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We report a case of 55 mm abdominal aortic aneurysm coinciding with a rare congenital anomaly of proximal origin of bilateral internal iliac arteries (IIAs). Because renal to iliac bifurcation lengths were bilaterally short (129 mm and 125 mm), a trunk-ipsilateral leg and an iliac leg were deployed before iliac branch component insertion into the iliac leg. With help of a pull-through wire, internal iliac component was delivered without migration of the main body. The left IIA was embolized, but the right IIA was successfully preserved with commercially available iliac branch endoprosthesis only from femoral approaches, and the patient fully recovered without any complication.

Background: Surgical reconstruction of the internal iliac artery (IIA) or its branches is sometimes demanding because of difficulty in distal clamping and suturing in the narrow pelvic space. Here we present a hybrid technique of ClampLess In-situ imMobilized Branching (CLIMB) to reconstruct IIA. Methods: in the CLIMB technique, an 8 mm artificial graft is sutured onto the surface of the common iliac artery (CIA) without clamping. Following puncture of the CIA wall, stent grafts are bridged from IIA to the graft. Finally, the graft is sutured to the ipsilateral external iliac artery (EIA). Concomitant endovascular aneurysm repair or IIA branch embolization can also be performed. We applied this technique to the patients unsuited for other IIA reconstruction. Results: eleven patients underwent the current technique. All but one patient underwent contralateral IIA interruption. Seven patients had a history of aorto-iliac repair before the index surgery. Iliac extender, internal iliac component, Viabahn VBX or Fluency covered stent were used for bridging the graft. Simultaneous IIA branch embolization was performed in 2 patients. Distal landing zones were IIA in 7 grafts, superior gluteal artery in 4 grafts and inferior gluteal artery (IGA) in 1 graft. Technical success was achieved in all cases. No patient complained of buttock claudication or other ischemic symptoms on the treatment side. During a mean follow-up period of 38 months, 11 out of 12 grafts were patent without any related endoleak. One IGA graft occluded at 56 months after surgery. Conclusions: the CLIMB technique is a viable alternative to preserve IIA with an acceptable mid-term durability.

Abstract Background It has been reported that median arcuate ligament syndrome is closely associated with gastric or pancreaticoduodenal artery aneurysms. Hemodynamic state plays an important role in the formation of the aneurysms. These aneurysms are treated with open resection or endovascular exclusion. However, whether revascularization of the celiac artery can prevent the aneurysm formation is unknown. This report indicated a possibility that prophylactic revascularization for celiac artery stenosis resulted in decreased shear stress on the collaterals, which may otherwise be susceptible to new aneurysms. Case presentation This report describes a 51-year-old man who presented with epigastric pain at our hospital. According to contrast enhanced computed tomography (CT), he was diagnosed with a ruptured right gastric artery aneurysm and celiac artery stenosis caused by the median arcuate ligament (MAL). He had a vascular anomaly of the common hepatic artery arising from the superior mesenteric artery (SMA). His vital signs were stable. We informed him of the situation and he chose open surgery rather than endovascular treatment. Following, we resected the aneurysm and transected the MAL. Intraoperative angiography after transection of the MAL showed the antegrade blood flow to the splenic artery instead of the retrograde flow via the prominent collaterals. Follow-up CT confirmed narrowed collateral vessels between the SMA and the celiac artery without de-novo aneurysms. Conclusion While the necessity of celiac artery release could be questioned, the present case supports the hemodynamic benefits of MAL transection in terms of de-novo aneurysm prevention.

The objective of this study was to determine how postoperative skin perfusion pressure (SPP) as a measure of blood flow after revascularization affects limb prognosis in patients with critical limb ischemia (CLI). We retrospectively reviewed 223 consecutive bypass surgery cases performed in 192 patients with CLI during a 10-year period. SPP was measured 1-2 weeks before and after the procedure. An SPP of 40 mmHg was set as the cut-off value for revascularization. Patients were grouped according to their postoperative SPPs, and amputation-free survival (AFS) was analyzed. An SPP of = 40 mmHg was recovered in 75% of the patients, but no significant difference was found between this group and the group that did not reach 40 mmHg. On the other hand, the values increased by = 20 mmHg from the preoperative values in 70% of the patients. This group had a significantly better AFS than the group that did not increase by 20 mmHg. Logistic regression analysis revealed that (1) a preoperative SPP of < 20 mmHg and (2) a high serum albumin level (> 3.0 g/dL) were significant factors in increasing SPP by 20 mmHg. These results showed that an increase in SPP of = 20 mmHg after bypass surgery was associated with better limb prognosis. [ABSTRACT FROM AUTHOR]

Background: The survival benefit of non-curative gastric resection for patients with stage IV gastric cancer is still unclear. Methods: Of the patients who underwent open abdominal surgery that was preoperatively intended to be a radical excision procedure for gastric cancer, 72 were diagnosed with stage IV during the operation. At this institution, non-curative gastric resection is performed whenever possible. Results: Non-curative gastric resection was performed in 44 of the 72 patients. According to the survival analysis, the median survival times in the gastric resection and no-resection groups were 1.9 and 0.9 years, respectively (log-rank test, p = 0.014). Based on the multivariate analysis, we selected gastric resection (hazard ratio [HR] = 0.309; 95 % confidence interval [CI] = 0.152-0.615) and postoperative chemotherapy (HR = 0.136; 95 % CI = 0.056-0.353) as independent factors associated with overall survival (OS). In the subgroup analyses of OS, the factors that were associated with gastric resection having no survival benefit were the existence of distant lymph node or liver metastasis (p = 0.527) and the lack of postoperative chemotherapy (p = 0.589). Conclusions: For patients who have distant lymph node or liver metastasis and those who will not undergo postoperative chemotherapy, non-curative gastric resection has no survival benefit. [ABSTRACT FROM AUTHOR]

Background: Reduction en masse of inguinal hernia is a rare condition following manual reduction of an unrecognized incarcerated inguinal hernia. The preoperative diagnosis and surgical treatment via an inguinal approach has been considered difficult. Case presentation: A 59-year-old man with lower abdominal pain was presented to our hospital. He was diagnosed reduction en masse of an inguinal hernia based on his CT findings which showed the presence a pre-peritoneal hernia sac containing the small bowel. An emergency operation via an anterior approach was performed and we found a hernial sac containing an incarcerated small bowel at the cranial and internal sides of the internal inguinal ring. Opening of the hernial sac revealed necrosis of the incarcerated small bowel and bowel resection was performed. Kugel patch was inserted into the pre-peritoneal space and the patient made an uneventful recovery. Conclusion: When it is accurately diagnosed, reduction en masse of an inguinal hernia can be treated with direct Kugel repair via an anterior approach. [ABSTRACT FROM AUTHOR]