Objective: This study aimed to analyze the perioperative and midterm outcomes after CFA endarterectomy. Methods: From April 2009 to March 2015, 26 patients (29 limbs) underwent CFA endarterectomy in our hospital. Results: 21 patients (24 limbs) underwent endarterectomy and vein patch plasty and 5 patients (5 limbs) underwent endarterectomoy and direct closure of arteriotomy. Operative time was 123.8±32.7 min. The ankle-brachial index improved from 0.62±0.21 preoperatively to 0.92±0.15 postoperatively. Neither peri-operative deaths nor major complications occurred. Outpatient follow-up was obtained in 25 patients (28 limbs). The primary patency rate was 100% at 3 years. Conclusion: Endarterctomy for patients with atherosclerotic CFA disease proved to be safe and effective.

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Objective: The purpose of this study is to evaluate the result of thoracic endovascular aortic repair for retrograde type A acute aortic dissection and complicated type B acute aortic dissection. Methods: Retrospective study was performed on 20 patients who underwent thoracic endovascular aortic repair for acute aortic dissection. Result: Mean age was 64.9±11.6 years old. Sixteen patients of all were male. Three cases were retrograde Stanford type A and 17 cases were Stanford type B. The number of complicated type B dissection was 8 cases, which included 4 with branch ischemia, 3 with rupture and 1 with lower extremity ischemia. Mean interval from the onset to the operation was 13.9±25.0 days. Type of device was 1 with TAG, 15 with Conformable TAG, 3 with RELAY Plus, and 1 with Najuta. Extra-anatomical bypass of neck vessels was added to 4 cases. Device success rate was 100%. There was no death after the operation and perioperative complications included one paraparesis and one cerebral infarction. The entry closure and thrombus on target area was obtained in all cases with no device-associated complications, such as endoleak and re-enlargement. Post-operative computed tomography demonstrated that true lumen dilated and false lumen diminished in early and mid-term. Conclusion: Thoracic endovascular aortic repair for acute aortic dissection was performed effectively and safely.

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A 61-year-old male was admitted to our hospital with left buttock pain and fever of more than 39 degree. He had been treated with an acupuncture treatment for lumbago 3 days before. He also suffered from gait disturbance and numbness of the left leg on admission. Magnetic resonance imaging showed an aneurysm with abscess formation in the left gluteal region. Computed tomographic scanning documented that the left internal iliac artery was large and tortuous, forming an aneurysm about 3 cm in diameter at his left hip region, and ran to the left popliteal artery. These findings established the diagnosis of persistent sciatic artery (PSA) aneurysm with infection. He was treated surgically next day on admission. At first, on the supine position, the left internal iliac artery was exposed retroperitoneally by para-rectal skin incision. The left popliteal artery was also exposed by small skin incision above the left knee. Both the arteries were cut off at the pelvis and the adductor magnus, respectively. The aneurysmal side of these arteries were closed. A vascular prosthesis (8 mm ringed expanded polytetrafluoroetylene graft) was interposed between these arteries. The graft was passed beneath the inguinal ligament along with the hypoplastic external iliac and femoral artery to avoid the contamination from the infectious aneurysm. Finally, the infectious PSA aneurysm was excised on the right lateral position. The sciatic neuralgia and fever disappeared immediately after the operation. Methicilline-sensitive staphylococcus aureus was detected both from the preoperative blood sample and intraoperative purulent discharge around the aneurysm. He was discharged on postoperative day 19 with no recurrence of infection.

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79-year-old man had a right abdominal pain. He underwent computed tomography (CT), which revealed a filling defect in the thoracic descending aorta. It caused major embolic complication, right renal infarction and superior mesenteric artery embolism. He was referred to our hospital. In addition, enhanced magnetic resonance imaging revealed a mass with ringed enhancement. Angiography showed a filling defect in the Th10 level. It is difficult to differentiate from the malignant tumor. Urgent surgery was performed because of dangerous embolism. Aortic wall including mass was removed en bloc and replaced with prosthesis graft under partial cardiopulmonary bypass. The mass, 32 × 18 mm in diameter, was revealed thrombus material with no macroscopic sign of malignance. The postoperative course was good to take a Coumadin. No recurrence thrombosis has been observed for a year. We reported a good result of a surgical treatment for mobile thrombus in thoracic aorta.

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Twenty-one years old woman was diagnosed with WEST syndrome and spastic quadriplesgia at age 7 months. She underwent tracheotomy at age 15 years due to repeated respiratory infections and laryngo-tracheal separation at age 20 years due to advanced lateral curvature. Periodic bronchoscopic examination demonstrated a beating of brachiocephalic artery in her trachea, which was thought to be a risk factor of trachea-innominate artery fistula. Preoperative computed tomography demonstrated the anatomical location of brachiocephalic artery and a communication of basilar artery. In the operation, we confirmed blood pressure in right upper limb decreased only mildly and regional cerebral oxygen saturation did not change by clamping the brachiocephalic artery. After resection of the medial head left clavicula and left upper sternum, brachiocepharic artery was transected in the midpoint. There was no postoperative complication such as a cerebral vascular accident and an ischemia of right upper limb. She was discharge at postoperative day 9.

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We present a rare case of multiple infected aortic aneurysms repaired by staged in situ graft replacement in kidney transplant recipient. A 57-year-old man who underwent kidney transplantation 8 months previously admitted with fever. Methicillin-sensitive Staphylococcus aureus was cultured from the blood. Computed tomographic scan showed saccular aneurysms in the descending aorta and the abdominal aorta. He was diagnosed with multiple infected aortic aneurysms. A staged in situ repair using rifampicin-bonded gelatin sealed grafts was performed. Postoperative course was uneventful. The patient was discharged without any evidence of remaining infection and perioperative development of renal failure.

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A 55 year-old man was crashed under stainless steel plates 300 kg in weight. He was diagnosed as left lung contusion, fracture of left 3rd–5th ribs and blunt aortic injury (BAI) with dissection of aortic arch to descending aorta and mediastinal hematoma. As CT revealed the increase of mediastinal hematoma within two hours after injury, emergency intervention was indicated. To avoid, left thoracotomy, extracorporeal circulation and hypothermic circulatory arrest for the replacement of arch to descending aorta, TEVAR was performed after the initiation of right axillary to left common carotid and left axillary bypass with 8×8 mm Gore-tex^TM graft. The operation time was 225 minutes and intraoperative blood loss was 50 ml. He discharged home 14 days after surgery and returned to job 1 month after. Postoperative CT revealed no endoleak and patency of bypass graft. This is a case report of TEVAR with supra-aortic bypass to treat BAI without other life-threatening injury.

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A 82-year old man with edema of lower extremities and dyspnea on effort was admitted to our hospital. Computed tomography showed multiple aneurysms, a 80-mm aneurysm of the distal aortic arch, a 75-mm aneurysm of the descending aorta, and a 53-mm aneurysm of the abdominal aorta with moderate left pleural effusion. The one-staged hybrid treatment, total arch replacement using open-stent grafting technique and “Antegrade” TEVAR, was selected considering of the following problems, frailty, interval rupture of two-staged treatment, and unsuitable access for “Retrograde” TEVAR. The operation was performed with median sternotomy. After the induction of circulatory arrest in moderate hypothermia, selective cerebral perfusion was initiated. Total arch replacement using handmade open-stent graft was performed. After weaning of cardiopulmonary bypass, “Antegrade” TEVAR was performed from the side-branch of the 4-branched graft. The postoperative course was uneventful with no cerebral complication or spinal cord injury. Recent development of endovascular treatment causes various options for high-aged patients with complex thoracic aortic aneurysm. In our successful case, “Antegrade” TEVAR was particularly efficient.

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A 65-year-old man with chronic atrial fibrillation was transferred to our hospital with the complaint of acute abdominal pain. He had ceased taking oral anticoagulant for polypectomy. Enhanced computed tomography revealed that the proximal portion of the superior mesenteric artery (SMA) was occluded and that the distal portion of the SMA was being perfused by collateral flow. Laboratory data revealed no signs of organ ischemia. Under the diagnosis of acute SMA embolism, emergent laparotomy was performed to assess the bowel necrosis and to revascularize the SMA. Because embolectomy with a Fogarty catheter was unsuccessful, bypass surgery to the SMA was performed using a saphenous vein graft. Intestinal resection was not required because there was no bowel necrosis. The patient was discharged 16 days after the operation without clinical signs of recurrent mesenteric ischemia.

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Axillary artery aneurysm and thromboembolism from the aneurysm is rare. The patient was a 47-year-old man and his chief complaint was sudden numbness of his right forearm during exercise. Contrast-enhanced computed tomography demonstrated a 35×33×50 mm fusiform aneurysm of the right axillary artery with mural thrombus. Right brachial artery was occluded. Because of the risk of re-thromboembolism and rupture, elective surgery was performed. Using the deltoid-pectoral approach, replacement of the aneurysm with an ePTFE graft was performed. Pathological examination revealed focal disappearance of medial smooth muscle cells without atherosclerotic change. His postoperative course was uneventful.

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Peripheral artery disease (PAD) has been treated in Japan following the TASC II guidelines. Antiplatelet drugs as adjuvant pharmacotherapy after revascularization has been recommended, and they should be started preoperatively or just after the surgery, to prevent the thrombotic occlusion at the treated site. About 20% of the Japanese population are considered to be the poor metabolizer of clopidogrel, but measuring the platelet function for investigating the effect of the drug is not generally accepted yet. A 60-year-old man underwent the Lt. Femoro — Popliteal above the knee bypass 20 months ago, however, his bypass graft was occluded for the local thrombosis. His platelet aggregation measured by VerifyNow PRU was 209, and % inhibition was 0% even though the patient had been taking clopidgrel regularly. Genotype investigation revealed that his CYP2C19 genotype was *2/*2, the poor metabolizer of clopidogrel. In the treatment of the PAD, point of care of the platelet function is important to prevent bleeding and the thrombotic complications during antiplatelet therapy.

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Ehlers-Danlos syndrome (EDS) is a rare connective tissue disorder, which is characterized by fragility of the skin, blood vessels, and joints. Arterial rupture is one of the most severe complications in patients with vascular type EDS. We herein report a case in which bilateral posterior tibial artery aneurysms led to the diagnosis of vascular type EDS. This case was a 27-year-old male with swelling of the left calf. His brother had an aneurysm of the carotid artery. He had thin skin with visible veins and skin hyperextensibility. Computed tomography showed bilateral posterior tibial artery aneurysms, sized 10 mm, and a left aneurysm which may have ruptured. These findings were suggestive of vascular type EDS, and conservative management was performed. After the treatment, his clinical symptoms were relieved, and no further rupture of the aneurysms occurred. Patients with vascular type EDS should be promptly evaluated, and the treatment must take into account the fragility of the patient’s skin, connective tissue, and blood vessels.

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We report a case of chronic left iliofemoral vein occlusion with ipsilateral arteriovenous fistulae (AVF) in the leg. The patient was a 58-year-old woman who had a history of left hemi-palsy due to cerebral infarction. The patient underwent implantation of an infra vena cava (IVC) filter in the left common iliac vein as she suffered from deep venous thrombosis and subsequent pulmonary embolism. However, the filter caused occlusion of the left iliac veins, after which atriovenous fistulae developed in the left pelvis. Left leg and the skin in these areas swelled notably. Palma bypass was performed using a saphenous vein graft and the venous pressure in the left leg subsequently decreased from 66 to 33 mmHg. The edema in the left leg consequently subsided and the patient was discharged without any complications. Palma bypass is the main treatment for iliofemoral chronic occlusion worldwide, however, few studies in Japan have reported on it. The technique was very effective for the treatment of hemi-iliofemoral vein occlusion and ipsilateral atriovenous fistulae.

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We report a case of acute interstitial nephritis after endovascular repair for a ruptured infected abdominal aortic aneurysm. A 67-year-old man had surgery for gastric cancer. Two months after the operation, the patient had an unconsciousness attack with decline of blood pressure. Laboratory data showed significant inflammation, and CT scan revealed an infected abdominal aortic aneurysm with a hematoma in the retroperitoneal space. He was diagnosed as a ruptured infected abdominal aortic aneurysm and underwent emergent endovascular repair using Gore Excluder^®. Antibiotics including β-lactam were administered to cover a wide range of bacteria. Renal function gradually worsened and white blood cell count rose with a high ratio of eosinophils. It was suspected that the patient developed acute interstitial nephritis caused by β-lactam antibiotics. Even though temporary hemodialysis was needed, renal function gradually improved after discontinuation of β-lactam antibiotics and administration of steroids. The patient was discharged on the 40th postoperative day, and has remained asymptomatic for 1 year after surgery.

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The chief complaint of this case is intermittent claudication of both lower extremities. His ankle-brachial pressure index (ABI) was low on both side, and enhanced computed tomography (CT) revealed that occlusion of the terminal aorta and bilateral iliac artery with several accessory renal arteries arising from border area of the occluded aorta. Bilateral aortoiliac stenting using kissing technique was performed, then the intermittent claudication was disappeared, and his ABI was improved to normal range. Postoperative enhanced CT demonstrated that successful recanalization of bilateral lower extremities with patency of all accessory renal arteries. There was no significant deterioration in the renal function during follow-up period.

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We had a case of recurrent Stanford type B acute aortic dissection (SBAAD) caused by endovascular aortic repair (EVAR) against abdominal aortic aneurysm. In this case, however, thoracic endovascular aortic repair (TEVAR) in combination with covered stent deployment made it possible for complete thrombosis in the false lumen after recurrence of SBAAD. A 64-year-old man complained sudden back pain. Enhanced CT examination showed SBAAD with complete thrombosis and abdominal aortic aneurysm with maximum diameter of 53 mm. EVAR was achieved at 32 days following the onset of SBAAD. Eight days after EVAR, the patient complained sudden abdominal discomfort, and enhanced CT examination showed that the false lumen was patent between distal arch and aorta just proximal of ostium of supra mesenteric artery. Furthermore, communication between true and false lumen was found in celiac artery. Three days after the recurrence of SBAAD, TEVAR was carried out for the proximal entry closure at the distal arch. In addition, 8×20 mm of Palmaz stent was deployed in celiac artery to restore blood flow in the true lumen. Four days after TEVAR, enhanced CT examination showed the residual communication into false lumen through the distal site of the stent in celiac artery. Covered stent was deployed in celiac artery for the residual entry closure 66 days after the recurrence of SBAAD. The last enhanced CT examination showed complete thrombosis in the false lumen after recurrence of SBAAD.

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The patient was a 75-year-old man who underwent a right axillo-bifemoral bypass and aneurysm resection for a mycotic abdominal aortic aneurysm in August 2003. Graft thrombosis occurred twice in two months after the surgery. A left axillo-bifemoral bypass was performed with a knitted Dacron graft. Eight months later, a mass appeared along with the graft, and was diagnosed as a perigraft seroma by enhanced computed tomography. Conservative management by puncture was performed, but the perigraft seroma was enlarged, and the patient was transferred to our hospital for operative treatment. In May 2009, we performed a left axillo-bifemoral bypass with an expanded polytetrafluoroethylene graft (ePTFE). A pathological study of the perigraft seroma confirmed that fewer collagen fibers were present around the graft. No recurrence occurred for 13 months until the patient stopped coming to hospital.

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