Objectives: We studied the protective effects of renal arterial perfusion in patients with abdominal aortic aneurysm (AAA) requiring renal artery reconstruction. Methods: In our institute, renal protection is attempted when renal artery reconstruction is required and proximal anastomosis without renal artery reconstruction is performed under simple clamp even supra-renal clamp is necessary. Between April 2012 and July 2020, 307 patients with abdominal aortic aneurysm underwent surgery and 63 cases were included in this study after excluding patients who underwent endovascular stent-graft implantation or patients with infective aneurysm, ruptured aneurysm and chronic dialysis. For renal protection, the renal artery was perfused with warm arterial blood from 6 Fr. sheath placed in the left brachial artery via rapid infusion pump at flow rate of 100 mL/min or circuit pressure less than 150 mmHg, and this renal protection was applied for 7 patients (Group P). Simple aortic cross clamp was applied for 56 patients and these patients were divided into supra-renal clamp group (Group C, n=21) and infra-renal clamp group (Group N, n=35). Post-operative serial change of eGFR was compared between the three groups. Results: Pre-operative renal function did not differ significantly between the three groups. Averaged renal ischemic time was 30 minutes in group C and averaged renal ischemic and perfusion time was 129 minutes in Group P. Post-operative eGFR was significantly lower in Group C than Group N or POD1 (65.8±26.4 Vs. 47.7±25.2, p=0.018), and POD5 (79.7±22.5 Vs. 63.9±26.7, p=0.024). However, eGFR of Group P did not differ significantly from that of Group N throughout post-operative period. Conclusion: Renal arterial perfusion with warm arterial blood prevented renal failure in patients with abdominal aortic surgery requiring renal artery reconstruction, even in those with expected renal ischemic time was no longer than 120 minutes.

Objectives: Appropriateness of device selection, procedure protocol and aortic remodeling effects of entry closure (TEVAR) with stentgraft (SG) for patent false lumen type B aortic dissection (TBAD) were compared between the patients with narrow true lumen (narrow group) and those with aneurysmal dilated false lumen (aneurysmal group). Methods: Twenty-six patients with narrow true lumen (narrow group) and 20 patients with aneurysmal false lumen (aneurysmal group) were included in this study. In narrow group, straight SG was implanted from Zone 3 regardless the distance between the left subclavian artery and entry. In aneurysmal group, straight or taped SG was implanted with proximal landing zone length 20 mm or more. Thoracic aortic anatomy was evaluated by CT and aortic remodeling was defined as true lumen diameter ≥50% of the aortic diameter and occlusion of false lumen. Aorta related death, retrograde type A aortic dissection (RTAD), stentgraft induced new entry (SINE) and aortic maximum diameter enlargement 5 mm or more (aortia expansion) were included in the aortic event. Results: There was no procedure related complication in narrow group and 1 patient died due to aortic rupture in aneurysmal group, Type Ia endoleak by enhanced CT 7 days after TEVAR was detected in one patient in each group. Achievement of aortic remodeling was significantly better in narrow group. Aortic event occurred in only one patient in narrow group, in whom aortic expansion was observed. In aneurysmal group, aortic event occurred 12 patients (60%) and 2 RTAD, 5 SINE and 8 aorta expansion were observed. Aortic event free rate was significantly better in narrow group. Conclusion: TEVAR procedure for the TBAD patients with narrow true lumen seemed to be appropriate, however, different TEVAR procedure or additional procedures would be required for those with aneurysmal dilated false lumen to obtain favorable outcomes.

Primary aortic angiosarcomas, especially those in the ascending aorta, are rare. The prognoses in most cases are extremely poor owing to the aggressive behavior of angiosarcomas and their delayed diagnosis. We report a case of angiosarcoma in the ascending aorta in a 55-year-old woman. The patient was admitted with multiple stroke recurrences. Preoperative computed tomography revealed irregular masses extending from the ascending aorta to the descending aorta. Transesophageal echocardiography showed swinging masses in the aorta. Although the mass appeared to be a thrombus, vegetation, atheroma, or tumor, it was difficult to establish a diagnosis. Surgery was planned to confirm a diagnosis and offer appropriate treatment. The surgical findings showed a large fungating tumor in the ascending aorta with invasion extending from the ascending to the proximal descending aorta, suggesting difficulty in en bloc mass resection. Total arch replacement using the frozen elephant trunk technique was performed to prevent further embolization from the residual tumor in the descending aorta. Histological analysis indicated angiosarcoma. The patient initially recovered well from the surgery; however, her condition deteriorated rapidly 8 days postoperatively, and she died 19 days postoperatively because of multiple cerebral emboli and brain metastasis. We present an extremely rare case of angiosarcoma in the ascending aorta causing recurrent strokes. The features observed on preoperative multimodality imaging are similar to those of non-tumor lesions. However, the prognosis is extremely poor because of the difficulty in establishing a preoperative diagnosis and aggressive behavior of angiosarcoma. We anticipate that this report will be vital in helping readers develop awareness of this very rare disease, contributing to early diagnosis and developments in treatment.

Isolated dissecting aneurysm of superior mesenteric artery (IDSMA) is a rare entity with limited studies about its treatment. We report a successful surgical case of chronic IDSMA. The patient was a 66-year-old man who had an incidentally found superior mesenteric artery aneurysm with a diameter of 30 mm. Enhanced CT scanning revealed that the dissection started at a distance of 25 mm from the origin of SMA and the false lumen had become aneurysmal changed. The middle colic artery and the jejunum artery branched from the narrowed true lumen and the right colic artery and the ileocolic artery branched from the aneurysmal false lumen. After the midline laparotomy, the aneurysm was opened and the vascular reconstruction using the great saphenous vein (GSV) was performed after the establishment of the connection between the femoral artery and the peripheral end of the aneurysm. After the proximal anastomosis of GSV with the entry of the false lumen, a branch of ileocolic artery and the right colic artery were reconstructed and the peripheral end of the aneurysm was oversewn and closed. Postoperative course was uneventful. Our surgical technique using the entry of the false lumen as the proximal anastomosis can preserve the blood flow of the true lumen and useful for the surgical treatment of IDSMA.

Catheter fractures are a rare complication of totally implantable venous access ports (TIVAPs); however, to the best of our knowledge, no study has reported fractured TIVAP central venous catheters (CVC) causing cardiac perforation or cardiac tamponade. An 82-year-old man presented to the emergency complaining of chest pain. With a history of advanced gastric cancer, the patient had undergone surgical treatment and TIVAP implantation thorough the right internal jugular vein four years ago. Chest radiography revealed that the CVC was fractured at the neck and had caused cardiac perforation and tamponade. An emergency operation confirmed that the perforation site was located on the right ventricle and that the fractured CVC was in the pericardium. The perforation site was sutured and repaired. Previous studies have explored the cause of CVC rupture. We suspected that in our case, the CVC fracture was caused by (1) a large distance between the clavicle and CVC flexion point; (2) a narrow CVC flexion angle; or (3) the CVC’s material-silicon. Interventional radiology helps remove fractured CVCs. In our case, cardiac surgery and suture repair were performed for cardiac perforation and tamponade.

An unusual case of abdominal aortic aneurysm (AAA) with simultaneous rupture in the retroperitoneum and inferior vena cava (IVC) is reported. The patient presented with lower abdominal subcutaneous bleeding and intense lower back pain. An urgent contrast-enhanced computed tomography demonstrated a fusiform infrarenal AAA that was 7.6 cm in diameter. It appeared to be ruptured in the right retroperitoneum. During the arterial phase, the IVC appeared dilated and opacified simultaneously to the aorta through an abnormal communication. The symptoms and treatment are discussed.

Objectives: This is an annual report indicating the number and early clinical results of annual vascular treatment performed by vascular surgeon in Japan in 2017, as analyzed by database management committee (DBC) members of the JSVS. Materials and Methods: To survey the current status of vascular treatments performed by vascular surgeons in Japan, the DBC members of the JSVS analyzed the vascular treatment data provided by the National Clinical Database (NCD), including the number of treatments and early results such as operative and hospital mortality. Results: In total 137,909 vascular treatments were registered by 1,076 institutions in 2017. This database is composed of 7 fields including treatment of aneurysms, chronic arterial occlusive disease, acute arterial occlusive disease, vascular injury, complication of previous vascular reconstruction, venous diseases, and other vascular treatments. The number of vascular treatments in each field was 21,680, 18,123, 4,765 2,418, 669, 48,625 and 41,629, respectively. In the field of aneurysm treatment, 19,982 cases of abdominal aortic aneurysm (AAA) including common iliac aneurysm were registered, and 64.1% were treated by endovascular aneurysm repair (EVAR). Among AAA cases, 1,824 (9.1%) cases were registered as ruptured AAA. The operative mortality of ruptured and un-ruptured AAA was 15.0%, and 0.7%, respectively. 37.9% of ruptured AAA were treated by EVAR, and the EVAR ratio was gradually increasing, but the operative mortality of open repair and EVAR for ruptured AAA was 14.5%, and 12.3%, respectively. There was no statistical significance. Regarding chronic arterial occlusive disease, open repair was performed in 7,277 cases, including 1,348 distal bypasses to the crural or pedal artery, whereas endovascular treatment (EVT) was performed in 9,248 cases. The EVT ratio was gradually increased at 56.0%. The number of varicose vein treatments decreased to 46,754 (11.2% less than 2016), and 73.7% of the cases were treated by endovenous laser or radiofrequency ablations. Regarding other vascular operations, 38,769 cases of vascular access operations and 1,548 lower limb amputation surgeries were included. Conclusions: The number of vascular treatments increased since 2011, and the proportion of endovascular procedures increased in almost all field of vascular diseases, especially EVAR for AAA and EVT for chronic arterial occlusive disease.