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Endovascular procedures have become the standard treatment for acute stroke caused by large vessel occlusion. Various strategies are available, including stent retrieval, aspiration catheter placement, and combined techniques. However, the first-pass effect can be maximized using the technique most familiar to each surgeon and institution. Therefore, it is necessary to understand the characteristics of each device and develop case-specific treatment strategies.

Currently, stricter indications for carotid artery stenosis are required owing to improvements in multifaceted medical treatment, including the intensive management of risk factors for atherosclerosis and lifestyle changes. High-risk factors for carotid artery stenting, such as vulnerable plaques, severe calcification, pseudo-occlusion, and difficult access, should be evaluated before endovascular intervention. Therefore, we need to understand the characteristics of each device to achieve maximum risk reduction for carotid artery stenting.

A 67-year-old male was admitted to our hospital for sudden onset chest pain and hoarseness. He underwent 2-debranching thoracic endovascular aortic repair for a ruptured aortic arch aneurysm four years prior. However, computed tomography (CT) revealed an aneurysmal rerupture due to a typeⅠa endoleak. We performed partial arch replacement with uncovered stent removal under intermittent hypothermic circulatory arrest. We needed to be more careful than usual open heart surgery because a non-anatomical bypass procedure was performed. The surgery was successful without any major complications, and the patient was discharged on the 23th postoperative day. Reinterventions post-endovascular repair are sometimes difficult;thus, open surgery could be useful for arch replacement.

A 62-year-old male patient underwent pancreaticoduodenectomy with modified Child reconstruction for distal cholangiocarcinoma. After eight years, a contrast-enhanced computed tomography (CT) revealed a recurrent lesion at the biliojejunal anastomosis, and a biliary stent was placed for obstructive cholangitis in the right posterior segment of the liver. A right hepatectomy was planned for a local recurrent lesion;thus, percutaneous transhepatic portal embolization was performed on the portal vein's right branch to enlarge the left liver. However, he was referred to our department for endoscopic retrograde biliary drainage for the subsequent cholangitis and liver abscess appearance. A double-balloon enteroscope under CO 2 insufflation was used to reach the bile duct-jejunal anastomosis. After removing the bile duct stent with grasping forceps, his general condition suddenly deteriorated, causing cardiopulmonary arrest. He was diagnosed with air embolism based on the findings of air in the heart, aorta, and brain on CT after the return of spontaneous circulation. Treatment for the air embolism and subsequent complications continued in the intensive care unit, but he eventually died 114 days after the onset of the air embolism due to his deteriorating general condition. Pathological autopsy revealed cholangiocarcinoma that extends from the porta hepatis to the posterior segment. Additionally, the proximity between the bile duct and vein extended by the adenocarcinoma and the fibrous obstruction of the vein were revealed, indicating the possibility of a bile duct-vein shunt.

In recent years, bridge to surgery(BTS), in which surgery is performed after colorectal stenting for obstructive colorectal cancer, has gradually become popular, and laparoscopic surgery is also a treatment option. From January 2020 to December 2022, we retrospectively evaluated clinicopathological factors in 18 colorectal cancer cases who underwent radical resection after colorectal stenting. We found no difference in patient background, histopathological factors, primary anastomosis rate, stoma creation rate, operative time, postoperative complication rate and length of hospital stay between the laparoscopic surgery(L)and open surgery(O)groups. Blood loss was significantly lower in group L. In T4 patients, laparoscopic surgery after colorectal stenting can be safely performed, but conversion to open surgery may be necessary. Surgery after colorectal stenting should be performed based on preoperative accurate imaging and sufficient experience.

Although ureteral stenting is a common conservative treatment for ureteral stricture, it is unclear whether a long-term indwelling ureteral stent protects the kidney against parenchymal atrophy and functional deterioration. In this study, we evaluated the changes in renal parenchymal thickness (RPT) and estimated the glomerular filtration rates (eGFR) in patients with indwelling ureteral stents for one year or more. As a control, we also evaluated changes in RPT associated with indwelling percutaneous nephrostomy (PNS) for one year or more. Polymer ureteral stents were used and replaced every three months. RPT was measured using computed tomography (CT). Totally, 69 renal units in 55 patients with baseline and follow up CT scans available were enrolled. The median follow-up period was 29 months. The etiologies of ureteral obstruction were malignant and benign disease in 27 and 28, respectively. RPT was reduced obviously in most cases. At 1 year, the median reduction rate of RPT was 17.3% in unilateral cases, which was significantly higher than that in the healthy contralateral kidney. There was a strong correlation between eGFR and total RPT including the contralateral kidney. The reduction rate of RPT in kidneys with ureteral stents including bilateral cases was also significantly higher than that in 39 renal units of 35 patients with PNS. The results of this study suggest that the long-term efficacy of indwelling ureteral stents in preserving renal function is limited. Regular imaging may be essential to evaluate the residual renal function.

Cerebrovascular complications in cardiovascular surgery have long been documented. It is very important to diagnose and evaluate the stenosis of carotid artery before cardiovascular surgery. When indicated, carotid endarterectomy( CEA) or carotid artery stenting( CAS) for severe carotid artery stenosis may be considered before cardiovascular surgery. However, it has not been necessary performed in the real-world. It seems to be appropriate to maintain a mean arterial pressure of 50-70 mmHg during cardiovascular surgery with extracorporeal circulation. In addition, perioperative cerebral metabolism and circulation monitoring using a near-infrared cerebral oxygen monitor such as rSO2 is very useful from the viewpoint of preventing exacerbation of cerebral ischemia.

Malperfusion syndrome of the visceral branches associated with acute aortic dissection brings an extremely poor outcomes leading to perioperative and long-term mortality in both Stanford type A and type B acute aortic dissection. The conventional surgical strategy for these cases has been to prioritize aortic repair and to improve blood flow of true lumen in aorta and visceral branches. Today, various techniques for early reperfusion have been reported. For bowel ischemia, it is necessary to evaluate substantial ischemia of the intestinal tract and hypoperfusion of the superior mesenteric artery( SMA) using contrast-enhanced computed tomography( CT) and intraoperative transesophageal echocardiography in addition to clinical presentation. The most important factor of the surgical intervention is the improvement of true luminal blood flow by reconstruction of the central aorta. However, an intervention to SMA prior to central aortic repair might be an important process for patients with Stanford type A acute aortic dissection to avoid irreversible bowel necrosis. In type B aortic dissection, thoracic endovascular aortic repair (TEVAR) with or without provisional extension to induce complete attachment (PETTICOAT) technique and additional SMA intervention based on intraoperative contrast findings are necessary. Renal malperfusion is also a risk factor of postoperative accute kidney injury( AKI) and perioperative mortality. The revascularizations of renal arteries might improve outcomes when renal blood flow was not recovered with central aortic repair.

We present a case of internal carotid artery (ICA) stenosis caused by mechanical stimulation by the hyoid bone (HB) and thyroid cartilage (TC). A 78-year-old man with a history of right ICA stenting four years previously was admitted for abrupt onset of dysarthria and left hemiparesis and diagnosed with ischemic stroke by magnetic resonance imaging. Three-dimensional computed tomographic angiography revealed internal carotid in-stent restenosis. Furthermore, the HB and TC contacted with the right ICA. Treatment involved antiplatelet therapy, partial HB and TC resection, and carotid artery restenting. Posttreatmently, the ICA was restored and stenosis improved. Since restenosis may occur posttreatmently in patients with carotid artery stenosis caused by mechanical stimulation of the HB and TC, it is necessary to consider treatments including not only carotid artery stenting but also partial bone structures resection and carotid endarterectomy.

The patient was a 68-year-old male. Pancreaticoduodenectomy(PD)for papillary carcinoma was performed. Computed tomography(CT)3 months after surgery revealed the migration of a lost Pit-stent into the bile duct. However, there were no symptoms. On CT 2 years after surgery, the lost stent had spontaneously fallen off. However, hepaticolithiasis was observed, and lithotripsy was performed using endoscopic retrograde cholangiopancreatography(ERCP). A pancreatic fistula after PD is an important complication. To prevent pancreatic fistulae, pancreatic stenting at the site of PD is performed in many cases. The postoperative in vivo kinetics of a lost stent remains to be clarified. Several case reports on complications have been published. In this study, we report a patient in whom the migration of a lost Pit-stent into the intrahepatic bile duct after PD led to hepaticolithiasis, and review the literature.

Carotid artery stenting(CAS)has emerged as a less invasive alternative to carotid endarterectomy(CEA), the standard surgical treatment for carotid artery stenosis. Major international randomized control trials(RCTs)have demonstrated its non-inferiority to CEA, and it is now recommended in the Japanese stroke treatment guidelines for both symptomatic and asymptomatic severe stenotic lesions. To ensure safety, it is essential to use an embolic protection device to prevent ischemic complications and maintain the quality of physicians proficient in both techniques and devices. In Japan, these two essentials are guaranteed with the aid of a board certification system by the Japanese Society for Neuroendovascular Therapy. Furthermore, preprocedural carotid plaque evaluation using non-invasive methods such as ultrasonography and magnetic resonance imaging to detect vulnerable plaques, which are considered at high risk for embolic complications, is frequently performed, thereby determining therapeutic indications to avoid adverse events. Thus, the results of CAS in Japan are far superior to those of RCT abroad, making this procedure the first-line therapy for carotid revascularization for decades.

We report a case of rectal cancer that was resected 1 year and 3 months after SEMS implantation. An 89-year-old man was previously diagnosed with sigmoid colon cancer at another hospital but did not undergo surgery. Three years and 7 months after the diagnosis, SEMS was implanted at another hospital. Four years and 10 months after the diagnosis, the patient was diagnosed with intestinal obstruction at our hospital. Since the SEMS was open on colonoscopy, the patient was also suspected of having flaccid constipation. The primary tumor was resected, and a colostomy was constructed in the descending colon. Bridge to surgery for obstructive colorectal cancer was performed within a few weeks after SEMS implantation. At our hospital, resection was performed after a long time. No complications, such as obstruction or perforation, were observed. In addition, although there were concerns regarding increased vascular invasion due to compression and drainage of the cancerous tissue, in our case, the vascular invasion was mild, and no distant metastasis or invasion of other organs was observed. SEMS can be used for long-term implantation and does not necessarily cause cancer progression.

A 53-year-old man was diagnosed as esophageal cancer, and esophagectomy was performed. Anastomotic stenosis was caused due to lymphorrhea and anastomotic leakage after surgery. Dilation was performed, though stenosis did not improved, we placed esophageal stent across the stenotic lesion. Pharyngitis occurred after indwelling esophageal stent, we hence removed the stent. Passage disorder was developed, we placed duodeneal stent which is more flexible. Stenosis is now palliated after placing duodeneal stent. Duodeneal stent could be an option for the tratment of anastomotic stenosis after esophageal surgery.

An 86-year-old man was hospitalized urgently to our department because of his worsening hemoptysis. He had undergone open thoracic aortic grafting for the Stanford type B chronic aortic dissecting aneurysm 30 years earlier. Contrast enhanced computed tomography (CT) revealed the distal anastomotic aneurysm, leakage of the contrast medium around the distal anastomotic site. We urgently performed thoracic endovascular aneurysm repair( TEVAR) for the distal anastomotic aneurysm. TEVAR was done under local anesthesia because of his poor respiratory condition due to hemoptysis. He recovered well without hemoptysis. Patients after open aortic surgery are expected to survive longer. Thus, special attention should be paid to the occurrence of anastomotic aneurysms.

A 79-year-old man with shortness of breath on exertion had right pleural effusion and ascites effusion on CT, and was diagnosed with adenocarcinoma on pleural cytology. Upper gastrointestinal endoscopy revealed a gastric cancer with pyloric stenosis, and biopsy from the same site revealed Group 5(tub2). The patient was diagnosed as unresectable advanced gastric cancer with pyloric stenosis and peritoneal and pleural dissemination. After placement of an uncovered metallic stent for the pyloric stenosis, SOX therapy was started. Three months after stent placement, a CT scan to determine the effect of chemotherapy showed stenosis in the gastrointestinal stent, partial breakage of the stent on the mouth side, and prolapse of the stent into the stomach. There were no symptoms such as abdominal pain, and the patient was placed on standby for retrieval of the dislodged stent. The prolapsed stent was retrieved endoscopically, and a covered metallic stent was additionally implanted as a"stent in stent". The patient has had no further passage obstruction and is currently undergoing chemotherapy. We report a case of fracture of a gastrointestinal stent during chemotherapy for unresectable advanced gastric cancer.

We describe an unusual case of a 73-year-old man with amaurosis fugax. He had repeated transient monocular symptoms, one of which features lighting bolt-shaped glittering in the full visual field of the right eye since medical treatment for hypertension and diabetes mellitus started. A few days later, he felt difficulty in speech as well as sensory and motor disturbance in the left upper extremity, which finally brought him to our hospital. An MR scan unveiled subacute infarctions dotted in the right cerebral hemisphere and severe carotid stenosis on the same side with a delayed distal flow. He was hospitalised with diagnosed an ischemic stroke. Despite being treated with antithrombotic agents, he had suffered similar visual symptoms repeatedly and therefore, carotid artery stenting was performed on Day 16 starting from the onset. The right ophthalmic artery and choroidal crescent became depicted angiographically after our surgery had been completed. His visual disturbance has never appeared since then. Consequently, it is suggested that the optic disorders were attributed to a hemodynamically precarious state in the area of the ophthalmic artery.

A 58-year-old man was admitted to our institution with sudden onset of hypotension and acute ischemia of left lower extremity. Electrocardiography showed ST segment elevation in leads V1~V6 and a transthoracic echocardiogram revealed antero-septal wall hypokinesis. He was given a diagnosis of acute myocardial infarction caused by left main coronary artery compression due to acute aortic dissection by enhanced computed tomography. We implanted a stent in the left main coronary artery and performed right external iliac-left femoral arterial bypass under general anesthesia. We performed a conventional total arch replacement and frozen elephant trunk and mitral valve repair at day 16. His postoperative course was good. Implantation of a left main trunk stent is an effective strategy for Stanford type A acute aortic dissection with left main coronary arterial occlusion before surgical repair.

Occlusion of internal ureteral stents commonly called double-J (DJ) stent leads to renal dysfunction, urinary tract infection, and difficulty in replacing the stent. We investigated the cause of stent occlusion and whether DJ stent occlusion persisted with change in the type of stent. The internal ureteral stent, Bird® Inlay™ Optima or Boston Scientific® Tria™, was inserted in 43 ureters of 33 patients who underwent replacement more than three times between September 2017 and June 2020. We defined stent occlusion as follows: a guide wire could not be passed through a stent during the replacement. In the first occlusion, the type of stent was changed. In the second occlusion, the stent placement interval was shortened from 12-13 weeks to 6-8 weeks. The presence of urinary stone and insertion of a urethral catheter had a high risk of DJ stent occlusion. Stent occlusion was observed in 20 of the 43 ureters. After the type of stent in 20 ureters with stent occlusion was changed, there were no DJ stent occlusions in 16 of the 20 ureters. Nevertheless, in 4 of the 20 ureters, even if we changed the type, DJ stent occlusion was still present; hence, the replacement interval was shortened. Therefore, changing the type of stent may be a recommended intervention for DJ stent occlusion.

Thoracic endovascular aortic repair (TEVAR) has been widely used in recent years as a treatment for thoracic aortic aneurysm, but open surgery may be required for various complications that cannot be controlled by endovascular treatment alone. It is often a more challenging operation. A 78-year-old man underwent two debranch TEVAR (zone 1) for thoracic aortic aneurysm eight years before, and he received TEVAR (zone 0) again with the Najuta stent graft for re-expansion of aneurysm due to typeⅠa endoleak two years before. Since the aneurysm continued to expand and the aortic valve stenosis progressed after that, we performed total arch replacement (TAR) and aortic valve replacement (AVR). The Najuta stent graft could be removed manually. As the debranched graft had to be cut off at sternotomy, selective cerebral perfusion (SCP) was initiated at normal body temperature. It should be noted that SCP at normal body temperature may require more perfusion than hypothermic SCP. TAR was performed in combination with frozen elephant trunk, and postoperative computed tomography (CT) confirmed the disappearance of endoleak. One year has passed since the operation, but the aneurysm has not re-expanded.

A 75-year-old male with a history of allergy to iodinated contrast media was referred for the treatment of the left subclavian artery aneurysm. The aneurysm was saccular and maximum diameter over 30 mm. Stent grafting was performed with the use of gadolinium-based contrast agent and intravascular ultrasound (IVUS). Ipsilateral vertebral artery was temporarily occluded with a balloon catheter to protect against distal embolism. The IVUS reduced the amount of gadolinium-based contrast agent. There were no neurological, renal or other complications after the treatment. Stent grafting of the left subclavian artery aneurysm may be safely performed with gadolinium-based contrast agent and IVUS, even if iodinated contrast media is contraindicated.

A 53-year-old woman had left pyonephrosis and bladder stone. A double-J ureteral stent was placed for left ureterostenosis and she was lost to followup. Five years later, she had back pain. Computed tomography revealed left hydronephrosis, pyonephrosis and bladder stone. After drainage by percutaneous nephrostomy and antibiotic treatment, left nephroureterectomy was performed. She has been free from recurrence of infection for 3 months after the surgery.

An 89-year-old man underwent carotid artery stenting for symptomatic left internal carotid artery stenosis. His postoperative course was uneventful;however, on postoperative day 4, he developed a food allergy rash throughout his body after consuming sushi. He developed right hemiplegia and aphasia the following day, and magnetic resonance imaging revealed left internal carotid artery occlusion. Angiography revealed stent thrombosis, and endovascular thrombectomy achieved partial recanalization;however, right hemiplegia and aphasia persisted. Eosinophilia and increased platelet aggregation suggested allergic stent thrombosis(Kounis syndrome type 3).

We present a case of a patient who survived carotid blowout syndrome(CBS)due to covered stent placement, but bled again 34 days later. A 67-year-old man with laryngeal cancer experienced cardiac arrest due to carotid blowout a day after he underwent the balloon occlusion test and abnormal feeder embolization of the tumor. After quick resuscitation, he was treated with endovascular therapy using a covered stent, since he had insufficient cerebral ischemic tolerance. We succeeded in stent placement and the bleeding stopped without any procedural complications. The patient survived after the procedure. However, bleeding recurred when a nasal endoscope was inserted 34 days later. The rupture point was immediately distal of the stent. We performed carotid artery occlusion with coils and n-butyl-cyanoacrylate. The patient survived, but his condition gradually weakened and died 97 days after stenting. Emergency hemostasis for carotid blowout using a covered stent is the only available treatment for patients who do not have sufficient cerebral ischemic tolerance. However, this procedure has a higher rate of re-bleeding than carotid artery occlusion. Moreover, it is an off-label treatment in Japan. Therefore, possible treatments for CBS including use of covered stent or treatments for non-ruptured CBS should be analyzed in the future.

We experienced 2 cases with distal stentgraft-induced new entry (distal SINE) after thoracic endovascular aortic repair( TEVAR) for type B aortic dissection and 1 case after total arch replacement and frozen elephant trunk method for type A dissection. We successfully performed additional TEVAR in all cases. If the stent graft is bent at deployment, distal SINE may occur on the great curvature side of the aorta by the spring back force. Therefore, we must pay attention to appropriate device selection, and even when remodeling of the aorta is good, meticulous follow-up is necessary.

We report a case of marked aneurysmal expansion by type II endoleaks 8 years after thoracic endovascular aortic repair. The preoperative chest computed tomography (CT) demonstrated the descending thoracic aorta of 95 mm with type II endoleak. We performed suture closure of 3 endoleaks and partial aneurysmorrhaphy via left thoracotomy under partial cardiopulmonary bypass. The postoperative CT showed no endoleak with shrinkage of the aneurysm. The patient was discharged on the 21th postoperative day uneventfully.

Matsui-Kitamura stent-graft (MKSG) is a home-made device for thoracic endovascular aortic repair (TEVAR) developed in Japan. A 76-year-old man who had been treated by TEVAR (zone 3) with a MKSG for ruptured thoracic aortic aneurysm was diagnosed as having type Ia endoleak caused by suture disruption and aneurysmal sac expansion 6 years later. He underwent TEVAR (zone 1) with debranching and type Ia endoleak disappeared. MKSG had been the effective device especially for acute aortic emergencies in the descending thoracic aorta until the stent-grafts became commercially available, but careful observation and appropriate re-intervention is mandatory for the continued life-saving contribution.

Introduction: The number of patients receiving chronic dialysis treatment in Japan currently exceeds 300,000 people. Few reports have described carotid endarterectomy(CEA)for chronic renal failure patients because of the unacceptable rate of perioperative stroke and other morbidities. A strategy for and treatment results of CEA for chronic renal failure patients in our hospital are described herein., Methods: The present study included 6 patients who underwent CEA while receiving dialysis treatment between April 2011 and November 2014., Results: Dialysis treatment was initiated due to diabetes in 4 patients and renal sclerosis in 2 patients. All the patients were men, with a mean age of 74.0 years. Two patients were symptomatic, and four were asymptomatic. In all the patients, heart vascular lesions and arteriosclerosis risk factors were present. Postoperatively, pneumonia transient cranial neuropathy, heart failure, and pneumonia in 1 case required extensive treatment. However, by the time of discharge from hospital, no cases had deteriorated compared with their pre-CEA state. The modified Rankin scale score on discharge was 0-2 for all the patients., Conclusion: CEA can be performed safely in patients receiving dialysis, but further operative procedures and careful postoperative management are likely to be needed for patients with CEA who are receiving dialysis.

An 87-year-old woman was admitted to our hospital for paralytic ileus, and she was treated using an ileus tube. Although her symptoms improved, abdominal fullness developed again on day 3 after ileus tube insertion. Abdominal computed tomography indicated intussusceptions at the ileum and the terminal part of the ileum;therefore, an emergency surgery was performed. During the surgery, antegrade intussusceptions were found in the ileum 60cm from the ileocecal valve and the terminal part of the ileum into the ascending colon. The intussusception of the anal side was resolved by manual reduction, but the oral side needed a partial resection of small bowel because of the presence of necrosis. There were no lesions, such as tumors, at the intussusceptions sites. Therefore, the two intussusceptions were thought to be caused by the ileus tube. We diagnosed a rare case of intussusceptions in the two parts of the ileum as a complication of the placement of an ileus tube.

A 43-year-old man underwent extracorporeal shock wave lithotripsy (ESWL) for a left ureteral stone and implantation of a loop stent for the treatment of stone pain in February 2011. However, he was lost to follow-up before the complete removal of the stones and stent. He presented to our hospital with left back pain in March 2015. An abdominal radiograph and a noncontrast computed tomography showed extensive stone formation throughout the stent. A single cystolithotripsy and a double endoscopic combined intrarenal surgery (ECIRS)were performed. All the stones and the encrusted ureteral stent were successfully removed.

A 62-year-old man was admitted due to consciousness disturbance and motor aphasia. Magnetic resonance (MR) images demonstrated watershed infarctions in the territory of the left middle cerebral artery, occlusion of the left internal carotid artery, and severe stenosis of the right internal carotid artery at the neck. He was treated with a recombinant tissue plasminogen activator. One month later, angiography revealed recanalization of the left internal carotid artery with residual severe stenosis at the neck. We attempted carotid artery stenting (CAS) on the left internal carotid artery, but could not pass the guide wire through the stenosis. Therefore, we performed CAS on the right carotid artery instead. At the second day after CAS, the patient showed consciousness disturbance, right hemiparesis, and motor aphasia. MR images showed a new infarction in the left cerebral hemisphere and bilateral multifocal segmental arterial constrictions. By keeping his blood pressure at a high enough level for one week, his symptoms were relieved, and MR images showed resolution of the vessel constrictions. From this case, we can conclude that this kind of multiple segmental vasospasms after CAS require contrasting treatments to those for hyperperfusion syndrome. Interventionalists should be aware of this condition and its treatments.

The present study investigated the short-term outcomes of 20 patients with obstructive colon cancer who underwent colonic stent placement as a bridge to surgery (BTS) during the 3-year period between April 2012 and March 2015. Subjects comprised 13 men and 7 women, with a mean age of 68.3 years. Placement and decompression were successfully achieved in all of the patients. Oral ingestion became possible from a mean of 2.7 days after placement. No serious complications associated with placement were encountered. Total colonoscopy was performed after placement in 17 patients (85%), and independent advanced cancer was seen in the proximal portion of the colon in 1 patient. Elective surgery was performed for all of the patients after placement. Excluding the 2 patients for whom preoperative chemotherapy or treatment of another disease was prioritized, the mean interval to surgery for the remaining 18 patients was 23.2 days. The operative procedure performed was laparoscopic surgery in 8 patients (40%). Although minor leakage (n=1) and abdominal wall abscess (n=1) were observed as postoperative complications, the patients generally had an uneventful course. Colonic stent placement for obstructive colon cancer is relatively easy and safe, and may be considered as an effective treatment method that enables favorable intestinal decompression preoperatively and one-stage resection.

A 66-year-old man (166 cm and 64 kg) with a history of hypertension was diagnosed with a.chronic aortic dissection (DeBakey IIIa type). He underwent thoracic endovascular aortic repair (TEVAR) under general anesthesia (sevoflurane and remifentanil) in an angiography room. After deploying a stent graft (Zenith TX2, Cook Japan, Tokyo) in the descending aorta via the right femoral artery, we checked the condition of the stent by angiography. No remarkable change of vital signs was observed. However, the angiography revealed a decrease in blood flow of both brachiocephalic and left common carotid arteries. The decision was made to operate immediately. The patient was transferred to the operating room under sedation with propofol. Cardiopulmonary bypass commenced 1 hour and 25 minutes after the decision to operate. Exploration of the aortic arch confirmed a retrograde ascending aortic dissection (rAAD). Ascending-arch vascular prosthesis was performed during circulatory arrest. The patient was extubated successfully the day after surgery. The present case demonstrates an intraoperative rAAD following stent placement TEVAR is believed to be less invasive compared to surgical treatment. However, it should be noted that TEVAR could provoke life-threatening complications such as rAAD.

With aging of population and increasing number of percutaneous coronary interventions, we frequently encounter patients with coronary artery disease (CAD) and coronary artery stents in the perioperative period. CAD increases the risk of perioperative myocardial infarction which worsens prognosis. It is important for us to evaluate those patients properly. In this review, we describe a classification and characteristics of perioperative myocardial infarction and highlight the mechanism and risk factors of stent thrombosis. We present a way of evaluation and perioperative management of patients with CAD, based on recent guidelines and findings. We present our real cases and perioperative management of CAD and coronary artery stents.

This study was conducted to investigate whether preoperative estimation of the cerebral blood flow (CBF) by single photon emission computed tomography (SPECT) can allow identification of patients at risk for hyperperfusion (HP) after carotid artery stenting (CAS). In 40 patients scheduled to undergo CAS, the CBF and cerebral vascular reserve (CVR) were measured prior to the intervention by resting and acetazolamide loading SPECT. The SPECT findings were classified into 4 types: Type 1, normal CBF in the resting state (CBFrest) and normal CVR; Type 2, normal CBFrest and reduced CVR; Type 3, reduced CBFrest and reduced CVR; and Type 4, reduced CBFrest and normal CVR. Four patients presented with HP after CAS. Patients with high proportions of Type 2 and Type 3 had high risk of HP after CAS. (ROC analysis: AUC=0.94, cutoff value of 75.8% had PPV of 75.0%, NPV of 97.2% and odds ratio of 105.0). The proportions of Type 2 and Type 3 in preoperative SPECT may identify patients at risk for the development of HP.

Objective: The endovascular approach to aortic aneurysm repair is widely spreading as an alternative to open repair. However infectious complications may be devastating. We described the experiences with infected aortic endografts and reviewed treatment and outcomes., Methods: Eight patients were treated due to infected aortic endografts between June 2008 and March 2014. Seven males and 1 female with median age of 66 years( range, 38-84years) had 5 infected thoracic endovascular aortic repairs (EVARs) [5/142:3.5%] and 3 endovascular aortic repairs (EVARs)[3/387:0.8%]. Median time from repair to presentation was 12 months (range, 2-27 months). As the factors associated with infection, hemodialysis due to chronic kidney disease in 1, surgical treatment for the huge atheroma in 1, dental treatment in 2, treatment for infected aneurysm in 1, urinary tract infection after surgery for prostate in 1, aortoenteric fistula after TEVAR in 2 were considered., Results: Five patients were treated with endograft explantation. The surgical mortality was 40% (2/5), during a follow-up, one more patient died with intracranial hemorrhage. The remaining 3 patients who were considered too high risk to remove the infectious endografts were treated conservatively with antibiotics. In 2 of them 1 died of respiratory failure, and multiple organ failure in 1., Conclusions: Infection of the endograft is a rare but devastating complication after endovascular repair of aortic aneurysms. Surgical removal of the infected prosthesis is accompanied with higher mortality, but antibiotics therapy cannot eradicate or cure the infection. In all cases, the factors associated with infection were calculated, and degenerative or infectious thrombi around the endovascular stent grafts were noted. Therefore, we consider that prophylactic antibiotic treatment may be necessary to prevent the bacteremia in the case of other surgical therapy or dental treatment.

Acute cholecystitis is an inflammatory disease of the gallbladder. Inflammation often remains in the gallbladder, but some patients may take a fatal course with exacerbation of inflammation. Although laparoscopic cholecystectomy is recommended for moderate and severe acute cystitis, sometimes cholecystectomy is impossible in elder patients. Because many elder patients have bad general conditions, cholecystectomy should not be performed. Such patients are generally treated by percutaneous transhepatic gallbladder drainage (PTGBD), but PTGBD has the risk of intra-abdominal bleeding. In previous reports, endoscopic gallbladder stenting (EGBS) has been shown to be an effective strategy in cirrhosis patients with symptomatic cholelithiasis as a bridge to transplantation. Recent studies on EGBS have demonstrated an effective long-term management of acute cholecystitis in elderly patients who are poor surgical candidates. Here, we reviewed EGBS for the management of acute cholecystitis.

Background and Purpose: In-stent thrombosis (IST) after carotid artery stenting (CAS) is a rare complication that can lead to severe thromboembolic events. The purpose of this study was to investigate the pathogenesis of IST after CAS., Patients and Methods: A total of 101 patients underwent CAS from January 2006 to September 2013 at our hospital. Five of these patients experienced IST. We reviewed their clinical course and treatment. In addition, we compared various parameters, including basal disease, preceding anti-platelet therapy, rate of stenosis, length of stenosis, preoperative examination, type of stent, length of stent, post dilatation, and postoperative examination, between the IST and the non-IST groups., Outcome: All cases in the IST group had low echoic plaque and open cell stent, and all thrombi were located at the dorsal side of the internal carotid artery and the distal side of the stent flexion. Four cases without neurological symptoms were found to have resolution of IST at 3-6 weeks after CAS with anticoagulant therapy. One case had symptomatic thromboembolism at 1 month after CAS, and the thrombus was removed along with the stent due to growth of the thrombus despite anticoagulant therapy. No significant differences were observed between the IST and non-IST groups with regard to the factors described in the methods section., Conclusions: This study did not identify factors related to IST. We hypothesize that soft plaque can easily protuberate in the context of a stent with a large cell and that protrusion plaque may increase the risk of thrombus formation in combination with turbulent flow at the site of stent flexion. Further investigation in a larger number of patients is needed to clarify the risk factors related to IST.

Purpose: To examine the complications and determine the detention period in obstructive colorectal cancer patients who received chemotherapy after placement of a stent in the colon., Patients and Methods: Seven out of 16 patients with colon cancer received chemotherapy in our hospital after stent placement as palliative therapy., Results: No complications such as perforation, restenosis, deviation, or bleeding were noted. Stent insertion after median 224 stenting period was (66-397) days., Conclusion: Systemic chemotherapy after stenting is associated with an increased risk of perforation or deviations, but no complications were noted in this study. More cases are needed to determine the optimal detention period.

Endobronchial intervention has been well established in therapeutic and palliative methods for patients with malignant and benign airway obstruction. Central airway tumor obstruction could lead to significant dyspnea or hemoptysis and dramatically lower the quality of life. Such symptoms can be relieved immediately via bronchoscopic intervention. Endobronchial therapies such as neodymium yttrium aluminum garnet( Nd:YAG) laser therapy, argon plasma coagulation and microwave coagulation or stent placement are well-established treatment options. Each of these modalities has its specific advantages and disadvantages. Laser therapy is direct thermal ablation applied to endobronchial tumors. It has sufficient power to vaporize tissues and produces an excellent coagulation effect. However, the risk of perforation is high. On the other hand, photodynamic therapy has the curative potential for patients with early superficial lung cancer using low power laser. Moreover, it has recently been approved for the treatment of other cancers including advanced lung cancer. Stent placement is an effective treatment to re-establish airway patency and immediately relieve the patient from life-threatening dyspnea. Stent restenosis, migration, mucus plug and hemoptysis are common short-term and longterm problems. It is important to select the appropriate treatment method for each patient to avoid complications and achieve successful results.

We report a case of a patient with a fistula between the right ureter and external iliac artery. The patient was a 75-year-old woman who had undergone abdominal radical hysterectomy for uterine cancer, and whole pelvis radiotherapy for right external iliac lymph node metastasis. Her post-operative course was complicated by hydronephrosis of the right kidney, which was treated by the insertion of a double-J stent. While removing the frequently obstructed double-J stent after percutaneous nephrostomy, arterial hemorrhage occurred from the external urethral meatus. Computed tomographic scan demonstrated right ureteral external iliac artery fistula formation located adjacent to the pseudoaneurysm. The patient was treated successfully with endovascular stent grafting and has showed no episode of hematuria since then.

A man in his sixties presented to our hospital with obstructive jaundice and was diagnosed with inoperable pancreatic cancer. Chemoradiotherapy was initiated, and an expandable metallic stent was inserted endoscopically to drain the biliary system. Six months later, he was referred to our hospital with 1-week history of epigastric pain and obstructive jaundice. On admission for further evaluation, he experienced hematemesis and went into severe shock. Upper gastrointestinal endoscopy and endoscopic retrograde cholangiopancreatography showed active bleeding from the duodenal papilla. Therefore, we performed endoscopic nasobiliary drainage (ENBD). On day 4, blood was detected in the ENBD tube, and the patient again experienced hematemesis. Emergent enhanced computed tomography revealed a right hepatic arterial aneurysm that had likely ruptured and caused the hemobilia. The aneurysm was successfully embolized, and the patient was discharged on hospital day 21.

Background: In this retrospective study, we investigated the clinical outcomes of endoscopic gastroduodenal stenting (EGDS) for gastric outlet obstruction( GOO) caused by unresectable gastric cancer( UGC)., Methods: A retrospective study was performed on 20 UGC patients with GOO between 2007 and 2012. We compared the clinical outcomes of EGDS using the WallFlex stent( GDS group, n=8) and palliative Roux-en-Y gastrojejunostomy( RYGJ group, n=12)., Results: The numbers of patients with a poor performance status and prior use of chemotherapy were higher in the GDS group than in the RYGJ group. No postoperative complications were observed, and the GOO score improved in both groups. The median days taken to resume oral food intake, the median duration of oral food intake, and the median survival time in the RYGJ and GDS groups were 4 and 3 days( p=0.0008), 301 and 151 days( p=0.0698), and 345 and 161 days (p=0.0070), respectively., Conclusions: EGDS for GOO caused by UGC can be performed safely even after chemotherapy and is beneficial in terms of improvement of oral food intake.

Malignant gastric outlet obstruction( GOO) compromises the ability to eat and drink. Surgical gastrojejunostomy has long been the standard palliative procedure for patients with GOO. However, it might not be applicable for patients with a poor general condition. In Japan, duodenal stenting for malignant GOO has been covered by health insurance since April 2010. In our hospital, 5 patients with malignant GOO underwent duodenal stenting using a WallFlexTM stent( Boston Scientific Corporation). Subsequently, we evaluated the safety and efficacy of duodenal stenting for malignant GOO. Most of the patients in this study were elderly, had systemic inflammation, and were malnourished. We achieved 100% technical and clinical success rates. Four patients were discharged from the hospital. No major complications such as perforation were noted. The median survival time after stenting was 86 days. In conclusion, endoscopic duodenal stenting for malignant GOO is safe and effective, and it could be an option for palliative therapy.

The patient was an 87-year-old woman who was diagnosed with atrial fibrillation, which was treated with an anticoagulant, and with chronic kidney disease. The patient was diagnosed as having liver dysfunction and lower cholangiocellular carcinoma (cStage I) on ultrasonography and magnetic resonance cholangiopancreatography. Since it was impossible to perform curative resection owing to the patient's decreased cardiac and renal function, we performed palliative endoscopic retrograde biliary drainage (ERBD) with a plastic stent (PS), and the patient was discharged 11 days later. However, the patient was readmitted because of fever (>38.0°C) and vomiting 124 days after ERBD. We assumed that the patient had developed cholangitis due to PS obstruction. Moreover, her blood culture was positive for Klebsiella pneumoniae. We were unable to replace the PS as the tumor had increased in size and hemorrhage from the papilla of Vater continued after the stent had been removed. The signs of inflammation improved after treatment of sepsis with antibiotics and immunoglobulins, and we performed percutaneous transhepatic cholangio drainage( PTCD) and eventually inserted a percutaneous transhepatic biliary endoprosthesis (PTBE) with an expandable metallic stent (EMS). The patient died 2 months later; no stent occlusion was observed. Our experience suggests that endoscopic biliary stents should be selected bearing in mind the patency of the stent and the prognosis.

A 23-year-old man and a 62-year-old man suffering from cystinuria underwent extracorporeal shock wave lithotripsy (ESWL) for right renal stone and left ureteral stone, respectively. They had double-J stents placed before ESWL, but since attempts to retrieve the stents were unsuccessful due to encrustation, they were referred to our clinic. Multimodal endourologic and open approaches including ESWL, transurethral ureterolithotripsy, and pyelolithotomy were required to render them stent- and stone-free. The guidelines do not recommend routine stenting before ESWL ; therefore, the indication and duration of indwelling stents should be minimized. Multimodal options including not only ESWL and endoscopic surgery but also open surgery, should be attempted for the management of encrusted stents. Close monitoring and follow up are important to the prevent complications of ureteral stents.

Carotid in-stent thrombosis can cause thromboembolic events although it is a rare complication of carotid artery stenting(CAS). We present a successful case of percutaneous mechanical thrombectomy for symptomatic subacute in-stent thrombosis. A 64-year-old man was hospitalized for the treatment of a cerebral infarction presenting with dysarthria and left upper extremity weakness. Following sufficient medical management including dual anti-platelet therapy, CAS was performed because cerebral angiograms showed severe and long-segment right internal carotid artery(ICA)stenosis. Although the stenosis was resolved, right cerebral infarction presented with progressive left hemiparesis 12 days after CAS. Emergency cerebral angiograms revealed right ICA occlusion due to in-stent thrombosis. Rapid revascularization with percutaneous mechanical thrombectomy of the in-stent occlusion was performed using the Penumbra Aspiration System because a microguidewire could not pass through the occlusion. Post-procedural angiogram revealed recanalization of the right ICA, and the patient was free from neurological events after the last procedure. The evaluation and treatment of peri-procedural in-stent thrombosis following CAS must be prompt and aggressive for prevention of catastrophic events. Percutaneous mechanical thrombectomy is a useful tool for rapid treatment of acute or subacute in-stent thrombosis after CAS.

Lower body ischemia due to bending of a stented graft at the thoracic aorta was rare, particularly when it occurred in several days after surgery. We experienced this complication and performed the 3rd-time thoracic endovascular repair( TEVAR).A 49-year-old man with a chronic aortic dissection of Stanford type B underwent TEVER;however we failed to close the entry because of the tortuously bended distal arch of the aorta. Then it was decided the patient undergo a hybrid treatment with arch replacement and frozen elephant trunk. Seventeen days after the surgery, the blood pressure of the patient's lower limb was reduced rapidly and his renal function deteriorated. Bending of the stent was revealed by computed tomography( CT). The patient underwent the 3rd-time emergency TEVAR, and his symptoms improved.

We report the use of ultrasound-guided carotid sinus nerve block for circulatory management during two-stage carotid artery stenting (CAS) in a patient with symptomatic carotid stenosis complicated with decreased cerebral perfusion reserve. The patient was a 70-year-old man with symptoms of ocular ischemia and markedly decreased perfusion of the left cerebral hemisphere observed in single photon emission computed tomography. Ultrasound-guided carotid sinus nerve block was conducted to prevent CAS perioperative circulatory fluctuations caused by carotid sinus reaction (CSR). We did not observe any hemodynamic instability during CAS. There were no complications associated with the nerve block. Although further research is required, the present findings suggest that ultrasoundguided carotid sinus nerve block may safely and effectively prevent CSR in CAS.