal aorta and common iliac arteries. We conducted endovascular aortic repair for this AAA in consideration of his past cardiovascular surgical histories and the risk of open repair regarding the vascular clamp injuries for fragile aorta and iliac arteries owing to focal dissections. The device of endovascular aortic repair (EVAR) was C3 Excluder, which was composed of polytetrafluoroethylene graft and nitinol frames without bare stents at the top end, could exclude the AAA without any type I/III endoleaks and aortic dissections uneventfully. EVAR with C3 Excluder stent graft is an excellent alternative of open repair for patients with AAA complicated with multiple focal dissections involving abdominal aorta and iliac arteries without any fear of vascular clamp injuries on open repair.

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Traumatic arteriovenous fistula (AVF) is not uncommon disorder, however its late discovery and presentation as high-output heart failure are rare. We report a case of traumatic superficial femoral AVF diagnosed approximately 40 years after initial injury. A 63-year-old man complaining of dyspnea was referred to our hospital. He had a history of a stub injury to the left thigh 40 years ago. Computed tomography (CT) and angiography revealed left superficial femoral AVF. After establishing the diagnosis of high-output heart failure due to the traumatic AVF, we performed surgical repair. After surgery, the patient’s symptoms improved significantly, but the left superficial femoral vein was thrombosed.

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Renal cell carcinoma (RCC) extends into the inferior vena cava (IVC) as a thrombus of tumor in 3 to 10% of patients with this disease. The presence of tumor thrombus associated with RCC has not been shown to be a determinant of survival. For this reason, an aggressive approach to resection has been advocated for several decades. So we report a surgical case of renal cell carcinoma with a tumor thrombus extending into IVC. A 63-year-old man complaining of low-grade fever was pointed out right renal tumor with a tumor thrombus extending into the IVC by enhanced computed tomographic-scanning in this hospital. Though he also had lung and bone metastasis, he wished to undergo an operation. Right nephrectomy and removal of an intra-IVC tumor thrombus were performed without a cardiopulmonary bypass. To prevent pulmonary thromboembolism, a temporary inferior vena cava filter was placed before laparotomy. The postoperative course was uneventful and the patient was discharged from the hospital 9 days postoperatively. The pathological diagnosis was renal clear cell cartinoma. In our experience, it is important to determine an adequate surgical procedure for a RCC with IVC tumor thrombus under considerable preoperative assessment.

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Even though the use of endovascular treatment for critical limb ischemia is increasing, an open surgical procedure is still preferred for the limbs in patients with a longer life expectancy. If the great saphenous vein is unavailable, then bypass surgery should probably not be performed. We herein report a case in which bypass surgery was performed by using the arm vein conduits. The case was a 57-year-old male with critical limb ischemia. The bilateral great saphenous veins had been used at previous bypass surgeries; therefore, he did not have any available autogenous vein grafts in the lower extremity. In the left upper extremity, he had an arteriovenous fistula for hemodialysis. His right side arm vein diameter was almost 2 mm, and the arteriovenous fistula between the right side of the brachial artery and arm vein was found to have dilated the right side arm veins. Given the sufficient diameter of the arm vein conduits, we performed distal bypass surgery, and accomplished good healing of the ulcer. An arm vein conduit can be used as an alternative to the great saphenous vein for autogenous vein grafting, and therefore, clinicians should evaluate the arm veins and consider using them as a conduit for bypass surgery in cases with critical limb ischemia.

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Endovascular repair of abdominal aortic aneurysm (AAA) have accepted widely as a low invasive treatment, but with a potentiality of a development of endoleaks, which can be a cause of AAA rupture after the treatment. We describe endovascular repair combined with Kilt technique to treat AAA with aberrant renal arteries (ARA) of horseshoe kidney. A 79-year-old man was referred because of a 60 mm infrarenal AAA with horseshoe kidney. The horseshoe kidney had 3 ARA from AAA connecting to isthmus. His renal function was almost normal. Preoperative selective renal artery angiography with enhanced computed tomography (CT) scan showed that more than two third of the total renal mass was supplied by the original renal arteries. Endovascular repair without reconstruction of ARA was done. In this treatment, Kilt technique was performed before main body deployment, to avoid an appearance type II endoleak from ARA and inferior mesenteric artery. The postoperative enhanced CT scan showed a slight isthmus reduction, without any endoleaks. Postoperatively, the renal function showed no serious damage. Endovascular Repair combined with Kilt technique may be considered appropriate in suited AAA cases with ARA of horseshoe kidney.

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