In this seminar, I would like to discuss the recent hybrid operations in patients with peripheral arterial diseases. Hybrid is generally defined as combinations of different types of things. In the surgical community, it is loosely defined as therapy combining open surgery (OS) and endovascular therapy (EVS). In practice, combination surgery of diseased inflow vessels by EVT and outflow vessels by OS is a typical example, namely, the combination therapy of thromboendarterectomy (TEA) for common femoral artery and EVT (PTA and stenting) for iliac artery in patients with PAD (ilio-femoral lesions). Also, there is the potential of various combinations of OS and EVT for complex lesions. Unfortunately, we do not have specific guidelines for hybrid therapy of PAD, but in clinical practices, justified decision-making for surgical indication is strictly required. I emphasize that the cardiovascular surgeon (or vascular specialist) must have the ability of decision-making for suitable combination therapy of OS and EVT which adheres to existing specific guidelines.

Frozen elephant trunk procedure is a hybrid of stent-grafting and open surgery for aortic arch disease. This procedure has widely spread all over the world as an original hybrid treatment with developing and marketing of the dedicated device. Although the most effective use of frozen elephant trunk technique is total arch repair for acute type A aortic dissection, this procedure can be indicated to all of aortic arch disease such as true aortic arch aneurysm and type B aortic dissection. A merit of this procedure is avoidance of suture anastomosis in descending aorta that is hard to suture without left thoracotomy, and subsequent diminishing pulmonary complications. Although a demerit of this procedure is increasing rate of spinal cord injury after operation, this complication is reduced to around 3% with some protection technique for spinal cord injury.

Objectives: We aim to assess the effect and significance of ultrasound-guided axillary nerve block on the diameter of basilic vein in vascular access surgery. Methods: 78 consecutive patients who underwent vascular access surgery with ultrasound-guided axillary nerve block were studied retrospectively. Diameter of basilic vein at the elbow level before and after the nerve block were measured and the dilatation rate was also calculated to assess the effect of nerve block on venous diameter. Results: Basilic vein diameter increased from 3.0+1.1 mm before the block to 4.1+1.2 mm after the block (p<0.001). Mean dilatation rate was 143+34%. The dilatation rate was inversely correlated with venous diameter before the block (p<0.001). Conclusion: Ultrasound-guided axillary nerve block induces significant basilic venous dilatation and that make the anastomotic procedure involving basilic vein possible, or much easier. This anesthetic technique was considered to be an effective option in vascular access surgery.

Objective: For endovascular aneurysm repair (EVAR), the treatment for AAA, we developed a Double D technique (DDT) for patients who are anatomically inadequate for treatment using commercially approved bifurcated stent grafts (SG). The DDT involves a parallel insertion and deployment of two limbs inside a deployed Aortic cuff. The aim of the study is to report the usefulness of DDT. Methods: In this study, we retrospectively reviewed clinical data from 6 patients who had been treated using DDT between 2012 and 2014. Result: The mean patient age was 73.5 years, and there were 4 men. The patients were treated for the following disease: 1 case was treated for a ruptured Abdominal Aortic aneurysm, 2 cases for bilateral Common Iliac artery aneurysms, 2 cases for Aortoiliac occlusive disease, and 1 case for a dissecting Aortic aneurysm. The indications for using the DDT were as follows: 3 cases had a narrow terminal aorta, 2 cases required the preservation of Inferior Mesenteric artery flow due to bilateral Internal Iliac artery occlusion, and 1 case had a narrow true lumen. The delivery success rate, the primary limb occlusion rate, and the secondary limb occlusion rate were 100%, 16.6%, and 0%, respectively. No endoleaks were observed. Conclusion: DDT could be a useful alternative for patients who are anatomically inadequate for the use of commercially approved bifurcated stent grafts.

Migration of the stent is one of the complications of endovascular aortic repair (EVAR) for abdominal aortic aneurysm (AAA), potentially leading to aortic rupture. Most migrations occur at proximal side of the stent and there are few reports of distal leg migration. We present a case where we successfully treated delayed the type Ib endoleak caused by leg proximal migration after EVAR for AAA and CIAA. The patient was a 74-year-old man diagnosed with infra-renal AAA and bilateral CIAAs. We first performed coil embolization of the bilateral internal iliac artery, then performed EVAR next. We chose Excluder device and deployed graft legs to the bilateral external iliac arteries. No intraoperative endoleaks were detected. Thirteen months after EVAR, a pulsatile abdominal mass developed, which was confirmed with enhanced CT as a type Ib endoleak. The right leg proximal migration caused the endoleak, and there was no right CIAA expansion. Six additional months later, the leg migration and the endoleak had progressed, and thus we proceeded to perform re-operation. We deployed an additional leg device from the right femoral artery approach, and the endoleak disappeared. Four months after re-operation, endoleaks had not been detected with enhanced CT.

We report the case of a 72-year-old man of mycotic aortic aneurysms caused by Klebsiella pneumoniae, those four times of surgeries were required for control. The patient was transferred to our hospital due to an enlarging saccular aneurysm of the infrarenal aorta and the right common iliac artery, which mycotic aneurysms were suspected. The day after admission, he underwent bifurcated graft replacement. Blood andaortic wall specimen cultures were positive for Klebsiella pneumoniae. Five days after initial surgery, a pseudoaneurysm was recognized at proximal anastomosis, and endovascular aneurysm repair (EVAR) was performed. On the 11th postoperative day, CT scan demonstrated the abscess around the vascular prosthesis, and the infected prosthetic bifurcated graft was partially replaced a vein graft, at the same time, retroperitoneal space had been continuously irrigated. On the 30th day after initial surgery, CT scan demonstrated a newly developed saccular aneurysm in thoracic aorta, and thoracic endovascular aneurysm repair (TEVAR) was successfully performed.On the 44th day after admission, the patient was discharged, and antibiotic therapyhad been administered for 6 months. To date, there has been no evidence ofrecurrence of any infection.

A 56-year-old man had a sudden onset of back pain and was diagnosed with acute type A aortic dissection with an aberrant right subclavian artery (ARSA). The entry site was very close to the ARSA. An emergency aortic arch replacement was performed without reconstruction of the ARSA because of its location and fragility. Subsequently, the origin of the ARSA expanded rapidly. Therefore, thoracic endovascular aortic repair (TEVAR) was performed to close the entry site and origin of the ARSA. A false lumen within the range of the TEVAR and the origin of the ARSA were thrombosed and reduced in size three months later.

The effectiveness of endovascular repair for retrograde type A acute aortic dissection (RTAAD) with an entry tear on the descending aorta has been reported. A 52-year-old man presented to our hospital with chest and back pain. He was diagnosed with RTAAD, which was conservatively managed because the false lumen of the ascending aorta was completely thrombosed. Following admission, resistant hypertension, renal dysfunction, and respiratory failure showed progressive worsening despite maximal medical therapy. Contrast-enhanced computed tomography (CT) indicated that the true lumen was severely compressed by the false lumen. Thoracic endovascular aortic repair (TEVAR) was performed to improve the organ malperfusion. For entry closure, the Gore CTAG stent graft was deployed on zone 3 from the left subclavian artery under rapid pacing, and two Zenith Dissection stents were placed under the bilateral renal artery. After the procedure, resistant hypertension, renal dysfunction and respiratory failure improved effortlessly and the patient discharged on postoperative day 24. CT scan showed complete resorption of the false lumen in the ascending aorta 3 months later. TEVAR, together with the use of bare stent, proved favorable for treatment of RTAAD with organ malperfusion.

We present a case of ruptured inflammatory abdominal aortic aneurysm associated with postoperative spinal cord ischemia. An 81-year-old woman who had a sudden abdominal pain was transferred in a state of shock. Computed tomography scan revealed an abdominal aortic aneurysm with an aortic wall thickness and hematoma of the retroperitoneal space. A clinical diagnosis of ruptured inflammatory abdominal aortic aneurysm was established and an emergency open operation was performed. The aorta was clamped just below the bilateral renal arteries. Postoperative findings involved paraplegia and hypoesthesia. Spinal cord ischemia is a rare and unpredictable complication in a surgery of infrarenal abdominal aortic aneurysm. To prevent spinal cord ischemia, reducing aortic cross-clamping time as short as possible and avoiding hypotensive episodes to keep adequate blood flow of collaterals seem to be the most important factors. Therefore, an endovascular repair for inflammatory abdominal aortic aneurysm could have been technically feasible and safe with low risk of complications such as postoperative spinal cord ischemia.

The infectious brachiocephalic arterial aneurysms have high risk of rupture. The standard treatment is open surgery. It oftentimes needs thoracotomy or transsternal approach, which is invasive. Therefore, some cases of endovascular repair have been reported these years. We also had experienced a case of endovascular repair for the infectious brachiocephalic arterial aneurysm. The patient is a 65-year-old man. He received a bifurcated graft replacement for infectious abdominal aortic aneurysm using a rifampicin-bonded graft and omental wrapping. At the same time, a brachiocephalic arterial aneurysm had been complicated. We followed this aneurysm. It rapidly expanded from 21 mm into 25 mm, and the PET-CT showed a ¹⁸F-fluorodeoxyglucose integrated (maximum standardized uptake value: 8.3) into this aneurysm. We diagnosed it infectious aneurysm and performed an urgent operation. At first, the right subclavian artery was bypassed using the right common carotid artery. Then, a stent graft was implanted between the right common carotid artery and the brachiocephalic artery. After deployment, a type 2 endoleak from the right subclavian artery appeared. Coil embolization at the origin of the right subclavian artery stopped a type 2 endoleak. After the operation, an antibacterial drug was administered for several months, and his postoperative course was uneventful. Endovascular repair for infective brachiocephalic artery is an available option especially in high-risk patients, but long-term results is unknown and follow up is required.