In this article, I would like to discuss on the two different treatment options(Open vs EVAR) for pararenal abdominal aortic aneurysm (the term “PRAAA” is not clearly defined and classified). Recently, complex endovascular treatment [Fenestrated EVAR(F-EVAR), Chimney (Snorkel) EVAR (C-EVAR, S-EVAR), Branched EVAR(B-EVAR)] have been developed and applied in selected patients, with encouraging early results; however, the high rate for secondary reinterventions and long-term results remain uncertain. This article introduce new devices and a new concept with endovascular aneurysm sealing(EVAS) are currently available on the market for the treatment of PRAAA. Open repair of PRAAA can be performed with low mortality and long-term survival is favorable from single-center experience in the real world and others. We conclude that open repair remains the golden standard treatment in most centers for PRAAA. However, EVAR of PRAAA may represent an alternative option in high-risk patients. Because the indications and circumstances for PRAAA vary based on patient-specific comorbidities and anatomy, it is recommended that vascular surgeons should be familiar with both treatment strategies and tailor-made strategy for improved long-term results for PRAAA.
Thoracic endovascular aortic repair (TEVAR) for thoracic aortic disease constitutes a paradigm shift in the treatment strategy of aortic dissection, as well as thoracic aortic aneurysms. Conventionally, most patients with Stanford type B acute aortic dissection are treated using conservative medical treatment during the acute phase. However, in patients with complicated type B aortic dissection who present with life-threatening complications, TEVAR has been introduced as a novel and less-invasive alternative and has shown better early results than those observed with conventional therapy. Recently, TEVAR was reported to be effective in not only promoting thrombosis of the false lumen but also in preventing aortic enlargement observed at long-term follow-up. TEVAR has been established as first-line therapy for complicated type B aortic dissection. In contrast, a considerable number of patients who received acute phase medical treatment required surgical intervention for chronic dissecting aortic aneurysms. With the increasing popularity of TEVAR for the treatment of complicated type B aortic dissection, prophylactic and pre-emptive TEVAR has been considered in patients with uncomplicated type B aortic dissection. However, supportive evidence for this strategy is limited, and reassessment is mandatory because it is continuously evolving. Although acute type A aortic dissection is a life-threatening condition, the results of open surgery continue to improve in the modern surgical era. Open surgical treatment is well established and recognized as a gold standard even in the endovascular era. Presently, the application of TEVAR for ascending aortic dissection has undergone a change, and TEVAR is considered a viable rescue option for patients with type A aortic dissection who are not eligible for open surgical repair. However, TEVAR for the descending aorta is well-established treatment for retrograde type A dissection. Several conceptual and technical issues remain unresolved, and technological advances would lead to the development of innovative disease-specific devices and solutions in the future for endovascular treatment of acute aortic dissection.
Objective: Although distal bypass surgery using vein grafts has been established with acceptable outcomes for critical limb ischemia, the issue affecting long-term outcomes is vein graft disease. This study aimed to analyze the perioperative and long-term outcomes of endovascular therapy (EVT) for failing vein grafts after distal bypass surgery. Methods: We retrospectively analyzed 50 failing vein grafts out of 315 vein grafts used for distal bypass from April 2009 to October 2016 in our hospital. The failing grafts were repaired by balloon angioplasty with a balloon size of 2.5 to 3.0 mm under low pressure and long inflation. Results: The initial success rate of 96% (48 grafts). During the median follow-up periods of 42 months, the frequency of EVT was 1.9 times. Secondary patency rate of the grafts were 83% at 12 months and 76% at 36 months. Freedom from major amputation rate was 95% at 36 months. Conclusion: Long-term outcomes including patency rate and amputation free rate of EVT for failing veins grafts were acceptable in this study. EVT could be a viable alternative to surgical revascularization in patients with graft failure after distal bypass surgery.
Objectives: Endovascular repair of the thoracic aorta (TEVAR) represents a therapeutic option for type B aortic dissection. However, the optimal timing for TEVAR is controversial. We examined the outcomes of TEVAR for chronic type B dissection and reviewed aortic morphology using pre- and postoperative CT scan images. Methods: Between 2012 and 2017, 12 patients underwent TEVAR for chronic type B dissection at our institution. We retrospectively reviewed the clinical and operative data including CT scan images, comparing the values between early group (5 cases, 3 month to 1 year from initial dissection) and late group (7 cases, more than 1 year from initial dissection). Results: There were no paraplegia, stroke, and death in our cohort. There was no difference in degree of the aortic remodeling between two groups. Conclusions: Outcomes after TEVAR for chronic type B aortic dissection were favorable. Aortic remodeling could be obtained in selected patients by closing an entry with TEVAR procedure.
Between September 2012 and July 2016, axillo-axillary loop grafts (AALG) using polyurethane vascular prostheses were implanted in 8 patients (6 with an arteriovenous graft; AVG and 2 with an arterio-arterial graft; AAG). The time from dialysis initiation to AALG implantation was 15.0±11.3 years. The primary and secondary patency rate was 66.7% and 88.3% at 1 year, 50% and 66.7% at 3 years. When the use of blood vessels of both upper and lower extremities for vascular access can not challenging, arterial superficialization or tunneled cuffed permanent catheter is usually selected. However, vascular access construction using a blood vessel prosthesis in the precordia also appears to be a useful option.
If the accessory renal arteries are large, making a sacrifice of them and prevention type II endoleaks from them during endovascular aneurysm repair (EVAR) is a point of controversy. A 75-year-old woman with horseshoe kidney (HSK) was referred for treatment of a 58 mm infrarenal abdominal aortic aneurysm (AAA). The HSK had an accessory renal artery (ARA) connecting isthmus. The ARA originating from aneurysm neck was 5.5 mm in a diameter. Preoperative estimated glomerular filtration rate (eGRF) was 57 mL/min. EVAR without reconstruction of the ARA was done. We selectively embolized the ARA and covered its ostium with aortic cuff, modified kilt technique, before main body deployment in order to prevent type II endoleaks. There were no endoleaks from the ARA and the HSK remained well perfused, with the infarcted segment of the isthmus only. The eGFR on day 2, two weeks, two months and six months were 44, 46, 49, 49 mL/min, respectively. EVAR without reconstruction of the large ARA and prevention type II endoleaks form it was successfully performed for AAA in a patient with HSK.
Blunt injuries rarely cause vascular injury; in particular, the common iliac artery (CIA) rupture is extremely rare. A 58-year-old man was working at a construction site when he took a strong blunt hit to the right quadrant abdomen. He subsequently felt severe pain and came to our hospital. At the time of arrival, the patient was in hypovolemic shock. The right common femoral artery was impalpable, the right lower limb was cold. Contrast-enhanced computed tomography was performed, and the right CIA rupture was detected. To stabilize his hemodynamics, he was transferred to the hybrid operation room, where laparotomy was performed while controlling hemorrhage by inserting an arterial occlusion balloon catheter through the left femoral artery. Surgical findings were rupture of the right CIA and severe calcification at the site of rupture. Moreover, damage to the sigmoid colon and mesocolon were observed. The CIA was ligated the proximal and distal site, followed by a femoro-femoral bypass. In addition, sigmoidectomy was performed. After the surgery, the patients developed rhabdomyolysis due to the ischemia-reperfusion of the right lower limb and temporarily required blood purification therapy. Sixty-six days after the surgery, the patient was discharged from our hospital, walking without any assistance. We saved the patient’s life and limb by using an arterial occlusion balloon to treat the severe hemorrhagic shock associated with the rupture of the CIA.
Infected aortic aneurysm has known not able to isolate pathogenic bacteria in some cases. Recentry, new pathogenic bacteria have indicated as a case of infected aortic aneurysm, and we treated two cases of infected aortic aneurysm by rare pathogens Helicobacter cinaedi.
Infected abdominal aortic aneurysm (IAAA) is a rare and life-threatening disease. An 86-year-old female was referred to our hospital because of fever, an abdominal pain, and a back pain. Biochemistry examinations showed a white blood cell count of 12300/mm3 and a C-reactive protein level of 16.5 mg/dL. Antibiotic therapy was administered. An immediate computed tomography angiogram (CTA) was performed, which showed a saccular shaped aneurysm and adjacent opacified extra-aortic space. The ruptured, infected and juxtarenal abdominal aortic aneurysm was diagnosed. Laparotomy was performed and the aorta was isolated and opened. A 4.0×2.0 cm defect of the intima, from which the aneurysm had arisen, was found in the posterior part of the abdominal aorta. The both renal arteries were cannulated and perfused with cold saline solution. Debridement of infected tissues and lavage of the aneurysmal sac were performed, thereafter, the defect was repaired by using bovine pericardial patch plasty. After reconstruction of the abdominal aorta, we performed omentopexy. Culture from abdominal aneurysmal tissue was negative. Antibiotic agents were administered for 4 weeks postoperatively until the patient demonstrated normal leukocyte and C-reactive protein levels. Thereafter, oral antibiotic treatment was continued for 11 months. No signs of recurrent infection and aneurysmal dilatation of the aorta were observed for 7 years after the procedure.
Immunoglobulin G4 (IgG4)-related disease is a systemic inflammatory disease that presents with increases of serum IgG4. IgG4-related aortitis can lead to aneurysms or dissection in the thoracic aorta. We report here a case of IgG4-related aortic aneurysm with cardiac tamponade. A 62-year old man with recurrent vomiting presented to our hospital’s ER. Computed tomography revealed a non-communicating aortic dissection with cardiac tamponade and we planned to perform emergency hemi-arch replacement. Intraoperative finding revealed thickening of the aorta and no aortic dissection. Upon histopathological inspection, an obvious thickening of the aortic wall along with infiltrations of IgG4 positive plasma cells was noted. In addition, serum IgG4 exceeded baseline values, and such this patient was diagnosed with an IgG4-related inflammatory thoracic aortic aneurysm.
Popliteal venous aneurysm is a rare disease; however, it sometimes induces fatal complications such as pulmonary embolism. A 19-year-old man was struck in the right buttock, and this caused a huge hematoma that required surgical removal. He developed cerebral infarction and pulmonary embolism on the next day after surgery. Although anticoagulation therapy was initiated with heparin, severe cerebral infarction and pulmonary embolism recurred. Emergent computed tomography revealed deep vein thrombosis and popliteal venous aneurysm with thrombosis in his right leg, and transthoracic ultrasound revealed a patent foramen ovale with thrombus. Then, he was referred to our department to resect the popliteal venous aneurysm. He underwent surgical resection of the venous aneurysm, and no thrombotic events occurred after surgery. Since popliteal venous aneurysm potentially induces catastrophic thrombotic complications such as acute pulmonary embolism or paradoxical cerebral embolism, accurate diagnosis and appropriate treatment including surgical resection of the aneurysm is mandatory to avoid fatal thromboembolic events.
Aortobronchial fistula (ABF) is a rare condition that can be fatal if left untreated. Despite improvements in surgical techniques, conventional open repair still has a high operative morbidity and mortality. Recently, successful treatment of ABF using thoracic endovascular aortic repair (TEVAR) was reported. We present two cases of ABF with descending thoracic aortic disease. Case 1 was that of an 81-year-old man who presented to the emergency department with hemoptysis. He had undergone graft replacement for treatment of a thoracic aortic aneurysm. Computed tomography (CT) revealed a descending thoracic aortic aneurysm infiltrating the adjacent lung parenchyma. Case 2 was that of a 78-year-old man who was admitted to our institution with complaints of hemoptysis. CT revealed a penetrating atherosclerotic ulcer of the descending thoracic aorta and periaortic hematoma adhering to the left bronchial tree. In both cases, TEVAR was successfully performed, with an uneventful postoperative course. Both patients continued receiving antibiotics. C-reactive protein levels remained within normal limit, and postoperative CT demonstrated accurate placement of the endografts with no endoleaks, reduced infiltration in the lung parenchyma, and no evidence of endograft infection. Despite the potential risks of ABF recurrence and endograft infection, TEVAR can be a good, life-saving option for patients with ABF accompanied by descending thoracic aortic disease.
Aneurysm dilatation and endoleak after endovascluar aortic repair (EVAR) requires the secondary intervention. We report a case of the secondary endovascular aortic repair for abdominal aneurysm dilatation with type 1a and type 2 endoleak. 88-year-old male underwent EVAR for infrarenal abdominal aortic aneurysm in 2.5 years ago. Computed tomography (CT) and angiography showed increasing the size of excluded aneurysm and type 1a and type 2 endoleak. Proximal landing zone below the left renal artery was not short, however, the origin of the right renal artery was located 15 mm proximal side to that of the left renal artery. Hand-made fenestrated aortic extension with a window of the left renal artery was successfully placed below the right renal artery. Postoperative CT showed disappearance of endoleak. This may be an alternative procedure for type 1a endoleak after EVAR.
Pseudoaneurysm of the brachial artery is uncommon, and is caused by trauma, iatrogenic factors and infection. We herein report a case of mycotic pseudoaneurysm of the brachial artery that occurred after resolution of Infective Endocarditis (IE). This case was a 77-year-old male, with a past medical history of multiple cerebral infarctions and subarachnoid hemorrhage (SAH) ruptured middle cerebral artery aneurysm one year ago, from complications of IE caused by Streptococcus agalactiae（Group B）. The aneurysm was resected and clipped, postoperative treatment with antibiotics was given for three months. He was discharged from the hospital after confirmation that blood culture was negative and the C-reactive protein (CRP) and peripheral white blood cell count was normalization. About one year after the operation, his right upper arm rapidly swelled without pain over one month. Computed tomography (CT) showed brachial aneurysm. The aneurysm was managed by resection and the brachial artery was reconstructed with his saphenous vein. This approach was taken because of expectations of rupture and embolism if conservatively observed. Histopathological findings showed that it was pseudoaneurysm and inflammatory cells around brachial artery. We diagnosed secondary mycotic pseudoaneurysm of the brachial artery after resolution of infective endocarditis from the histopathological findings and antibiotic treatment history.
We encountered a case of an abdominal aortic injury due to blunt abdominal trauma. The patient, a 31-year-old man, met with a traffic accident while getting in the passenger seat of a car and was admitted to our hospital. The patient presented hypovolemic shock and abdominal pain. In addition, no femoral pulse was found in the bilateral legs, which appeared pale. An enhanced CT demonstrated free air and hemorrhage around the small bowel and colon, and blunt aortic injury at the level of inferior mesenteric artery with large intimal flap. Aortic lumen below the large intimal flap were reduced in size. We performed an emergency operation based on diagnosis of bowel injury and limb ischemia due to abdominal aortic injury. The large intimal flap of the abdominal aorta, small bowel, and colon were resected by laparotomy. After the operation, symptom of lower limb ischemia was improved. A post-operative enhanced CT revealed the absence of intimal flap, dilatation, and stenosis at the flap resection site of the abdominal aorta. The occurrence of abdominal aortic injury due to blunt abdominal trauma is rare. However, an abdominal aortic injury that is associated with bowel and abdominal solid organ injury can be potentially fatal. Therefore, physicians should carefully consider the possible diagnosis of an abdominal aortic injury due to blunt abdominal trauma. Once the patient is diagnosed with such injury, he should be treated appropriately.
Autologous venous bypass is the first-line treatment for femoropopliteal total occlusion, but the procedure is difficult when the venous condition is poor. In this study, we report our experience with a 67-year-old man in whom superficial femoral artery thrombendarterectomy using a ring stripper and autologous venous bypass were performed. Lower extremity arterial CTA that was performed during the first postoperative year revealed a stenotic lesion; therefore, vasodilation was performed. At 2 years postoperatively, the patient has presented with no additional symptoms.
Popliteal artery injury is most often associated with knee dislocation or fractures near the knee joint. Of the 143 cases of popliteal artery injury caused by trauma, that were previously reported in Japan, only 15 occurred without dislocation or fracture. A 47-year-old man with an isolated crush injury of the right lower limb, was transported to our hospital. He complained of pain and tenderness in the right femoral and popliteal region. Distal arterial pulsations in the right popliteal artery were absent and an adventitial hematoma of the right popliteal artery and muscle crush injury around the right knee, were seen on computed tomography. No fractures around, or dislocation of the right knee joint were detected. The patient was successfully treated with a right femorotibial bypass using saphenous vein graft. Prompt evaluation for artery injury is recommended in the patients with blunt knee trauma, especially in the absence of knee dislocation or fracture. Revascularization should be performed as required.