First choice of treatment for failing or failed vascular access is widely accepted to be percutaneous intervention. There are two types of vascular access; Arteriovenous Fistula (AVF) and Arteriovenous Grafting (AVG), and each access type which has different stenotic lesions of predilection should be approached in different way. In this short lecture, I will introduce procedural details of percutaneous balloon angioplasty for vascular access, treatment options for recalcitrant or recurrent stenotic lesion, or central venous stenosis/occlusion, and new devices such as stent-graft, and Drug-coated Balloon (DCB).

Objectives: To clarify the secure change of neck and leg diameters after EVAR. Methods: 76 patients after EVAR were divided into groupA(n=16) required additional treatments for re-expansion and groupB(n=60) without additional treatments. The annual change in neck and leg diameters were compared between the two groups. Results: There were no significant differences between the two groups in preoperative minor axis of aneurysm, size of neck, bilateral iliac arteries, main body nor bilateral legs of the stent grafts. Postoperative aneurysm became bigger in group A, while kept smaller in group B, showed significant differences between the two groups. The oversize effect was lost by 2 years after surgery in group A, while still presented by 5 years after surgery in group B. But the oversize effect was estimated to disappear by 9 to 10 years after surgery in group B. The oversize effect of the common iliac arteries was disappeared until the first year after surgery. Conclusion: Neck and legs expanded after surgery. Reintervention after EVAR will increase in the future according to the disappearance of the neck oversize effect.

67-year-old male underwent right and left femoral popliteal below knee (F-PBK) bypass surgery (right with prosthetic bypass and left with autologous vein bypass). Two years after the right F-PBK bypass operation he suffered from sudden pain of right lower thigh with his foot skin cold and he was transferred to our hospital, diagnosed with acute limb ischemia due to prosthetic bypass occlusion. We didn’t know the exact mechanism of the occlusion and performed emergent thrombectomy through prosthetic bypass and anterior tibial artery. Following contrast CT scan revealed remaining stenosis and thrombus nearby distal anastomosis at right knee. Three dimentions (3D) CT analysis revealed that right knee flection had caused deformity and stenosis of prosthetic bypass, which seemed to be the origin of the thrombosis. To prevent re-occlusion, we placed two bare metallic stents overlappingly into it. One year has passed without re-occlusion of the bypass. Certainly this case is not a common method, but it could be one mean for stenosis of F-PBK prosthetic bypass which seems to have few choices to treat.

Most renal artery aneurysms are asymptomatic and are often identified accidentally by computed tomography (CT) or ultrasonographic examination of other diseases. A 57-year-old female patient was diagnosed as having multiple saccular renal artery aneurysms with three outflow arteries at the right renal hilum on CT accidentally. One of the aneurysms was 26 mm in diameter, which was indicated for surgery due to a risk of rupture. Through median laparotomy, inferior vena cava was mobilized and good surgical field was obtained. After the administration of a renal protective solution, the aneurysms were resected and three outflow arteries were reconstructed by using a tailoring technique. Postoperative renal dysfunction could be prevented by an appropriate use of a renal protective solution and the reconstruction of all outflow arteries. One year and four months after the surgery, all outflow arteries were patent without stenosis and the reconstructed arteries did not re-expand.

A combination of Moyamoya disease and abdominal aortic aneurysm is extremely rare. Moyamoya disease carries the risk of perioperative brain hemorrhage or infarction. We report a successful endovascular aneurysm repair for abdominal aortic aneurysm in Moyamoya disease while monitoring parameters including blood pressure, partial pressure of carbon dioxide in arterial blood, and regional cerebral oxygen saturation. No neurological abnormalities observed in the perioperative period. Endovascular aneurysm repair entails less risk of hemodynamic instability than open repair, and could therefore be an option for abdominal aortic aneurysm repair in Moyamoya disease.

A 26-year-old man underwent left orchietomy for testicular tumor and inferior vena cava (IVC) tumor embolization 8 years ago, and had a retrievable IVC filter implanted. 7 years ago, he underwent retroperitoneal lymph node dissection for metastasis. The patient had been on dialysis for renal failure due to chemotherapy. This time, an upper gastrointestinal endoscopy was performed to examine the black stool and anemia, and the protrusion of the IVC filter leg in the duodenum was confirmed. With the cooperation of a gastrointestinal surgeon, the gastrointestinal tract was dissected, the leg that perforated from the inferior vena cava to the duodenum was cut between the dissected IVC and the duodenum, the tip of the leg in the duodenum was removed, and the damaged part of the duodenum was repaired. The IVC filter retrieval kit was inserted transvenously, and the filter was successfully removed. This is a rare case of successful removal of a filter perforation by laparotomy combined with transvenous filter removal.

We experienced a case of delayed hemiplegia after hemiarch replacement for acute Stanford type A aortic dissection. The patient was a 65-year-old man who presented to his local physician for sudden chest pain. He was diagnosed as acute Stanford type A aortic dissection with false lumen occlusion and brought to our hospital. The patient was in a clear conscious state before surgery and had no motor impairment in extremities. Cardiopulmonary bypass was established between left femoral artery and right atrium, and hemiarch replacement was performed with moderate hypothermic circulatory arrest at a bladder temperature of 27°C and selective cerebral perfusion. The postoperative course was good, and the patient was weaned from the ventilator 8 hours after surgery. Ten hours after surgery, the patient developed incomplete paralysis of the right lower extremity, and a CT scan of the head showed no acute intracranial lesion. Spinal cord ischemia was considered to be the cause of the symptom and we promptly commenced spinal cord drainage, steroid pulse, and naloxone administration. Immediately after the start of the treatment, the patient was enabled to raise his right knee. Rehabilitation was continued, and the patient was discharged from the hospital on the 20th day after the operation with ADL equivalent to that before the surgical procedure.

The case was a 77-year-old man. His abdomen was pinched by a 2-ton iron pillar. Computed tomography showed intra-abdominal hematoma and the right common iliac artery occlusion, and he was transferred to our hospital for treatment. We decided that intra-abdominal hemostasis was necessary prior to revascularization surgery. Considering that it would take time before reperfusion, we made an external shunt at the emergency outpatient department and started lower limb perfusion. The surgery was performed by opening the abdomen and stopping bleeding only, and the treatment for the intestinal tract was done after revascularization of the lower limbs. The exposed right femoral artery was occluded by dissection, left and right femoral artery crossover bypass surgery was performed. After that, we excised the injured part of the small intestine, and removed the external shunt. The postoperative course was good, and the arteries of both lower limbs were well visualized by CT, and the patient was able to walk by rehabilitation. In a case of simultaneous onset of intra-abdominal bleeding and common iliac artery occlusion due to abdominal trauma, we constructed an external shunt prior to surgery and then performed simultaneous surgery of abdominal opening and lower limb bypass. We saved his life and attained limb salvage without reducing his ADL.