Endovascular therapy has made remarkable progress. For the treatment of carotid artery stenosis with the advent of embolic protection devices, carotid artery stenting (CAS) has become a viable alternative. However, carotid endarterectomy (CEA) has excellent and strong evidence for carotid artery stenosis and is still the gold standard treatment. We have reviewed the evidences for CEA and CAS and summarized the guidelines of the Society for Vascular Surgery (SVS), and outline the indications and limitations of CAS for carotid stenosis.
An 84-year-old man developed right cerebral infarction recently twice a year. Enhanced computed tomography revealed innominate artery stenosis with irregular atheroma and diameter of innominate artery was expanded to 17 mm. The atheroma was considered to be the cause of cerebral infarction, and the patient was referred to our hospital for treatment. Endovascular therapy was thougut to be inadequate due to vascular diameter and the difficulty of brain protection. The operation was performed by direct ligation of innominate artery and revascularization by axillo-axillary artery crossover bypass. The postoperative course was uneventful, and the patient was discharged on 6th postoprerative day. One year after the operation, no new symptoms have been observed. The ligation of innominate artery and axillo-axillary artery crossover bypass were effective and less invasive strategy for innominate artery stenosis with irregular atheroma.
We report a rare case of left persistent sciatic artery (LPSA) in a patient with an abdominal aortic aneurysm (AAA) and a left internal iliac aneurysm (LIIA). The AAA and LIIA were first identified on computed tomography (CT) after orthopedic surgery in a 74-year-old man. The LPSA had to be preserved because it provided the major blood supply to the lower limbs. Endovascular aortic repair (EVAR) with an iliac branch system (Gore Excluder iliac branch endoprosthesis [IBE]) was performed to preserve the LPSA and repair the aneurysm. We performed a coil embolization before placement of the IBE because branches from the internal iliac aneurysm can cause type II endoleak. The surgical procedure was completed without any complications, and no endoleak was observed on the final angiography. Postoperative CT revealed optimal flow in the LPSA after 1 year 6 months, and no aneurysm or thrombosis was observed. Placement of an IBE can be effective for preserving LPSA.
A 72-year-old man was referred to our hospital because of left upper limb pain. Contrast-enhanced computed tomography showed occlusion of the left brachial artery and the masses in the aortic arch, which were suspected to be thoracic aortic thrombi. We performed emergency thrombectomy of the left brachial artery. On the following day, the patient developed a walking disorder and dysarthria. Head magnetic resonance imaging (MRI) showed cerebral infarction in the cerebellum and occipital lobe. We administered anticoagulation therapy as treatment of cerebral infarction. One-hundred four days after operation, the patient developed higher cortical dysfunction. Head MRI showed brain tumors and an abscess in the left cerebrum and cerebral ventricle. Contrast-enhanced computed tomography showed the rapid growth of the masses in the aortic arch, and infarct regions in the left adrenal gland, spleen, and kidneys. Systemic metastasis of an intraluminal tumor was suspected. The patient was received palliative care and died 111 days after the surgery. An autopsy was performed. The white tumor had grown into the aortic lumen, like a polypoid lesion. The pathological diagnosis was intimal sarcoma of the aorta, and there were multiple metastatic lesions in the brain, spleen, kidneys, and adrenal gland. Aortic intimal sarcoma is a very rare disease. However, we should not exclude the possibility that acute arterial occlusive disease can be caused by an intraluminal tumor.
A 65-year-old man was admitted to our emergency department after a motor bicycle accident. Computed tomography showed that a left main pulmonary artery pseudoaneurysm accompanied by intimal injury at an aortic isthmus, subarachnoidal hemorrhage and abdominal hemorrhage. An emergency burr hole surgery and laparotomy were performed. On the 10th hospital day, confirming a lowered risk of intracerebral bleed, we performed surgical repair of the left main pulmonary artery with bovine pericardium. The laceration of the left main pulmonary artery occupied more than a half of its circumference. On the 17th hospital day, he underwent endovascular repair of thoracic aorta. The patient recovered well and was transferred to different hospital on the 72nd hospital day. Approximately 8 months after surgery, there were no findings, such as pseudoaneurysm or aneurysm recurrence. We herein report a rare case of blunt traumatic pulmonary artery pseudoaneurysm that was repaired operatively.
Persistent sciatic artery is a rare vascular anomaly, which is often associated with an aneurysmal formation. The aneurysm may cause compressive and limb-ischemic symptoms, such as buttock pain and claudication, and acute limb ischemia due to distal embolization. However, rupture of the persistent sciatic artery aneurysm is an uncommon complication. Herein, we report a rare case of a trauma-induced rupture of persistent sciatic artery aneurysm treated surgically. We also reviewed previous literature about the persistent sciatic artery aneurysm to indicate the appropriate timing of treatment.
We report on a valid case of ABTHERA treatment system was effective for abdominal compartment system (ACS) after ruptured abdominal aortic aneurysm operation along with relevant literature. A 71-year-old male was brought into our hospital due to abdominal pain and was diagnosed as a ruptured abdominal aortic aneurysm by plane CT. ACS occurred to urgent EVAR, and the ABTHERA treatment system, which is a method of abdominal Negative Pressure Wound Therapy, was performed. This system facilitated the management of intestinal edema and exudate, intestinal tract color tone observation, and closing abdominal wall.
We herein report a rare case of a lethal sequela of infected pseudoaneurysm after endovascular treatment of bilateral common iliac artery. A 68-year-old female who had undergone endovascular stenting for stenotic lesions of bilateral iliac artery 4 months ago was referred to our division because of infected left common iliac pseudoaneurysm. The patient presented with left back pain and fever elevation. The blood cultures were positive for Staphylococcus caprae. The computed tomographic angiogram demonstrated infected pseudoaneurysm at left common iliac artery. Emergent extra anatomical bypass grafting, resection of infected pseudoaneurysm and augmentation of greater omentum were successfully carried out simultaneously. Her postoperative course was uneventful.
An 86-year old man with a history of graft replacement for abdominal aortic aneurysm 20 years previously and for thoracic aortic aneurysm 12 years previously was admitted to our hospital with a diagnosis of rt. internal iliac arterial aneurysm (IIAA). Computed tomography (CT) revealed dilated rt. IIAA 47 mm and extravasation from the previously replaced Dacron graft. Endovascular aneurysm repair (EVAR) was indicated anatomically and performed with Gore Excluder. Postoperative CT revealed the aneurysm without extravasation. Non-anastomotic pseudoaneurysm was rare and EVAR was effective and minimally invasive.
Endovascular treatment has recently become more common, and there may be an increase in the number of situations in which vascular surgery is required to deal with puncture complications. Here we present the case of an 80-year-old woman who underwent endovascular treatment at another hospital, then subsequently developed a brachial artery pseudoaneurysm and was referred to our hospital. Ultrasonography revealed a high origin of the radial artery from the axillary artery, and showed that the radial artery ran superficial to the brachial artery in the cubital fossa. It also revealed a pseudoaneurysm that was continuous with the brachial artery, as well as an arteriovenous fistula between the brachial artery and radial vein via the pseudoaneurysm. We selected ultrasound-guided thrombin injection (UGTI) as treatment. During the injection, we tried to prevent thrombus outflow from the artery to the vein by compressing the upper arm. The pseudoaneurysm became a thrombus, and both it and the arteriovenous fistula were treated completely. Caution should be exercised in the presence of vascular anomalies as they may cause unexpected complications. In carefully selected patients, UGTI is useful as a minimally invasive treatment for pseudoaneurysm even if it is associated with arteriovenous fistula.
Acute aortic occlusion (AAO) of an abdominal aortic aneurysm (AAA) is extremely rare and causes widespread ischemia, resulting in high mortality and morbidity. We present a case of AAO of an AAA that was successfully treated with endovascular aneurysm repair (EVAR) using balloon thrombectomy. An 82-year-old woman presented to our emergency department with marked coldness and weakness of the bilateral legs. Contrast-enhanced computed tomography (CT) revealed an infrarenal AAA (41 mm in diameter) that was acutely thrombosed with extension into the bilateral common and external iliac arteries, and she was diagnosed with AAO of an AAA. Proximal neck anatomy of the AAA confirmed suitability for EVAR, and we performed balloon thrombectomy followed by EVAR, which restored blood flow through the iliac arteries. Bilateral limb movements improved, and we observed no symptoms attributable to pelvic or lower limb ischemia postoperatively. Notably, CT performed one month preoperatively had revealed an infrarenal AAA without mural thrombus or significant stenosis of the bilateral iliac and femoral arteries. Considering the potential risk of peripheral obstructive lesions, AAA morphology, comorbidities, and/or fraility, EVAR combined with balloon thrombectomy could be a less invasive therapeutic strategy for immediate revascularization in patients with AAO of an AAA.
We report here five cases of arterial occlusion due to blunt trauma. Case 1: A 36-year-old man was struck his lower abdomen by a bucket of power shovel. Computed tomography showed occlusion of the left common femoral artery. Case 2: A 49-year-old man fell off a boat and got his right groin trauma. Intima of the right superficial femoral artery was teared, resulting in occlusion. Case 3: A 71-year-old man got entangled in a net of the fishery and fell off a ship. He got occlusion of the popliteal artery. Case 4: A 79-year-old man slipped and fell on a road, and his right humerus was broken. Computed tomography showed occlusion of the right brachial artery. In these four cases, arterial dissecting occlusion resulted in limb ischemia. Vein graft bypassing and replacement were performed to rescue these limbs in three cases and another, respectively. Case 5: A 78-year-old man was struck his right groin by an anchor. Dissecting occlusion occurred from the proximal external iliac artery to the common femoral artery. Bare metal stenting through the true lumen of the ipsilateral femoral artery was performed for entry closure, and a good blood flow recovery was obtained with expansion of the true lumen. Vein graft bypassing and interventional radiology effectively treated blunt artery trauma.
We present a rare case of 79-year-old man who had performed successful repair of suprarenal abdominal aortic aneurysm (AAA) with a left-sided inferior vena cava (IVC). Surgical approach and exposure of AAA was performed via Stoney’s incision and retroperitoneal approach. To get a good operative field, crossing part of IVC was transected. Venous cannula for extracorporeal circulation was inserted from the cephalad portion of IVC. Transected IVC was reconstructed with tubularized bovine pericardium after completion of the thoraco-abdominal aortic replacement.
A 68-year-old man had a history of open stent graft implantation with left subclavian artery reconstruction for an aortic arch aneurysm. He was undergoing hormone replacement therapy for hypothyroidism. A month after operation, he died of hemorrhagic shock due to hemoptysis and massive hemothorax, and tension pneumothorax. Histopathological examination revealed perforating the remaining aortic aneurysm wall to the lung. Pathological findings showed myxedema-like degeneration of the aortic media. The thyroid gland was found to have chronic thyroiditis (Hashimoto’s disease). Although atherosclerosis changes due to hypercholesterolemia, and myxedema of tissues have been reported in hypothyroidism, it is extremely rare that myxedematous changes in the aortic wall can be confirmed pathologically. Chronic thyroiditis may also present with aortic medial lesions, it is necessary to consider arterial dissection and aneurysm.
The case, 76-year-old man underwent endovascular aneurysm repair (EVAR) for abdominal aortic aneurysm with maximum diameter of 75 mm 4 years ago. The patient was referred to our hospital for back pain, anemia and gastrointestinal bleeding. CT showed an enlarged abdominal aortic aneurysm with maximum diameter 90 mm, and no endoleak. An urgent surgical repair was performed using thoracoabdominal aortic aneurysm surgery approach. The aneurysm sac was found to be filled with gelatinous material without evidence of thrombus or active bleeding, so we diagnosed enlargement of the aneurysm as Type V endoleak. The postoperative course was uneventful and there was no particular problem with postoperative CT. Thoracoabdominal approach provides good surgical fields and is very useful to control proximal aorta in cases of open conversion after EVAR.
A 67-year-old man had surgical repair of right external iliac artery—right superficial femoral artery bypass. 32 days after the operation, excretion of pus was observed from right femoral incision and he was diagnosed with prosthetic graft infection. For the purpose of preserving graft, the wound was treated by VAC therapy. After 49 days we closed the wound. After that, we experienced two cases, both succeeded in wound healing. VAC therapy was effective for granulation tissue formation and infection control. We found that VAC therapy had therapeutic benefits for an infected prosthetic graft in the groin.
Hereon, we report the performance of emergent endovascular aortic repair in an 85-year-old female for a ruptured abdominal aortic aneurysm of 10 cm. An intra-aortic occlusion balloon was inserted preoperatively from the left brachial artery for hemodynamic stability. After endovascular aortic repair, open abdominal management was required to treat the onset of abdominal compartment syndrome. We could not close the abdomen owing to retroperitoneal swelling, therefore, we used computed tomography to ensure there was no major leak, before removing retroperitoneal hematoma. We opened the residual abdominal aneurysm, removed the hematoma around the stent-graft in the aneurysm, and performed aneurysmorrhaphy. The retroperitoneal swelling was improved, and we could close the abdomen easily.