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.
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.