Hybrid aortic arch repair (HAAR) consists of thoracic stent-graft repair and procedures to maintain cerebral blood flow. Several hybrid techniques have been used, including arch artery debranching, parallel graft technique, fenestration or branching of endograft, or a combination of theses. We provided an overview of HAAR by presenting literature reviews as well as our clinical experience. The experience consisted of 172 patients who had undergone HAAR. The 30-day mortality was 3% (5/172). Persistent neurologic deficits occurred in 7 patients (4%), respiratory failure in 5 (3%), de novo aortic dissections in 3 and spinal cord injury in 2. 17% of the patients experienced type Ia endoleak. Seventeen patients required redo thoracic endovascular aortic repair. Fifty-six late deaths occurred during the follow-up period, including aortic-related death in 9 patients. In conclusion, hybrid arch debranching repair should be performed for elderly or high-surgical-risk patients. However, refining techniques and device technology is likely to reduce late endograft-related events.

Endovascular aneurysm repair (EVAR) has become the standard therapy alongside open surgery repair (OSR) for abdominal aortic aneurysm (AAA) and it is rapidly becoming prevalent. There has been substantial technical progress with respect to EVAR since its introduction. Technical contrivance can be used to manage even inappropriate EVAR cases, including those involving a hostile neck, deficient access route, or aneurysm rupture. However, there are some controversies over reinterventions in relation to long-term outcomes. Although a long-term result has not yet been analyzed in Japan a randomized controlled trial (RCT) held in the West reported that OSR is superior to EVAR for avoiding reinterventions and aneurysm-related death. The RCT involved the use of older devices and proceeded in a different way from the present study; therefore, different results may be obtained for Japanese EVAR outcomes. However, this Western RCT result should be considered as an important warning. Type II endoleak also must be managed in order to improve long term outcomes of EVAR. Efforts to improve both technical methodology and long-term outcomes are necessary to ensure EVAR as a minimally invasive therapy for patients with AAA.

Deep femoral artery aneurysms are rare among arterial aneurysms and treatment has not reached consensus. We describe a deep femoral artery aneurysm that was surgically repaired and a review of the literature. An 80-year-old man was hospitalized with a painful swollen left groin . Computed tomography revealed a mass caused by a ruptured aneurysm in the deep femoral artery. Aneurysmectomy proceeded without reconstruction of the deep femoral artery because the distal femoral-popliteal outflow tract was patent. The patient had an uneventful postoperative recovery and was discharged without complications. We believe that a deep femoral artery aneurysm with a diameter ≥20 mm is a reasonable indication for surgical repair. If femoral-popliteal outflow is patent, surgical resection or ligation of deep femoral artery aneurysms without reconstruction is simple and safe.

The epithelioid hemangioma (EH) is classified as a benign vascular tumor and rarely occurs at peripheral large arteries. Here we report a case of EH at the left brachial artery of a young male patient. A 30-year-old man was referred to our hospital because of a mass inside his left upper arm. Magnetic resonance imaging and ultrasonography suggested a tumor at the branchial artery. We performed tumorectomy with en-block resection of the brachial artery followed by arterial reconstruction using a reversed saphenous vein graft. The pathological examination revealed that the tumor was an epithelioid hemangioma. The patient has had an uneventful course without recurrence for more than 2 years. However, because EH may recur locally, careful follow-up is required.

A 53-year-old man (height 170 cm, body weight 160 kg, body mass index 55.4 kg/m²) was referred to our hospital for acute aortic dissection with cardiac tamponade. Although his hemodynamics were stable on arriving in the operating theater, his blood pressure increased at tracheal intubation and then gradually decreased until pulseless electrical activity (PEA). The cardiac tamponade was released immediately via median sternotomy and spontaneous return of circulation was noted. The ruptured ascending aorta was compressed to control massive bleeding and extracorporeal circulation was established by transapical aortic cannulation. The ascending aorta was then incised under circulatory arrest, its distal section was located, and a hemi-arch replacement was performed. Postoperatively, the patient was mechanically ventilated with high-positive-end-expiratory pressure and kept in Fowler’s position because of severe hypoxia. We judged that long-term ventilation management would be necessary and a tracheotomy was performed using a percutaneous tracheostomy kit on the eleventh postoperative day. After tracheotomy, the patient exhibited normal consciousness with no significant brain damage. Although dialysis was required temporarily, it was withdrawn on postoperative day 26. The ventilator was withdrawn on postoperative day 33. The patient was transferred to the hospital on postoperative day 54 and subsequently discharged; he has returned to work. In morbidly obese patients, an access route for extracorporeal circulation is very difficult to secure. Transapical aortic cannulation was useful to provide a quick access route. Although early tracheostomy bears a risk of mediastinitis, early percutaneous tracheostomy was advantageous for withdrawal of the ventilator and aggressive rehabilitation.

A 51-year-old man had undergone graft replacement of the descending thoracic aorta for a DeBakey IIIb chronic dissecting aneurysm. In that operation, double-barrel distal anastomosis was performed between the vascular prosthesis and the thoracic aorta. Six years later, the residual false lumen of the thoracic aorta was not thrombosed and its maximal diameter had enlarged to 66×80 mm. Therefore, we performed endovascular aortic repair with the candy plug technique. During the operation, the stent graft was placed in the true lumen for coverage of the proximal intimal fenestration and the candy plug was inserted into the false lumen to prevent reentry of blood flow. The patient’s postoperative course was uneventful, and he was discharged on the 9th postoperative day. At 4 months after the operation, contrast computed tomography revealed the absorption of the false lumen and the enlargement of the true lumen, and that the diameter of the descending aorta decreased to 49×69 mm. The candy plug technique is a useful treatment for a residual thoracic dissecting aneurysm after graft replacement of the descending thoracic aorta.

A 69-year-old man with chronic renal failure has taken hemodialysis for 24 years. His vascular access was often troubled with refractory shunt stenosis, resulting in venous hypertension on the right upper arm. Thus, the percutaneous transluminal angioplasty with balloon-expandable stent was performed in February 2016. Unfortunately, the right subclavian vein got occluded with severe edema and pain on the right arm in December 2016. The crossover bypass from the right cephalic vein to the left cephalic vein using a 6-mm diameter polytetrafluoroethylene graft was performed, which led to prompt and effective decompression of severe venous hypertension and edema on the right upper arm.

A 90-year-old patient was transferred to our hospital because of sudden syncope and abdominal pain. An enhanced computed tomography led to a diagnosis of ruptured abdominal aortic aneurysm. The patient was in shock after arrival (Rutherford classification level 3) and underwent emergency operation by laparotomy. A retroperitoneal hematoma was found extending above the renal arteries; it was diagnosed as Fitzgerald type III. A round ostium of the ruptured site measuring 20×20 mm was found on the right side of the abdominal aorta. Although straight graft replacement was performed, bowel necrosis progressed intraoperatively, resulting in thinning and perforation of the descending colon. Therefore, the bowel tract extending from the left side of the transverse colon to the beginning of the sigmoid colon was resected. The surgical site was irrigated with abundant warm saline, and a drain was placed. The graft was coverd using the greater omentum, and colostomy was performed. To prevent postoperative septic shock, polymyxin B-immobilized fiber column-direct hemoperfusion (PMX-DHP) and polymethylmethacrylate membrane-continuous hemodiafiltration (PMMA-CHDF) were performed. Thrombomodulin was also administered to treat disseminated intravascular coagulation. The patient recovered from respiratory and renal failure and was transferred to another hospital for rehabilitation. She is currently independent in activities of daily living and walks with a cane to an outpatient clinic. We have described an extremely rare case in nonagenarian of ruptured abdominal aortic aneurysm complicated by bowel necrosis and perforation.

Prosthetic graft infection after abdominal aneurysm surgery is a fatal complication. The recommended treatment is surgical removal of the infected graft; however, this treatment is invasive. A 65-year-old man who had undergone open graft replacement for a common iliac artery and aortic aneurysm. Two months after the surgery, the patient visited our hospital with pyrexia. The level of inflammatory reaction was elevated. Enhanced computed tomography (CT) showed enlargement of the perigraft aneurysmal sac and an increased density of the surrounding fat tissue. Based on these findings, the patient was diagnosed with prosthetic graft infection. Antibiotic therapy was initiated. On the fifth day after admission, enlargement of the site was observed on CT. CT-guided puncture and closed drainage of the fluid collection around the prosthetic graft were performed. A discharge of white pus was observed. The pyrexia resolved the next day, and the drain was removed on the seventh day after the puncture. Methicillin-susceptible Staphylococcus aureus was detected in the aspirated pus. The patient’s treatment was switched to oral antibiotics and was discharged on the 38th day after admission. The patient has had no relapse for 10 months, after the CT-guided drainage. CT-guided drainage is a minimally invasive technique that is useful for both detecting causative microorganisms and treatment in patients with prosthetic graft infection. Clinicians might consider using this treatment strategy when treating prosthetic graft infection after abdominal aneurysm surgery.

Because of the risk of venous rupture and the high rate of restenosis with angioplasty, we performed a surgical treatment for two dialysis patients with cephalic arch stenosis (82-year-old woman, and 76-year-old man). They had a loop-type prosthetic arteriovenous fistula at the right forearm. Previous prosthetic vascular graft was anastomosed with a new prosthetic vascular graft and the opposite site of the new graft was anastomosed with distal site of the basilic vein to transpose the blood flow from the cephalic vein to the basilic vein. After the operation, the venous dialysis pressure decreased, flow volume at the brachial artery increased, and resistance index decreased. The benefit of this surgical procedure is to preserve proximal site of the basilic vein for future creation of new vascular access.

The patient was a male in his 60s. He underwent abdominal endovascular aortic repair (EVAR) four years ago. Due to a type II endoleak from the inferior mesenteric artery (IMA) and lumbar artery, we carried out four intravascular coil embolizations but the endoleak still remained. Due to a prominent complication of polycystic kidney and hepatic cysts in addition to a difficult ventrotomy, a watch and wait approach was taken, with a rupture occurring during the follow-up. We performed surgery to save his life. We cut open the aneurysm and confirmed bleeding from the lumbar arteries as the cause of the endoleak, then put in a suture to stop the bleeding. Because the right leg of the stent graft easily fell out, we controlled the bleeding by placing an occlusion balloon in the descending aorta in advance. The indwelling stent graft was preserved, so we carried out reconstruction by interposing new artificial blood vessels in both legs of the stent graft, respectively. In some cases, saving the life of the patient due to rupture after EVAR may be difficult. We hereinafter reported on a case in which we gave some consideration to the procedure and managed to save the life of the patient.

Arterio-enteric fistula to the lower gastrointestinal tract is a rare disease and considered to be poor prognosis. Although endovascular treatment for the disease has been reported, control of infection is a severe problem especially in the lower gastrointestinal fistula. An 88-year-old man presented with rectal bleeding. Rupture of the right internal iliac artery aneurysm was detected on CT. Emergency operation with aneurysm excision and colostomy was performed. The postoperative course was favorable. He was discharged on postoperative day 32.

A 78-year-old man was hospitalized with left lower limb ischemia. Computed tomography and angiography revealed the diffuse aneurysmal disease with arteriomegaly extending between the infrarenal abdominal aorta and the bilateral popliteal arteries. The left superficial femoral and popliteal arteries showed thrombotic occlusion. Staged operations were performed. Initially, we performed left ilioprofunda reconstruction with a heparin-bonded expanded polytetrafluoroethylene (HePTFE) graft and a concomitant profunda femoris-below knee popliteal bypass using a reversed saphenous vein graft. Subsequently, the infrarenal abdominal aorta, bilateral external iliac arteries and the left internal iliac artery were reconstructed using a trifurcated knitted Dacron graft. The inferior mesenteric artery was directly implanted into the graft; however, the right internal iliac artery had to be sacrificed. Eventually, the right superficial femoral and the above-knee popliteal arteries were reconstructed using a HePTFE graft. Postoperative computed tomography demonstrated complete revascularization between the infrarenal abdominal aorta and the bilateral popliteal arteries.

Essential thrombocythemia (ET) is a myeloproliferative disorder characterized by elevation of platelet count and an increased tendency for thrombotic events. We report a case of acute, previously revascularized for chronic occlusion, arterial occlusion of lower extremities associated with ET in whom the legs were salvaged by multiple revascularizations. A 54-year-old man was diagnosed with ET. He first visited our unit at the age of 43 for chronic arterial occlusion of the lower extremities. After controlling platelet count by drug therapy, a right femoro-posterior tibial artery bypass was created using saphenous vein (SV) graft, and a thromboendarterectomy of the deep femoral artery was performed. Three years later, we performed left iliac artery stenting and femoro-popliteal artery bypass using SV graft. After that, he was diagnosed with recurrent acute left lower extremity artery occlusion by thrombosis in peripheral artery and bypass graft. We performed revascularizations, thrombectomy or additional bypass, for a total of five times. Agents to reduce platelet counts, anticoagulants and anti-platelets along with routine monitoring of the blood flow and five prompt additional revascularizations for ischemia in lower extremity have remained the mainstay strategy for limb salvage. The patient is under strict observation. We also reviewed the published cases of chronic arterial occlusion of the lower extremities associated with essential thrombocythemia and have outlined their treatment modalities.

We report a successfully treated case of prolonged infection after endovascular treatment for MRSA-related infected abdominal aortic aneurysm using suprarenal fixed endograft. An 82-year-old man had no major omentum because of multiple abdominal surgical operations for colonic cancer and gastrointestinal stromal tumor. Before 29 months, impending rupture of infected abdominal aortic aneurysm by MRSA was treated endovascular aortic repair using suprarenal fixed endograft. MRSA infection was treated antibiotics and open drainages but it was not completely controlled. Radical operation for endograft infection was performed by extraanatomic reconstruction and removal of endograft without omental covering over infectious space. Intravenous antibiotics had been administrated for 4 weeks postoperatively. There was no recurrence of MRSA infection during 28 months after radical operation.