Objectives: Unexpected systemic inflammatory response with high fever and increase in C-reactive protein (CRP) occurred frequently after endovascular abdominal aortic aneurysm repair (EVAR). This excessive inflammatory response affects on the postoperative course. We evaluated the effects of steroid on the postoperative inflammatory response after EVAR. Methods: Steroid therapy, intravenous infusion of methylprednisolone 1000 mg just after the anesthesia induction, was started since December 2012. After induction of the steroid therapy, 25 patients underwent EVAR with steroid therapy (Group S). These patients were compared with the 65 patients who underwent EVAR without steroid therapy (Group C) in white blood cell count (WBC), CRP and maximum body temperature (BT) on postoperative day 1–5. Results: There was no significant difference in age, female gender, operation time, maximum aneurysm diameter between the two groups. There was no postoperative infective complication in the both groups. WBC did not differ between the two groups, however, CRP was significantly suppressed in Group S than in Group C on POD 1, 3 and 5. Also BT was significantly lower in Group S than Group C on POD 1, 2 and 3. Conclusions: Steroid pretreatment before implantation of the stentgraft reduces the early postoperative inflammatory response after EVAR, without increasing postoperative infection.

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Although traumatic popliteal artery injury is rare, without quick, correct treatment, it carries a high risk of amputation. We report two cases of popliteal artery trauma in which amputation was avoided by surgical treatment. Case 1 was a 55-year-old man who fell into a ditch. The left leg had a 12-cm popliteal fossa laceration, a pulseless dorsal artery, and paleness and coldness distally. Computed tomography showed popliteal artery obstruction. Case 2 was a 53-year-old man injured in a traffic accident. The right lower leg was swollen and pale, with a pulseless dorsal artery. Computed tomography showed popliteal artery obstruction plus tibial and fibular fractures. In both, we performed revascularization from a posterior approach after harvesting the greater saphenous vein with patients in the supine position; subsequently, blood flow was improved. The operative view showed that the popliteal artery was completely severed in Case 1 and dissected in Case 2. The time until reperfusion was 7 and 10 hours, respectively. After the greater saphenous vein was harvested via the supine position, repair of traumatic popliteal artery injury via the posterior approach was effective.

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We encountered an endovascular repair of primary entry closure of chronic type B dissection with aortoiliac occlusive disease. The patient was 67-year-old man who had undergone right axillo-bifemoral bypass 17 years previously. Enhanced computed tomography revealed that the false lumen of distal aortic arch enlarged and a saccular aneurysm developed at the false lumen of mid-descending aorta. We performed primary entry closure with stent graft via left axillary artery. This procedure may be valuable treatment for primary entry closure of chronic type B dissection with aortoiliac occlusive disease.

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A non-anastomotic pseudoaneurysm is rare, and we present an unusual case of non-anastomotic pseudoaneurysm that occurred almost two decades postoperatively. A 62-year-old man had undergone abdominal aortic replacement with a bifurcated prosthesis graft 20 years previously. A Y-shaped Dacron graft had been used, and proximal anastomosis was performed at the infrarenal neck of the aneurysm. The graft was then anastomosed end-to-side to the right common femoral artery, and end-to-end anastomosis was performed to the left common iliac artery. The right common iliac artery was ligated, and his initial postoperative course was uneventful. However, 18 years later, computed tomography revealed a pseudoaneurysm developing at the non-anastomotic site due to prosthetic graft failure. The failed portion of the graft was resected and was replaced with a 16-mm J graft. The second operative course was uneventful. This case demonstrates the importance of carefully monitoring patients for the potential formation of pseudoaneurysms, especially if an arterial graft has been used below the groin, and even if it has been many years since the initial surgery was performed.

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Ruptured abdominal aortic aneurysm remains one of the high mortality diseases. A common treatment for this condition is open repair, but recently this treatment is increasingly reported as endovascular repair (EVAR). The main problem following EVAR is a pathogenesis abdominal compartment syndrome (ACS) and continued hemorrhage for a variety of endoleak. We report a case of EVAR and damage control surgery (DCS) for free wall ruptured abdominal aortic aneurysm. A 78-year-old male with unconsciousness and abdominal pains was admitted to our hospital by a helicopter. A computed tomography scan revealed the retroperitoneal hematoma around abdominal aortic aneurysm. Surgical treatment consisted of emergent EVAR. Anesthesia induction brought about a reduction in blood pressure and abdominal distention, thus we suspected free wall rupture. Open abdominal surgery was performed for ACS after EVAR without endoleak. Because of excessive bleeding and non-identifiable hemorrhagic spot, a hemostasis was of great difficulty. Hence we employed DCS including the abdominal gauze-packing and temporary closure. After the operation he was managed by combined modality therapy in intensive-care unit. Two days later we performed second look operation. Because of confirmed hemostasis we performed de-packing and permanet closure. The patient slowly recovered and changed hospital on the 96nd hospital day.

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Acute arterial obstruction of the upper limb merely leads to severe ischemic tissue defect. We experienced a case of massive and progressive tissue defect due to acute upper limb ischemia, successfully treated by bypass operation. The patient was a 73 years-old man who had had atrial fibrillation and cerebral infarction. He was found lying down alone at his room and diagnosed cerebral infarction. His left thumb and index finger had massive tissue necrosis. The finger amputation and debridement were performed in nearby hospital. Although skin graft had been performed for the skin defect, the graft became necrosis. Angiography revealed the interruption of left brachial artery. SPP was 42 mmHg at the palm. We diagnosed severe upper limb ischemia due to thrombus derived from atrial fibrillation, combined with tissue necrosis due to compression on his left upper limb. Brachio-ulnar artery bypass and debridement of necrotic tissue were performed at our hospital. After 5 months, left hand showed good granulation and epithelization. We concluded that bypass surgery should be performed for severe upper limb ischemia without missing an opportunity in case of progressive tissue defect.

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Antiphospholipid antibody syndrome (APS) precipitates arterial and venous thrombosis and Systemic lupus erythematosus (SLE) occasionally has vasculitis. They sometimes coexist and rarely cause ischemic necrosis in digits or limbs. A 60-year-old woman with steroid therapy presented pain and cyanosis in bilateral toes. We started antiplatelet therapy, but ischemic necrosis progressed rapidly. Ischemic necrosis in the right 1st, 3rd, 4th toes and the left forefoot developed. Angiography showed occlusion of the bilateral anterior tibial, posterior tibial and dorsalis pedis arteries. There was the communicating branch from peroneal artery to plantar artery which developed well in the right foot, but left plantar artery flow was maintained by poor collateral flow from peroneal artery. For the left foot with severe ischemia, left below knee popliteal- posterior tibial artery bypass, left transmetatarsal amputation, and right 1st, 3rd, 4th toes amputation were performed. Postoperative two years have passed, bypass graft is patent and she has no foot symptom.

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Although the first line treatment of diabetic foot is conservative treatment, surgical bypass is sometimes needed for treatment of neuro-ischemic type of diabetic ulcer. We report a case of limb salvage by tiblal artery bypass for severe diabetic foot with massive tissue defect and sustained infection. Patient was a 60-years-old man who had right foot ulcer with untreated diabetes. Although he had underwent antibiotic treatment and debridement of infected tissue, skin ulcer and necrosis extended to the dorsal surface of right foot. Angiography revealed small lesion on the tibial arteries. SPP was 47 mmHg at the dorsal region of right foot. Even so, because the necrosis had progressed, he underwent a right below knee popliteo-dorsalis pedis artery bypass for limb salvage. After 6 months, foot ulcer healed with additional skin grafting. We conclude that in case of progressive tissue defect with diabetic foot surgical intervention should be performed aggressively to control infection, even if the arterial lesion is mild.

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Hepatic artery aneurysms are relatively rare. In some cases, a rupture of an aneurysm into the retroperitoneal or the biliary tree is the first clinical manifestation. In cases of ruptured aneurysms into the biliary duct, both pseudoaneurysms and hemorrhaging into the intrahepatic biliary tree have so far been reported. However, a common hepatic artery (CHA) aneurysm rupturing into the common bile duct is a rare occurrence. We herein describe the case of a 59-year-old man who was admitted to our hospital with hematemesis and melena due to a rupture of a CHA aneurysm into the common bile duct. The CHA aneurysm involved the proper hepatic artery (HA), the right and left HAs, and the gastroduodenal artery. Aneurysmectomy was performed followed by vascular reconstruction of the right HA with a PROPATEN^TM (W.L. GORE & Associates, Inc. Flagstaff, AZ, USA) to avoid hepatic ischemia. In addition, choledochectomy and biliary tract reconstruction were performed due to the strong adhesion of the aneurysm to the common bile duct. The postoperative course was uneventful. When treating a HA aneurysm involving the proper HA, direct vascular reconstruction following aneurysmectomy is necessary. In addition to performing aneurysmectomy and vascular reconstruction, biliary tract reconstruction is also required in this very rare case.

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Giant cell arteritis (GCA) is a disease of unknown origin affecting patients over 50 years of age. It presents with the inflammation of the medium and large arteritis. While there are few reports of this disease in Japan, its association with thoracic aortic aneurysms and aortic dissections has been reported. Here we present a case of GCA that was diagnosed from histological findings after surgery for acute type A aortic dissection. The patient was a 65-year-old man who underwent total arch replacement for an acute type A aortic dissection. Postoperatively, he developed systemic inflammation and a mild protracted fever. We administered antibiotics and conducted careful follow-up observations. On the 10^th postoperative day, histological findings revealed infiltration of many multinucleated giant cells from the ascending aorta to aortic arch involving brachiocephalic artery, and made a diagnosis of GCA. The inflammation gradually improved with the administration of steroids. A postoperative computed tomography (CT) scan confirmed a dissecting aneurysm of the anastomosis of the brachiocephalic artery with narrowing of the true lumen. There were no symptoms and the patient was in the acute stage of dissection, we implemented the wait-and-see approach. A CT scan obtained six months later revealed expansion of the anastomotic aneurysm with severe stenosis of the true lumen. Hence, we inserted a stent graft from the right common carotid artery and achieved a favorable result.

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Perigraft seroma is a well-known complication of reconstructive vascular surgery, but a large seroma is rare. A 77-year-old man underwent right axillo-femoral and femoro-popliteal artery bypass with an expanded polytetrafluoroethylene graft (ePTFE) for arteriosclerosis obliterans. Two months after surgery, a large seroma was observed along the axillofemoral bypass graft. Since there was no improvement after puncture and drainage, the graft was removed and replaced by a new Dacron graft. The patient did not have any recurrent seroma or exacerbation of limb ischemia until the time of his death due to rectal cancer 20 months after surgery. A histopathological examination showed that there was a poor growth of fibroblast on the surface of the vascular graft. The seroma could have enlarged from cracking of the thin fibrous connective tissue. Although the cause and treatment of seroma are uncertain, removal of the graft and replacement with a new graft is reported to be the most effective treatment, and was also effective in our patient.

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We present a case of traumatic pseudoaneurysms of the brachiocephalic artery and the right subclavian artery caused by a traffic accident. A 68-year-old man, who had a left pneumonectomy previously, was brought to our emergency department with multiple sternal fractures and right lung contusion. On admission, CT scan showed mediastinal hematoma with localized dissection of the brachiocephalic artery. Initially we chose a conservative treatment for this patient. Follow-up CT scan on day 6 revealed pseudoaneurysms of the brachiocephalic artery and the right subclavian artery. We performed an emergency operation, including bypasses using woven Dacron grafts from ascending aorta to the right common carotid artery and the right axillary artery and exclusion of two pseudoaneurysms. The patient survived the operation without phrenic palsy or recurrent nerve injury, progressed well and was discharged after intensive respiratory physiotherapy. Initial treatment for traumatic vascular injury of chest should be chosen considering the patient’s condition. Since intensive observation including repeat CT scan or lab data sometimes shows the progression of the lesion, it is important to be ready to quickly shift to aggressive treatment.

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69-year-old woman with hypertension and hyperlipidemia was referred to our hospital because of suspected acute ischemia of the right lower limb. Physical examination revealed bilateral pain and paleness of the lower limbs, paresthesia and paralysis of the right lower limb and an ulcer between the fourth toe and fifth right toe. Computed tomography (CT) showed occlusion of the right popliteal artery and an irregular lesion of the descending aorta, which was suspected to be a thoracic aortic thrombus. We performed an emergency thrombectomy because of acute arterial occlusive disease of the right lower limb. After the thrombectomy, due to recurrent emboli, we performed descending aorta replacement because of recurrent emboli despite anticoagulant therapy. The pathological diagnosis was intimal angiosarcoma of the thoracic aorta. In this case, we presumed that acute arterial occlusive disease of the lower limb was caused by an intimal angiosarcoma.

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An 82-year-old man with a history of knitted Dacron graft replacement for abdominal aortic aneurysm 13 years previously presented with abdominal pain. Computed tomography (CT) revealed multiple extravasation from the Dacron graft and false aneurysm, and angiography showed four extravasation points at the body (non-anastomotic lesion) and the legs (non-anastomotic or anastomotic lesions) of the Dacron graft. Because the patient had undergone laparotomy twice with a stoma formation, endovascular aneurysm repair (EVAR) was taken into consideration. A Zenith iliac plug was placed into the Dacron graft via the right femoral artery, followed by an aortic converter inserted from the left femoral artery. Finally, femorofemoral crossover bypass was performed to supply the adequate blood flow to the right leg. Although his symptom disappeared after this operation, delayed-phase CT images demonstrated type Ib or type III endoleak with no signs of progressive dilatation of the false aneurysm. The patient has been strictly followed on the outpatient clinic over 11 months postoperatively. Non-anastomotic false aneurysm is rare and EVAR using ancillary components such as converter and iliac plug may be an effective and less invasive surgical option even if typical EVAR is not applicable because of some anatomical restrictions.

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A 83-year-old woman visited our hospital with a 2-day history of abdominal pain. He had mild tenderness all over the abdomen, but no signs of peritoneal irritation. Abdominal contrast-enhanced CT revealed thrombus in the main trunk of the superior mesenteric artery (SMA), however there were no signs of intestinal necrosis. Since there were no symptoms of intestinal necrosis, conservative treatment was instituted. CT done 12 hours after the initial CT showed no symptoms of intestinal necrosis. But the abdominal pain was not reduced, thrombolysis via a catheter placed in the superior mesenteric artery (SMA) was planned. Urokinase was administered by continuous infusion at the dose of 240000 units/day for 3 days. Angiography confirmed significantly decreased thrombus in the main trunk of the SMA. In addition, the clinical symptom was also disappeared. The subsequent clinical course was satisfactory. Thrombolysis via a catheter placed in the SMA could be an effective treatment option for sub-acute SMA thrombosis without intestinal necrosis.

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