Objectives: The aneurysmal sac shrinkage has been reported as the strong predictor of favorable long-term outcome after endovascular abdominal aortic aneurysm repair (EVAR). We evaluated the effects of perioperative and intraoperative factors on the aneurysm sac shrinkage. Methods: EVAR was performed for 296 patients during 2009.8–2021.12. nine patients with type Ia, Ib or III, 69 patients with sac diameter change less than 5 mm, and 5 patients with sac re-expansion after shrunk more than 5 mm were excluded. Thus, patients with sac shrinkage 5 mm or more (79 patients, shrinkage group) and with sac expansion 5 mm or more (18 patients) were included in this study. Antifibrinolytic therapy with tranexamic acid 1500 mg/day for 6 month after EVAR (TXA) was introduced in 2013 March and patent aortic side branches were coil embolized during EVAR since July 2015. Patients’ background and patent aortic side branches at the end of EVAR were evaluated. Results: Univariate analysis for comparison between patients with sac shrinkage and sac expansion revealed that male (82.3% vs. 55.6%, p=0.021), without antiplatelet therapy (40.5% vs. 66.7%, p=0.044) and TXA (79.8% vs. 38.9%, p<0.001) were significantly associated with sac shrinkage. By multivariate analysis, the odds ratio of sac shrinkage was 11.7 for male, 0.1 for the patients on antiplatelet therapy and 6.5 for the patient received TXA. The patients with patent inferior mesenteric artery (IMA) were less in shrinkage group (20.3% vs. 77.8%, p<0.001) and with 2 or less patent lumbar artery (LA) were more in shrinkage group (82.3% vs. 33.3%, p<0.001). The odd ratio of sac shrinkage was 7.8 for occluded IMA and 3.9 for 2 or less patent LA. Conclusion: The possibility of sac shrinkage would be high for the patient with occluded IMA and 2 or less patent LA at the end of EVAR, and received TXA after EVAR.

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.

Objective: The perfusion index (PI) is a physiological marker for evaluating the peripheral circulation. We explored the possibility of using PI as a screening tool for development of critical limb ischemia in peripheral artery disease (PAD). Method: We measured the PI in 79 limbs of 70 PAD patients. Data were analyzed to find a correlation between the PI and PAD severity. Result: The PI tended to be lower as PAD became severer. Especially, there were significant differences between the Fontaine 1 and Fontaine 4 groups in average PI and minimum PI, and between Fontaine 1 and two other groups (Fontaine 2 and Fontaine 4 groups) in maximum PI. A mild correlation was found between PI and the ankle brachial index. These data were used to calculate an average PI of 0.27 as a cut-off value for critical limb ischemia (CLI). In 65 asymptomatic PAD patients and claudication, significantly more patients with a PI value greater than the cut-off value developed CLI than those with a PI lower than the cut-off. Conclusion: The PI can be a useful tool for evaluating the development of CLI in mild PAD patients, and patients tended not to progress to CLI when their average PI was higher than 0.27.

Objectives: We aim to investigate the results of stenting for central venous occlusions and stenoses in the hemodialysis patients. Methods: Twenty-nine cases treated with endovascular recanalization with deployment of bare metal stent (BMS) for central venous occlusions (24 cases) and recurrent stenoses (5 cases) between 2014 and 2018 were retrospectively analyzed. Results of these procedures including success rate, operative time, estimated blood loss, morbidity, primary patency, assisted primary patency and freedom from target-lesion revascularization (TLR) were evaluated. Results: Nine lesions were in brachiocephalic vein (Occlusion/Stenosis: 8/1) and 20 lesions were in subclavian vein (Occlusion/Stenosis: 16/4). Procedural success was 94% (29/31 cases) and operation time/estimated blood loss was 68±39 min/28±54 g. Symptom were relieved or disappeared in all successful cases. Morbidity (extravasation of contrast medium) was 3% (1/29). During the period of observation, 1 stent fracture with occlusion and 1 stent migration to periphery were recognized. 1-year primary patency, freedom from TLR, and assisted primary patency were 40% (median patent time: 256 days), 67% (median patent time: 524 days), and 77%, respectively. Conclusion: Stenting for central venous occlusions and stenoses in the hemodialysis patients is safe and durable treatment option. However, considering its off-label use and potential hazard including vessel rupture, stent migraion, and stent fracture, the indication for BMS deployment should be conservative, and interventionist should be well acquainted with prevention and measures to these complications.

Objectives: The optimal surgical management for primary infected abdominal aortic aneurysm (IAAA) is controversial. Here, we report the early and long-term results of surgical treatments with the resection of the IAAA and in situ graft reconstruction with pedicled omental coverage that was performed at out hospital. Methods: Between 2010 and 2017, 27 consecutive patients (26 males, 1 females, median age 69 years) with IAAA were surgically treated with the resection of the IAAA, in situ graft reconstruction and covered with a pedicled omental flap. Perioperative and long-term outcomes were reviewed retrospectively by medical records. Results: Clinical manifestations, including pyrexia, fever and abdominal pain, were observed during the treatment of the patients. Aneurysm excision and in situ graft reconstruction with omental coverage were performed for all cases. In 13 cases (48.1%), tissue culture was positive. The antibiotic was administered intravenously for 9 to 47 days (median 18 days) postoperatively, and after confirming the reduction of the inflammatory response, it was administered as oral agents for 24 to 443 days (median 169 days).There was no perioperative death or re-infection. Perioperative complications were found in 8 cases (29.6%) of minor spinal cord infarction, ileus, chylous ascites, and cholangitis due to choledochlithiasis. During the observation period of median 1147 days, there was no recurrence of infection, graft infection, or disease-related death. There were six deaths due to other diseases. And the overall survival rate was 76.2%. Conclusion: According to our study, the long-term outcomes of surgical treatment with in situ graft reconstruction for IAAA were considered satisfactory.

Objectives: Endovascular repair of the thoracic aorta (TEVAR) represents a therapeutic option for type B aortic dissection. However, the optimal timing for TEVAR is controversial. We examined the outcomes of TEVAR for chronic type B dissection and reviewed aortic morphology using pre- and postoperative CT scan images. Methods: Between 2012 and 2017, 12 patients underwent TEVAR for chronic type B dissection at our institution. We retrospectively reviewed the clinical and operative data including CT scan images, comparing the values between early group (5 cases, 3 month to 1 year from initial dissection) and late group (7 cases, more than 1 year from initial dissection). Results: There were no paraplegia, stroke, and death in our cohort. There was no difference in degree of the aortic remodeling between two groups. Conclusions: Outcomes after TEVAR for chronic type B aortic dissection were favorable. Aortic remodeling could be obtained in selected patients by closing an entry with TEVAR procedure.

Objective: To clarify the localization of and surgery for atypical incompetent perforating veins (IPVs) other than Dodd, Boyd, Cockett perforators, which have not been previously discussed. Methods: Forty-three atypical IPVs, diagnosed by venous ultrasonography and treated surgically from January 2014 to June 2018, were analyzed from the viewpoint of localization and surgical treatment. Results: All atypical IPVs passed through the fascia in the area between the muscle compartments in the same way as the typical IPV. The IPVs were most commonly located in the posterolateral part of the lower thigh (16), around the popliteal fossa (9), and in the posterolateral part in the lower calf (7). For 42 IPVs, surgery consisted of direct ligation and resection at the fascia level, and foam sclerotherapy was performed for 1 IPV. The blood flow of the perforating vein was blocked under the fascia in 40 IPVs, but to and fro flow at the fascia level remained in 3 IPVs. Conclusion: Atypical IPVs causing varicose veins were most common in the posterolateral part of the lower thigh. For treatment, it is important to ligate and cut them without leaving stumps with related branches outside the fascia under precise ultrasonic observation.

Objectives: We aim to assess the effect and significance of ultrasound-guided axillary nerve block on the diameter of basilic vein in vascular access surgery. Methods: 78 consecutive patients who underwent vascular access surgery with ultrasound-guided axillary nerve block were studied retrospectively. Diameter of basilic vein at the elbow level before and after the nerve block were measured and the dilatation rate was also calculated to assess the effect of nerve block on venous diameter. Results: Basilic vein diameter increased from 3.0+1.1 mm before the block to 4.1+1.2 mm after the block (p<0.001). Mean dilatation rate was 143+34%. The dilatation rate was inversely correlated with venous diameter before the block (p<0.001). Conclusion: Ultrasound-guided axillary nerve block induces significant basilic venous dilatation and that make the anastomotic procedure involving basilic vein possible, or much easier. This anesthetic technique was considered to be an effective option in vascular access surgery.

Objective: We examined the effects of the introduction of endovascular aortic repair (EVAR) on treatment for abdominal aortic aneurysms (AAAs). Subjects: We compared patients in the following three periods: period I (January 2002–December 2006, 105 patients), period II (January 2007–December 2011, 242 patients, duration of 5 years after the introduction of EVAR), and period III (January 2012–December 2016, 237 patients, duration of 5 years after period II). We used the American Society of Anesthesiologists (ASA) classification for risk assessment. Results: In the Open repaier (OR) group, the incidences of ASA class 2 increased and classes 3 and 4 decreased significantly in periods II and III compared with period I. In all periods, there were no in-hospital deaths. Suprarenal aortic cross-clamping was required in 18 patients (19.1%) in period III and 5 patients (6.3) in period I, and the difference was significant (P<0.05). In the EVAR group, no differences in age, sex, or ASA classification class were observed between periods II and III. In period II, one patient died due to aneurysm rupture during surgery. Significant differences were observed when comparing both groups in periods II and III: patients in the EVAR group were older (P<0.01) and the OR group had a higher proportion of ASA class 2 patients and the EVAR group had a higher proportion of ASA class 3 or 4 patients (P<0.01). Among all AAA surgeries, rupture occurred in 25 patients (23.8%) in period I, 18 patients (7.4) in period II, and 16 patients (6.8) in period III. The number of ruptures was significantly lower in periods II and III than in period I (P<0.01). Conclusions: The findings of this study suggest that EVAR should be indicated for high-risk patients and had the good outcome of AAA treatment.

Objectives: Uncomplicated type B aortic dissection is generally treated with medical management including antihypertensive therapy. The purpose of this study is to investigate risk factors associated with the aortic enlargement in medically treated patients. Methods: Between July 2004 and April 2016, 127 consecutive patients with acute type B aortic dissection were treated in our institution. Of these, 104 patients diagnosed with uncomplicated type B dissection were managed medically as an initial treatment. According to the diameter of the dissected aorta, these patients were retrospectively placed into 2 groups: 1) enlargement group (group E: n=36); and 2) unchanged group (group U: n=68). Results: There was statistically significant difference regarding the initial diameter of the dissected aorta (group E: 42±7 mm, group U: 36±7 mm) (p<0.01). As regards the aneurysm growth rate, a significant difference between both groups was noted (group E: 10±32 mm/half-year, group U −3±19 mm/half-year) (p<0.05). In all 104 patients, 42 patients (40.4%) had patent false lumen with the average number of 1.5 intimal tears. Multivariate analysis showed the relationship for aortic enlargement were patent false lumen (p<0.05, 95% CI 0.407–0.935) and initial aortic diameter (p<0.01, 95% CI 1.076–1.158). Aortic event free survival (1/5/10 years) was 100/86/77% in group E and 92/79/79% in group U, respectively no differences between two groups (p=0.747). Conclusions: The medically managed patients with uncomplicated chronic type B dissection showed excellent survival rate during long-term follow-up. The results of surgical or endovascular treatment in patients underwent initial medical therapy were also satisfactory. The patent false lumen and aortic diameter at the onset may impact on aortic enlargement. Considering our results, the feasibility of elective endovascular repairs in stable dissection remains controversial even in the endovascular era.

Objective: Patients of aorto-iliac aneurysms who undergo endovascular aortic repair (EVAR) require internal iliac artery (IIA) occlusion with coil embolization and its coverage with the stentgraft to prevent type 2 endoleak after extending the endograft into the external iliac artery. However, it has become well recognized that IIA occlusion cause buttock claudication and other various sequelae due to pelvic ischemia. We retrospectively analyzed IIA occlusion outcomes. Methods: From October 2008 to February 2015, 71 patients with aorto-iliac aneurysms underwent IIA occlusion prior to EVAR. The relationship between pelvic circulation and symptom of pelvic ischemia was studied. Results: Buttock claudication occurred in 17 patients (22.9%) of all. Eight patients (14.8%) in unilateral IIA occlusion group (54 patients) and nine patients (52.9%) in bilateral IIA group (17 patients) had sequelae of claudication. The sacrifice of the communication of superior gluteal artery (SGA) and inferior gluteal artery (IGA) led to buttock claudication in 18 (64.3%) of 28 limbs. Instead, only 4 of 60 limbs had buttock claudication, when we preserved the communication between SGA and IGA. In all patients, staged treatment of aorto-iliac aneurysms with IIA occlusion and EVAR were done successfully without pelvic ischemic complications except for buttock claudication, and postoperative CT scanning showed no endoleakage. Conclusion: IIA occlusion prior to EVAR is recognized as a safe and reasonable strategy. It is emphasized that preservation of the communication of SGA and IGA is important to prevent buttock claudication.

Objectives: Aneurysm shrinkage after EVAR is the strong factor of favorable outcomes after endovascular abdominal aortic aneurysm repair (EVAR), and type II endoleaks is the risk factor of no aneurysm shrinkage or aneurysm enlargement in the long term. In this study, we evaluate the aortic side branches relate to early postoperative type II endoleak, and performed coil embolization for those vessels for prevention of type II endoleak. Methods: Patency and diameter of aortic side branches including inferior mesenteric artery (IMA) and lumbar artery (LA) were evaluated in 56 consecutive patients with abdominal aortic aneurysm who were scheduled for EVAR. Coil embolization with Interlock was performed in 24 patients during EVAR for all patent IMA and LA with maximal diameter more than 2.0 mm. Computed tomography was performed one week after EVAR for evaluation of endoleak. Results: In patients with IMA more than 2.5 mm in diameter, the frequency of type II endoleak was approximately 90% regardless of the number of patent LA. In case with patent IMA less than 2.5 mm or with 2 or more patent LA larger than 2.0 mm, the frequency of type II endoleak was 46 to 67%. Coil embolization for IMA was successfully performed in 15/16 patients (94%). Coil embolization of LA was performed for patent LA larger than 2.0 mm and 29 out of 45 Las (64%) was successfully occluded. There was no perioperative complication associated with coil embolization. The frequency of type II endoleak was significantly lower in patients with coil embolization than those without coil embolization (4.2% vs 58.9%, p<0.0001). Conclusion: Patent IMA and LA in diameter larger than 2.0 mm were associated with type II endoleak one week after EVAR, and coil embolization with Interlock during EVAR is safe and effective procedure to prevent type II endoleak.

We examined the outcomes of aortic remodeling for chronic type B aortic dissection (cTBD) after thoracic endovascular aneurysm repair (TEVAR). Objective & Methods: Thirty-eight patients underwent TEVAR for cTBD at our institution. We classified cTBD patients into the early cTBD group (16 cases, 2 weeks-4 months from onset) and late cTBD group (22 cases, >4 months from onset). Results: There were no cases of paraplegia, stroke, and hospital death in both groups. There was no worsening of complicated cases. We achieved false lumen thrombosis in cases with a double-barreled thoracic aorta. The early cTBD group had more complete shrinkage cases (60%) than the late cTBD group (11%). Conclusion: We obtained favorable mid-term outcomes after TEVAR for cTBD patients. Early cTBD patients obtained good aortic remodeling with TEVAR.