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Aortoduodenal fistula after endovascular treatment of abdominal aortic aneurysm is a very rare but life-threatening complication. Herein, we describe 4 cases of aortoduodenal fistula diagnosed at 15 to 78 months after the index aortic intervention, all successfully treated by surgery. All patients underwent primary repair of the duodenal wall, creation of tube duodenostomy, stent graft removal, and in situ reconstruction using a rifampicin-soaked prosthesis. Patients received prolonged antibiotic treatment for at least 2 months postoperatively, and all were free of recurrent infection at follow-up. Prompt and appropriate surgical intervention is required to effectively manage this condition.

Objective: This multicenter observational study was conducted in order to investigate the incidence of cancer in patients with critical limb ischemia. Materials and Methods: We prospectively investigated the incidence of cancer in 68 patients with critical limb ischemia over a two-year period. Patients underwent an intensive examination at enrollment, which included tumor marker levels and chest and abdominal computed tomography, as well as one- and two-year follow-up examinations. We compared the observed incidence of cancer with the expected incidence calculated from national cancer rates by the standardized incidence ratio (SIR). Results: The majority (83.6%) of the patients were men, and 92.5% of the patients had a peripheral arterial disease that was classified as Fontaine stage III or IV. During enrollment, newly diagnosed cancers were detected in seven patients. Four additional cancers were detected during the follow-up period. All of the detected cancers were asymptomatic. We observed an increased risk of cancer (SIR, 4.04; 95% confidence interval, 1.31-9.42) in patients with critical limb ischemia. Conclusion: This study suggests that critical limb ischemia is associated with an increased risk of cancer. Our findings should be taken into serious consideration by future investigators considering the use of therapeutic angiogenesis.

BACKGROUND Specialized proresolving mediators from ω-3 polyunsaturated fatty acid may control resolution of inflammation. We evaluated the influence of two specialized proresolving mediators, resolvin D1 (RvD1) and protectin D1 isomer (PD1 iso) on neointimal hyperplasia after balloon injury. MATERIALS AND METHODS Sprague Dawley male rats at 12-14 wk of age were injured as a model of balloon angioplasty. Then, 1 μg/rat of RvD1 or PD1 iso was administered intravenously via the tail vein immediately and 2 d after angioplasty. The proliferation of injured artery and the infiltration of leukocytes, monocytes, and macrophages at 3 d after injury were evaluated by immunostaining. The activity of the inflammatory transcription factor nuclear factor kappa-light-chain-enhancer of activated B cells (NFκB) in the injured artery at 3 d after injury was evaluated using an enzyme-linked immuno sorbent assay kit. The proliferation of the neointima was evaluated by calculating the ratio of the neointimal and medial areas using specimens at 14 d after injury. RESULTS RvD1 and PD1 iso attenuated proliferation of medial cells (P

The prevalence of arteriosclerosis obliterans (ASO) and critical limb ischemia (CLI) is currently increasing, and arterial reconstruction is often attempted to salvage the limb. Some patients cannot undergo attempted revascularization because of contraindications, and they only receive conservative treatment. In this study, we investigate the comorbidities and survival rates of patients with CLI who receive conservative treatment. Thirty-five patients with CLI due to ASO, who had not undergone revascularization surgery (C group), were enrolled. As controls, 136 patients with CLI due to ASO who did undergo revascularization (R group), mainly via bypass surgery, were enrolled. Coronary artery disease, heart failure, and respiratory dysfunction were factors indicating conservative treatment. Limb salvage rates and survival rates were not significantly different between the two groups. Patients who had survived for less than two years after surgery had a higher prevalence of chronic heart failure, cardiovascular disease, and end-stage renal disease compared to patients who had survived for more than two years. The use of statins, dual antiplatelets, aspirin, or warfarin did not influence whether a patient survived for longer than two years. 77% of patients survived for more than two years after receiving only conservative therapies. Surgical revascularization did not improve the prognosis of patients with CLI as compared with the conservative therapy. Clinicians might start with conservative treatment while considering other treatment options for patients with CLI.

The main objective is to examine whether the severity of peripheral arterial disease (PAD) affects the expenses and hospital stay of the patients who undergo bypass surgery below the inguinal ligament for PAD. Eighty consecutive patients who underwent infrainguinal bypass surgery for PAD between January 2012 and December 2014 were included in the study. Patients were divided into groups according to their critical limb ischemia (CLI) symptoms and the Wound, Ischemia, and Foot Infection (WIfI) classification. As endpoints, we assessed the duration of postoperative hospital stay and expenses during hospitalization. CLI was a significant factor for longer hospital stay and increased medical expenses (p = 0.009 and p = 0.001). In the patients with CLI, significant factors for longer hospital stay and increased medical expenses were (1) history of distal bypass (p = 0.33 and p = 0.003, respectively) and stage 4 local lower limb status in WIfI classification (p = 0.0007 and p = 0.053). PAD severity was associated with prolonged postoperative hospital stay and increased medical expenses. The presence or absence of CLI and its severity according to the WIfI classification correlated with medical expenses and hospital stay duration between the milder and severe groups.

BACKGROUND Wound healing is one of the most important endpoints after revascularization for critical limb ischemia. The purpose of this study was to evaluate the risk factors for wound healing after revascularization for critical limb ischemia (CLI). METHODS A retrospective study was conducted at a single university hospital, and data were collected retrospectively between January 2005 and September 2016. All admitted patients who were diagnosed with CLI and underwent revascularization for the first time were enrolled. The risk factors for wound healing were analyzed. RESULTS The risk factors for wound healing were analyzed in 153 patients. The cumulative rate of wound healing at 12 months after revascularization was 79%. The independent risk factors for wound healing were non-ambulatory status (hazard ratio, 1.95; 95% CI [1.22-3.21], P=0.004), and wound, ischemia and foot infection (WIfI) stage 4 (hazard ratio, 1.89; 95% CI [1.25-2.91], P=0.002). CONCLUSIONS In our study, non-ambulatory status and WIfI stage 4 were independent risk factors for wound healing after revascularization. WIfI criteria well reflected the prognosis of patients with CLI in wound healing, as well as limb salvage.

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.

Fatigue limit estimation using infrared thermography has recently received attention as a method for reducing the time required for product design. In this study, the applicability of a method based on mean temperature and dissipated energy measurements was experimentally investigated on a titanium alloy; fatigue plate specimens were fabricated from the titanium alloy Ti-6Al-4V ELI. The fatigue limit of these specimens obtained from conventional fatigue testing was found to be 620 MPa. The estimated fatigue limit obtained from mean temperature measurements was found to be 600 MPa, although estimating the fatigue limit using dissipated energy measurements was difficult because little significant change in dissipated energy values with the stress amplitude was observed. These tendencies are probably attributed to the crystal structure displaying different deformation properties and high vibration absorption properties. The resonance components from the fatigue testing instruments (noise components) were calculated from the frequency analysis of the time-series temperature fluctuation data measured by infrared thermography. The increase in the dissipated energy values (with the noise components subtracted) against the stress amplitude changed at a certain stress amplitude and the fatigue limit could be estimated to be 565 MPa. Therefore, the relative error between the fatigue limit value obtained from conventional fatigue testing and the estimated values was within 10%. The fatigue limit could be estimated more accurately by considering the influence of different deformation properties between tensile and compressive loading due to the crystal structure differences in the dissipated energy measurement.

Background Carotid endarterectomy is the established treatment for carotid artery stenosis, and remains the primary surgical option due to its superior outcomes compared to carotid arterial stenting. However, Japanese patients are known to have unfavorable anatomical conditions for carotid endarterectomy, with a relatively higher level of the carotid artery bifurcation than in the Western population. We investigated the outcomes of carotid endarterectomy in our institute and evaluated the procedural quality by comparing patients based on higher or lower lesion levels. Methods The clinical data of 65 patients who underwent carotid endarterectomy were collected retrospectively. The outcomes reviewed included stroke-free survival and stroke-free rate. The patients were divided into a higher group ( n = 25) and a lower group ( n = 40), based on lesion location in respect of the 2nd cervical vertebral level. Results There was no perioperative death and only one case of stroke in the higher group within 30 days after carotid endarterectomy. At 5 years after carotid endarterectomy, the stroke-free survival rates were 83.4% in the higher group and 87.8% in the lower group, while the stroke-free rates were 96.0% and 94.0%, respectively; there were no significant differences between groups. Conclusions Stenotic lesion level did not affect the outcome or procedural quality of carotid endarterectomy.

Background In this study, we aimed to clarify both systemic and local prognosis after surgical interventions for critical limb ischemia (CLI) due to vasculitis or connective tissue related disease, and to search for any risk factors that can worsen the prognosis. Methods One hundred and ninety three patients that underwent surgical interventions for CLI between 2005 and 2014 were followed up for a median of 2.7 years. The patients were grouped into a group with vasculitis or connective tissue related disease (V) or with atherosclerosis (control: C). Two groups were retrospectively reviewed and compared. Results Thirty-one patients were grouped into the V group. At three years after intervention, V group showed significantly higher survival rate compared to C group (89% vs. 73%). On the other hand, limb survival rate after bypass surgery was significantly lower (74% vs. 94%), due to lower patency of the bypassed graft. Within V group, preoperative skin perfusion pressure of lower than 20 mmHg showed significantly worse prognosis of the limb. (HR 1.8; P=0.01) Regarding specific diseases, systemic scleroderma, rheumatoid arthritis and systemic lupus erythematosus tended to show worse prognosis. Conclusions Patients with CLI due to vasculitis or connective tissue related disease have a longer life expectancy with lower limb salvage rate that can lead to low quality of the remaining life.

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.

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.

ObjectiveWe aimed to investigate risk factors associated with more rapid growth of abdominal aortic aneurysms (AAA)

Objective: The purpose of this study was to examine non-dynamic and non-morphological factors that may be related to abdominal aortic aneurysm (AAA) rupture. Methods: Of the 205 consecutive AAA patients who underwent open surgery between 2004 and 2008 in our department, comparisons were conducted between patient groups based on the following AAA types: non-ruptured “large” AAAs with a diameter ≥ 65 mm (non-rupture group; n=26) and ruptured “small” AAAs with a diameter

Calciphylaxis, a systemic disorder seen in 1%-4% of patients with end-stage renal disease, is a cause of penile ischemic gangrene. We present a case of successful revascularization surgery for penile calciphylaxis. An arterial bypass to the deep dorsal penile vein relieved the rest pain and stopped expansion of the gangrenous lesion.