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Background Mycotic aortic aneurysm constitutes a potentially devastating disease that necessitates prompt suspicion and diagnosis. There is no exact consensus for treatment, but removal of infected tissues and prolonged use of antimicrobials based on the identified causative microorganisms seem widely acceptable and have been similarly practiced worldwide. However, some patients still show no identified microorganisms. In this study, we sought to determine whether there is any clinical significance or differences of note in culture-negative mycotic aortic aneurysms. Methods Between October 2003 and August 2018, 71 patients were identified as treated for mycotic aortic aneurysms at a single tertiary institution. Review of medical records and imaging studies were completed to collect the following information: demographics, previous medical/surgical history regarding potential infection sources, laboratory and radiologic findings, clinical presentations, treatment method, and morbidity and mortality rates. For analysis, patients were categorized into two groups: the blood and/or tissue culture–positive (CP) group and the blood and/or tissue culture–negative (CN) group. The latter was further divided as CN with identified microorganism by molecular biologic methods [CN(+)] and CN with no identified microorganism [CN(−)]. Results More patients in the CP group were symptomatic than were in the CN(+) group (100% vs. 80%; P = .034). However, identification of causative microorganisms did not result in a difference in symptom status upon comparing the [CP + CN(+)] and [CN(−)] groups. Inflammatory markers were the most elevated in the CP group and least elevated in the CN(−) group. The aneurysm growth rate seemed slower in the CN(−) group than in the CN(+) and CP groups (1.3 vs. 3.4 vs. 9 mm/month respectively). Aneurysm rupture at initial presentation was more prevalent in the CP group (33.3%). 18F-Fluorodeoxyglucose-positron emission tomography showed increased uptake regardless of whether or not the microorganisms were identified. Early mortality and disease-specific mortality rates during the follow-up period were higher in the CP group but without statistical significance. Conclusions Compared with the CP group, the CN groups appeared clinically less severe, and also exhibited a relatively less devastating course as exhibited by the slower aneurysm expansion rate and smaller number of ruptured aneurysms at the initial presentation.

Background The benefits and necessity of revascularization for asymptomatic carotid stenosis remains under debate. This study aimed to determine the more durable and beneficial alternative between carotid revascularization and optimal medical treatment (OMT) alone for asymptomatic carotid stenosis. Methods We performed a retrospective analysis of patients with asymptomatic severe carotid stenosis at a tertiary institution between 1994 and 2017. We compared revascularization (carotid endarterectomy [CEA] and carotid artery stenting [CAS]) with OMT alone by using inverse-probability-of-treatment weighting with propensity scores to account for selection bias. The primary end point was a composite of any stroke, myocardial infarction, and death within 30 days, plus ipsilateral stroke thereafter. Results A total of 1089 patients were included in the analysis (56% CEA, 25% CAS, 19% OMT alone). Patients who underwent CAS consistently showed greater risk regarding the primary composite end point compared with those who received OMT alone (hazard radio [HR] 3.32, 95% confidence interval 1.014–10.868; P = 0.047), but the CEA group showed no significant difference (HR 1.19, 95% confidence interval 0.385–4.584; P = 0.761). The CAS group had the greatest rates of any stroke within 30 days (4.0%, P = 0.0006) and ipsilateral stroke thereafter (3.68%, P = 0.0009). There was no death within 30 days. In the long-term outcomes, neither CEA nor CAS showed significant differences in HR compared with OMT alone. Conclusions Our study suggests that for stroke prevention in asymptomatic severe carotid stenosis, CAS might be inferior to the other 2 options regarding early outcomes. However, further investigation is required regarding the efficacy and durability of OMT alone.

Purpose: Primary tumor at the carotid bifurcation is uncommon, which includes paraganglioma, schwannoma, and lymphoma. Due to their rarity, characteristics of these tumors and problems related to their surgical treatment have not been well known. We tried to elucidate different clinical characteristics and surgical complications of these tumors. Materials and Methods : : We retrospectively reviewed 21 patients with carotid bifurcation tumor from the Vascular Surgery division of a Korean tertiary institution from 1995 to 2018. We investigated patients’ demographics and clinical features, image characteristics, treatment details, and surgical outcomes. Results : : During the period from January 1995 to January 2018, we experienced surgical resections of 21 carotid bifurcation tumors which included 16 (76.2%) paragangliomas and 5 (23.8%) schwannomas. The most common clinical feature was a non-tender cervical mass. According to Shamblin classification, paragangliomas were classified into class II in 68.8% and class III in 25.0%. On the preoperative computed tomography images, all the paragangliomas showed characteristic splaying of the carotid bifurcation and hypervascularity of the tumors. On the contrary, all the schwannomas showed hypovascularity and splaying sign in 60%. Surgical complications related to cervical nerve injury developed in 50% and 60% of patients with Shamblin class III paraganglioma and schwannoma, respectively. During the mean follow-up period of 25 months (range, 1 to 163 months), distant metastases developed in 2 (12.5%) of paraganglioma patients. Conclusion : : Neurologic complications were more common after surgical resection of Shamblin class III paraganglioma and schwannoma. For patients with paraganglioma, postoperative periodic follow-up examination is advised to detect distant metastasis.

Objectives To validate the accuracy of high-risk criteria for carotid endarterectomy (CEA) and analyze the correlation between age and outcome of CEA and carotid artery stenting (CAS) in risk groups. Methods We reviewed a prospectively managed vascular surgery database in a single tertiary referral center, and 2482 internal carotid arteries (ICAs) had undergone carotid revascularization from November 1994 to December 2021. To validate high-risk criteria for CEA, patients were classified as high risk (Hr) and normal risk (Nr). Subgroup analysis was performed with patients older or younger than 75 years to investigate the relationship between age and outcome in each group. Primary endpoints were 30-day outcomes including stroke, death, stroke/death, myocardial infraction (MI), and major adverse cardiovascular events (MACEs). Results A total of 2345 ICAs in 2256 patients were enrolled. The number of patients in the Hr group was 543 (24%) and the number in the Nr group was 1713 (76%). CEA and CAS were performed on 1384 (61%) and 872 (39%) patients, respectively. The 30-day stroke/death rate was higher with CAS than CEA in both the Hr (1.1% vs. 3.9%, p = 0.032) and Nr (1.2% vs. 6.9%, p < 0.001) groups. In unmatched logistic regression analysis of the Nr group ( n = 1778), the rate of 30-day stroke/death (OR, 5.575; 95% CI, 2.922–10.636; p < 0.001) was higher for CAS than CEA. In propensity score matching of the Nr group, the rate of 30-day stroke/death (OR, 5.165; 95% CI, 2.391–11.155; p < 0.001) was also higher for CAS than CEA. In the age Conclusions In patients older than 75 years in the Hr group, there were relatively poor 30-day treatment outcomes in both CEA and CAS. Alternative treatment is needed that can expect better outcomes in older high-risk patients. In the Nr group, CEA has a significant benefit compared with CAS, and CEA should be recommended more to these patients.

The objective of this study was to investigate the factors associated with the complication rate and treatment outcomes of arteriovenous malformations (AVMs) during a 20-year period.This was a retrospective study of 306 patients (135 men, 171 women; mean age, 30.8 years) with body and extremity AVMs who were treated between 1996 and 2017. A total of 913 sessions of endovascular treatment were performed. Patients were divided into two decades of the study period to compare complications and clinical results. Group 1 comprised 107 patients treated in the first decade of the study period, and group 2 comprised 199 patients treated in the last decade. AVMs were classified according to the angiographic findings. Complication rates, number of treatment sessions, and treatment results were compared between the two groups.Minor complication (group 1, 20.1%; group 2, 18.5%) and major complication (group 1, 3.1%; group 2, 4.1%) rates were similar between groups (P = .79). The mean number of treatment sessions in group 1 and group 2 was 4.2 and 2.3, respectively, indicating a 45% reduction in treatment sessions (P .0001). The treatment failure rate decreased from 9.3% in group 1 to 1.5% in group 2 (P = .04). The clinical success rate was 54.2% in group 1 and 64.3% in group 2 (P = .10).With an accumulation of AVM treatment experience, the number of treatment sessions and the rate of treatment failures were significantly reduced.

OBJECTIVE We report the results of a pilot clinical study that evaluated the safety and efficacy of a newly-developed, retrievable flow diverter (FloWise; Taewoong Medical) for the treatment of internal carotid artery (ICA) aneurysm. MATERIALS AND METHODS A total of 10 patients were enrolled. Inclusion criteria were 1) unruptured aneurysm with a dome size of ≥ 8 mm and a neck size of ≥ 4 mm at the ICA, or 2) two or more unruptured aneurysms of any size able to be spanned by a single FloWise at the ICA. Co-primary effectiveness end points were technical success of FloWise placement, and a 50% or greater decrease in aneurysm volume at the 6-month follow-up angiogram. The primary safety end point was the new development of neurological deficits persisting for more than 1-month post-treatment. RESULTS Ten patients harboring 14 ICA aneurysms (median diameter, 9.4 mm; range, 2.3-31.0 mm) were enrolled between January 2016 and July 2017. FloWise placement was successful in all patients. There were no newly-developed neurological deficits during the 6-month clinical follow-up period. One patient did not receive follow-up imaging due to pregnancy. Nine patients with 12 aneurysms received a 6-month angiographic follow-up. Ten aneurysms (83.3%) showed decreases in volume greater than 50% (mean volume decrease, 82.8 ± 32.9%), of which 8 (66.7%, 95% confidence interval, 35.4-98.0%) showed complete occlusion. One patient was retreated due to mass symptom aggravation. CONCLUSIONS In this pilot study, FloWise appeared to be safe and effective for ICA aneurysm treatment. A prospective multicenter study to validate the effectiveness and safety of FloWise would be worthwhile.

Background Although the first choice of treatment for abdominal aortic aneurysm (AAA) is endovascular aneurysm repair, especially in elderly patients, some patients require open surgical repair. The purpose of this study was to compare the mortality outcomes of open AAA repair between octogenarians and younger counterparts and to identify the risk factors associated with mortality. Methods All consecutive patients who underwent elective open AAA repair due to degenerative etiology at a single tertiary medical center between 1996 and June 2020 were included in this retrospective review. Medical records and imaging studies were reviewed to collect the following information: demographics, comorbid medical conditions, clinical presentations, radiologic findings, surgical details, and morbidity and mortality rates. For analysis, patients were divided into two groups: older and younger than 80 years of age. Multivariate analysis was performed to identify factors associated with mortality after elective open AAA repair. Results Among a total of 650 patients who underwent elective open AAA repair due to degenerative AAA during the study period, 58 (8.9%) were octogenarians and 595 (91.1%) were non-octogenarians. Patients in the octogenarian group were predominantly female and more likely to have lower body weight and body mass index (BMI), hypertension, chronic kidney disease, and lower preoperative serum hemoglobin and albumin compared with patients in the non-octogenarian group. Maximal aneurysm diameter was larger in octogenarians. During the median follow-up duration of 34.4 months for 650 patients, the median length of total hospital and intensive care unit stay was longer in octogenarians. The 30-day (1.7% vs. 0.7%, P = 0.374) and 1-year (6.9% vs. 2.9%, P = 0.108) mortality rates were not statistically significantly different between the two groups. Multivariate analysis showed that low BMI was associated with increased 30-day (odds ratio [OR], 16.339; 95% confidence interval [CI], 1.192–224.052; P = 0.037) and 1-year (OR, 8.236; CI, 2.301–29.477; P = 0.001) mortality in all patients. Conclusion Because the mortality rate of octogenarians after elective open AAA repair was not significantly different compared with their younger counterparts, being elderly is not a contraindication for open AAA repair. Low BMI might be associated with increased postoperative mortality., Graphical Abstract

Purpose This study was conducted to determine factors associated with long-term graft patency after lower extremity arterial bypass (LEAB). Methods Database of LEABs for patients with chronic arterial occlusive disease (CAOD) at a single institution was retrospectively reviewed. To determine the factors we compared demographic, clinical, and procedural variables between 2 patient groups; group I (graft patency < 2 years) and group II (graft patency ≥ 5 years after LEAB) using univariable and multivariable analyses. Results Among 957 LEABs, 259 limbs (group I, 125 limbs and group II, 134 limbs) in 213 patients were included for the analysis. On a univariable analysis, younger age (69 years vs. 66 years, P = 0.024), hypertension (60.8% vs. 74.6%, P = 0.017), claudication (51.2% vs. 70.9%, P = 0.001), absence of prior intervention (50.4% vs. 73.9%, P < 0.001), common femoral artery based bypass (57.6% vs. 70.1%, P = 0.035), above-the knee bypass (36.8% vs. 64.2%, P < 0.001), postoperative graft salvage procedure (3.2% vs. 14.8%, P = 0.001), and statin use (75.2% vs. 88.8, P = 0.004) were associated with long-term patency. On a multivariate analysis hypertension (odds ratio [OR], 1.91; P = 0.038), claudication (OR, 2.08; P = 0.032), no prior intervention (OR, 2.48; P = 0.001), vein graft (OR, 4.36; P = 0.001), above-the knee bypass (OR, 4.68; P < 0.001), and graft salvage procedures (OR, 7.70; P < 0.001) were identified as independent factors. Conclusion These factors can be considered in decision making before treatment of patients with CAOD.

Background Aortic anatomy is important in determining the success or failure of endovascular aortic aneurysm repair (EVAR). Endoleak is another issue which should be addressed for a long-term durability of the procedure. Internal iliac artery (IIA) embolization is required to prevent type II endoleak when the iliac landing zone is not sufficient such that the iliac limb should be extended down to the external iliac artery (EIA). Pelvic ischemia is an important complication of IIA embolization, but its incidence and severity is not exactly known. Our experience suggests this to be common but not severe. In this study we reviewed the clinical outcomes of patients who underwent IIA embolization to facilitate EVAR at one of the major tertiary medical centers in South Korea. Methods We performed a retrospective review of the patients who underwent IIA embolization prior to EVAR between November 2005 and June 2018 at a single tertiary medical center in South Korea. Patients were interviewed via telephone to determine the severity of buttock claudication according to a previously defined pain scale. Results The majority of 139 patients in both the unilateral and bilateral IIA embolization groups experienced no (N.=83, 60.0%) or mild (N.=51, 36.7%) buttock claudication. Only three patients in the unilateral IIA embolization group reported that their symptoms affected daily life, but without need for any measures for pain relief. Symptom duration was longer in the bilateral embolization group (12.6 months) compared to the unilateral group (6.6 months) without statistical significance (P=0.559). There were no critical complications such as buttock necrosis, spinal cord ischemia, or ischemic colitis. Conclusions Based on our experience, IIA embolization does cause buttock claudication of a certain degree. However, the most of them experienced mild discomfort rather than such symptoms severely affect their quality of life. Considering the risks of general anesthesia and complications of surgical procedures, IIA reconstruction along with EVAR may not be necessary.

We evaluated the therapeutic outcomes of embolotherapy for bone arteriovenous malformations (AVMs) affecting the extremities using ethanol, coils, and n-butyl cyanoacrylate (NBCA).We reviewed the data from 36 patients (18 males, 18 females; mean age 25 years; age range, 1-64 years) with bone AVMs affecting their extremities who had undergone embolotherapy using ethanol, coils, and NBCA from December 1996 to July 2019. Of the 36 patients, 19 had had pure bone AVMs and 17 mixed bone and soft tissue (MBS) AVMs. Embolotherapy was performed using direct puncture or a transvenous or an intra-arterial approach (range, 1-18 procedures; mean, 5 procedures). During the 178 embolotherapy procedures, ethanol was used in all 36 patients, except for 1. Coils were used in 14 patients, and NBCA and a lipiodol mixture in 9 patients. The therapeutic outcomes were evaluated by the clinical symptom response and the degree of devascularization on follow-up angiography or computed tomography. The major and minor complications were also evaluated.The clinical success (cure or markedly improvement) rate of embolotherapy for pure bone AVMs was significantly better than that for the MBS AVMs (88% vs 18%; P .001). The complete devascularization rate of the bone AVM component of the MBS AVMs was 71%; however, the cure rate of the MBS AVMs was 0% owing to the remaining soft tissue AVMs. Of the 36 patients, 12 experienced complications, including 11 minor (2 skin bullae formation and 10 transient peripheral nerve injury) and 1 major (longstanding nerve palsy).Embolotherapy for bone AVMs affecting the extremities using ethanol, coils, and an NBCA mixture is effective and safe for the resolution or improvement of symptoms, especially in those with pure bone AVMs.

Purpose: Femorofemoral crossover bypass (FCB) is a good procedure for patients with unilateral iliac artery disease. There are many articles about the results of FCB, but most of them were limited to 5 years follow-up. The purpose of our study was to analysis the results of FCB with a 10-year follow-up period. Materials and Methods: Between January 1995 and December 2010, 133 patients were operated in Samsung Medical Center (median follow-up: 58.8 months). We retrospectively analysed patient characteristics, the preoperative treatment, the operative procedure, and material used. Results: The indications for FCB were claudication in 110 and critical limb ischemia in 23 patients. Three patients were died due to myocardiac infarction, intracranial hemorrhage, and acute respiratory failure within 30 days after surgery. The one-year primary and secondary patency rates were 89% and 97%, the 5-year primary and secondary patency rates were 70% and 85%, and the 10-year primary and secondary patency rates were 31% and 67%. The 5-year and 10-year limb salvage rates were 97% and 95%, respectively. Conclusion: Our long term analysis suggests that FCB might be a valuable alternative treatment modality in patients with unilateral iliac artery disease.

Management of arteriovenous malformations (AVMs) remains challenging because of their unpredictable course and high morbidity rate. In this case report, we present a patient with a huge AVM on the right calf who suffered complications of compartment syndrome, rhabdomyolysis, skin necrosis, and nerve damage after sclerotherapy. Limb salvage was achieved in spite of these devastating complications. A multidisciplinary team approach is important especially when making decisions for the management of a complicated AVM.

Purpose Adventitial cystic disease (ACD) is a rare condition that causes intermittent claudication and non-atherosclerotic disease without cardiovascular risk factors. The etiology and optimal treatment of ACD remain controversial. The purpose of this study was to analyze surgical treatment results for ACD and to elucidate optimal treatment options. Materials and methods We retrospectively reviewed 30 patients with ACD who underwent surgery from 2006 to 2018. Twenty-two patients had arterial ACD, six had venous ACD, and two had combined venous and arterial ACD. We reviewed demographic and clinical characteristics, treatment details, and procedure outcomes. Results Recurrence occurred in 6 cases either after cyst excision alone (4/17) or patch angioplasty (2/2). There was no recurrence after vessel excision with interposition grafting (0/7). Therefore, vessel excision was a statistically significant factor in recurrence prevention (P=0.026). Among the six recurrences, joint connections of the cystic lesions were found in four of the six (66.7%). Conclusion As a curative surgery for ACD, vessel excision with interposition grafting is a better strategy to prevent recurrence than simple cyst excision alone.

PURPOSE To evaluate the safety and efficacy of ethanol and coil embolization of type II arteriovenous malformation (AVM) according to a new subtype classification. MATERIALS AND METHODS Eighty-four type II AVMs in the body or extremity of 79 patients who underwent AVM treatment from 1996 to 2017 were retrospectively subclassified according to the angiographic morphology of the draining vein as type IIa (arterioles shunt to focal segment of single draining vein), type IIb (arterioles shunt to venous sac with multiple draining veins), and type IIc (arterioles shunt along long segment of draining vein). Coil and ethanol embolization of the focal or long segment of the draining vein or the venous sac was performed with direct puncture or transvenous approach according to subtype. Treatment outcomes, number of treatment sessions, and complications were analyzed. RESULTS AVM cure (ie, complete embolization) rates were 95%, 76%, and 65% in types IIa, IIb, and IIc AVMs, respectively. The cure rate of type IIa AVMs was significantly better than that of type IIc AVMs (P = .015). Median numbers of treatment sessions were 1 in types IIa and IIb AVMs and 2.5 in type IIc AVMs, with a significant difference between type IIc and the other 2 types (P < .05). Minor complications occurred in 20% of patents and major complications occurred in 7%. CONCLUSIONS The cure rate of type IIa AVMs was significantly better than that of type IIc AVMs, which also required significantly more treatment sessions than the other 2 types.

This study was designed to analyze the efficacy and complications in endovenous LASER ablation (EVLA) with 1470 nm diode lasers using low linear endovenous energy density (LEED) combined with high ligation for varicose veins of the great saphenous vein (GSV). One hundred and sixteen limbs of 102 patients were analyzed using 6 W with 2 mm/s constant pullback speed delivered by 30 J/cm LEED. The SFJ was ligated with a small inguinal incision. The complications and status of the GSV were checked at 1 and 6 months postoperatively. The occlusion rates for the GSV were 98 (84.5 %) at 1 month and 116 (100 %) at 6 months, postoperatively. The rate of partial occlusion was higher in males than in females (p = 0.004). There were 2 DVT, 27 feelings of the cord (23.3 %), and 36 numbness at the knee area (31.0 %) at 1 month, and 3 feelings of the cord (3.4 %) and 6 numbness of the knee (8.6 %) at 6 months postoperatively. The diameter and depth of the GSV did not affect the rates of feeling of the cord or numbness (p = 0.728, 0.208, 0.247, 0.884, respectively). EVLA with a 1470-nm diode laser using low LEED combined with high ligation for the GSV has lower complication rates and higher occlusion rates of GSV.

Purpose Open surgical conversion (OSC) is the last treatment option for patients with endovascular aneurysm repair (EVAR)failure. We investigated the underlying causes of EVAR failure requiring OSC and attempted to determine strategies to avoid OSC after EVAR. Methods We retrospectively reviewed the database of patients who underwent OSC after EVAR from 2005 to 2018 in a single institution. Twenty-six OSCs were performed in 24 patients (median age, 74.5 years; 79.2% of males) who had undergone standard EVAR. We investigated pre-, intra-, and postoperative computed tomography or angiographic images and outcomes of the OSCs. Results Two main indications for OSC were persistent endoleak (50.0%) and endograft infection (EI) (38.5%). All 13 patients who underwent OSC due to endoleaks received EVAR outside of indications for use. Among 10 patients who underwent OSC due to EI, we found overlooked infection sources in 7 (70.0%) at the time of EVAR or during the surveillance period. OSC was performed at a median of 31.8 months (interquartile range, 9.4-69.8) after EVAR as an emergency (15.4%) or elective (84.6%) surgery. Aortic endograft was removed in 84.6% of cases (totally, 57.7%; partially, 26.9%), whereas it was preserved in 4 cases (15.4%). After 26 OSCs, 2 early deaths (7.7%) and 2 aortoenteric fistulae (7.7%) developed as major complications. Conclusion OSC after EVAR was associated with relatively higher perioperative morbidity and mortality. To avoid OSC after EVAR, we recommend careful assessment of coexisting infection sources and avoidance of EVAR for patients with especially unfavorable anatomy for EVAR, particularly the in proximal neck.

Open surgery of abdominal aortic aneurysm (AAA) or aortoiliac occlusive disease (AIOD) sometimes requires left renal vein division (LRVD) to gain adequate exposure of the abdominal aorta. The aim of this study is to evaluate the effect of LRVD on the postoperative renal function using propensity score matching (PSM).From July 1996 to January 2018, we retrospectively reviewed 698 patients who underwent open aortic surgery, including 543 AAAs and 155 AIODs, at a single institution. 66 patients (9.6%, 47 AAAs, 19 AIODs) needed LRVD during the operation. A 1:3 ratio PSM was used to control the selective bias between the LRVD and non-LRVD groups. We investigated preoperative and postoperative renal function including serum creatinine (sCr) level and estimated glomerular filtration rate (eGFR, mL/min/1.73 mThe LRVD group had a significantly higher rate of renal artery reconstruction (15.2% vs. 3.3%, P 0.001) and suprarenal clamping (54.6% vs. 9.5%, P 0.001) and higher incidence of juxtarenal AIOD (24.2% vs. 5.4%, P 0.001). With PSM, 63 patients in the LRVD group and 144 patients in the non-LRVD group were enrolled in this study. The baseline characteristics were well balanced in the groups after PSM. There were no significant differences in preoperative eGFR (72.4 ± 21.3 vs. 76.1 ± 25.0, P = 0.306) and postoperative eGFR on day 3 (69.5 ± 26.6 vs. 77.5 ± 28.5, P = 0.065), day 7 (73.3 ± 24.8 vs. 78.5 ± 27.4, P = 0.264), and in the long-term follow-up period (69.0 ± 22.2 vs. 68.9 ± 27.1, P = 0.986, 50.2 month ± 45.50) in the 2 groups. Only the sCr level (1.40 ± 0.59 vs. 1.21 ± 0.62, P = 0.045) and eGFR (59.5 ± 23.9 vs. 71.4 ± 26.0, P = 0.002) were significantly worse on postoperative day 1 in the LRVD than in the non-LRVD group. There were no significant differences in 30-day mortality (1.6% vs. 1.6%, P = 1.00).The patients in the LVRD group underwent initial drop in renal function; however, eGFR improved during the follow-up period. There was no difference in renal function and postoperative mortality between LRVD and non-LRVD groups. Therefore, LRVD is a safe and durable procedure during complex abdominal aortic surgery.

Background Primary closure (PC) and patch angioplasty (PA) during carotid endarterectomy (CEA) have been disputed in many studies. Some studies announced that PC is associated with a higher restenosis rate. The aim of this study was to evaluate the outcomes of PC and PA using propensity score matching (PSM). Methods Between November 1994 and October 2016, 1,044 patients underwent primary CEA procedures at our institution and were retrospectively analyzed. The study endpoints included rates of ipsilateral stroke, any clinical stroke, cranial nerve palsy, hematoma, bleeding warranting repeat surgery within 30 postoperative days. We also investigated the restenosis rates, overall survival, stenosis-free survival, and stroke-free survival during follow-up (median follow-up 37.1 months). Results This study includes 435 cases of PC and 476 cases of PA. After PSM analysis, baseline characteristics (age, gender, hypertension, diabetes, dyslipidemia, smoking, atrial fibrillation, previous percutaneous coronary intervention or coronary artery bypass grafting, contralateral carotid occlusion, degree of carotid stenosis, and symptomatic status within 6 months) were balanced. Finally, 377 pairs of matched cases were analyzed. Statistical analysis showed no significant differences between the 2 groups in ipsilateral stroke (P = 0.45), clinical stroke (P = 0.75), cranial nerve palsy (P = 1), hematoma (P = 0.18), bleeding which required reoperation (P = 0.12) within 30 postoperative days, and restenosis rates during follow-up (P = 0.16). In addition, there were no differences between the 2 groups during follow-up in overall, stroke-free, and restenosis-free survival with P values of 0.136, 0.07, and 0.06, respectively. Conclusions According to the analysis using PSM, there were no significant differences between PC and PA closure during CEA in perioperative and long-term outcomes.

Hepatic artery aneurysm is rare, but appropriate treatment is mandatory. We report a 50-year-old woman with an asymptomatic large hepatic artery aneurysm. The aneurysm was found as a result of abdominal computed tomography (CT) performed as a part of the screening. An open surgery was performed due to the size of the aneurysm. Aneurysmectomy was achieved, and the proper hepatic artery was anastomosed with gastroduodenal artery for adequate blood flow to the liver. Adequate hepatic circulation was confirmed postoperatively by duplex ultrasonography and CT. The patient was discharged on the 9th postoperative day.

Background Cephalic arch is one of the sites most susceptible to stenosis in brachiocephalic arteriovenous fistula (BCAVF). We performed a retrospective study to identify the incidence of cephalic arch stenosis (CAS) in BCAVF, to compare the patency of percutaneous transluminal balloon angioplasty (PTA) with that of cephalic vein transposition (CVT), and to establish the optimal treatment strategy for CAS. Methods Between January 2011 and June 2016, 462 patients underwent BCAVF creation. CAS was defined as >50% stenosis at the confluence of the cephalic and axillary veins on ultrasonography. Treatment was planned for clinically significant CAS, which was defined as >25% reduction in flow volume compared to previous examination, elevation of venous pressure, delayed puncture site hemostasis, and/or acute thrombotic occlusion. Results Seventy-seven (16.7%) patients had CAS and 42 of them (54.5%) were treated for clinically significant CAS. PTA was performed in 36 patients (85.7%), and CVT was done in 6 patients (14.3%) as the initial treatment. Nine patients underwent CVT after PTA, resulting in a total of 15 patients treated with CVT. Investigation of the patency of the 36 cases of PTA and 15 cases of CVT revealed that primary-assisted patency rates at 6 and 12 months were 68.2% and 57.3% for PTA and 100.0% and 87.5% for CVT, respectively (P = 0.038). Secondary patency rates at 6 and 12 months were 72.0% and 56.9% for PTA and 100% and 100% for CVT, respectively (P = 0.010). The median intervention rate was 2.5 interventions per access-year in the 36 cases treated with PTA and 1.5 interventions per access-year in the 15 cases treated with CVT. Conclusions CAS is a common cause of BCAVF dysfunction, and careful surveillance is warranted. CVT should be considered for treatment of CAS to achieve better long-term patency with fewer reinterventions.

Objective This study identified predictors affecting maturation and patency of autogenous radiocephalic arteriovenous fistulas (RCAVFs). Methods We retrospectively reviewed the prospectively collected clinical data of all patients who underwent primary RCAVF creation and evaluated the effect of clinical variables and findings of preoperative duplex ultrasound mapping on primary maturation and patency rates of RCAVFs. Results From August 2008 to December 2010, 383 vascular access procedures were performed in 371 patients; of these, 331 (86.4%) were autogenous AVFs, 283 (85.5%) were primary first AVFs, and 186 (65.7%) of these were RCAVFs. The primary maturation rate was 88.2% at a mean of 39 ± 24.1 days after the operation. By multiple logistic regression analysis, minimum cephalic vein (CV) diameter >2 mm was an independent predictor of RCAVF maturation (odds ratio, 3.672; 95% confidence interval, 1.394-9.673; P = .008), which was more easily achieved in nondiabetic patients. During the mean follow-up of 47.2 ± 23.1 months, primary patency of RCAVFs was 80.3% at 1 year and 76.5% at 2 years. A Cox proportional hazard model showed diabetes was the only independent risk factor of primary patency (hazard ratio, 2.008; 95% confidence interval, 1.022-3.945; P = .043). Nondiabetic patients with a CV diameter >2 mm had significantly higher primary maturation rate and higher primary patency than diabetic patients with a CV diameter ≤2 mm. Conclusions There were different risk factors affecting RCAVF primary maturation and primary patency. A CV with a small-diameter of ≤2 mm combined with diabetes was an independent risk factor of failure not only of primary maturation but also of primary patency in RCAVF.

BACKGROUND AND PURPOSE: Coiling of complex aneurysms is still difficult even with current adjuvant techniques. This study sought to evaluate the safety and effectiveness of a combination of multicatheter plus stent or balloon for the treatment of complex aneurysms. MATERIALS AND METHODS: All complex aneurysms that underwent coiling with the combination technique were identified from prospectively maintained neurointerventional data bases. “Complex aneurysm” was defined as a wide-neck aneurysm with branch incorporation into or a deep lobulation of the sac. The clinical and angiographic outcomes were retrospectively analyzed. RESULTS: Sixty-two complex aneurysms (12 ruptured, 50 unruptured) in 62 patients (mean age, 57 years; male/female ratio, 12:50) were treated with a combination technique by using a multicatheter plus stent ( n = 42, 3 ruptured) or balloon ( n = 20, 9 ruptured). Treatment-related morbidity (grade 3 hemiparesis) occurred in 1 patient (1.6%). Except for 1 patient who had treatment-related morbidity, none of the other patients with unruptured aneurysms developed new neurologic symptoms at discharge. Nine of the 12 patients with ruptured aneurysms had good outcomes (Glasgow Outcome Score, 4 or 5) at the latest follow-up (mean, 32 months; range, 6–72 months), and 1 patient died from an initial SAH. Posttreatment control angiograms revealed complete occlusion in 27, neck remnant in 34, and incomplete occlusion in 1 aneurysm. At least 1 follow-up catheter or MR angiogram was available in 80.6% ( n = 50) (mean, 21 months; range, 6–65 months). There were 4 minor and 3 major recurrences (14.0%). CONCLUSIONS: In this case series, the combination technique by using multicatheter plus stent or balloon seemed safe and effective for the treatment of complex aneurysms.

BACKGROUND The prognosis of ischemic anterior circulation intracranial dissection (AC-ICD) is poor and its optimal management is still controversial. OBJECTIVE To evaluate the safety and efficacy of a self-expanding stent for ischemic AC-ICD. METHODS Eight patients (mean age, 36 years) underwent self-expanding stenting for ischemic AC-ICD. Imaging findings of ischemic AC-ICD, the reason for stenting, and the clinical and angiographic outcomes were retrospectively evaluated. RESULTS AC-ICD involved intracranial internal carotid artery to middle cerebral artery (MCA) in 2, intracranial internal carotid artery alone in 3, and MCA alone in 3 patients. Six AC-ICDs showed complete or near occlusions while 2 had a severe degree of stenosis. Six AC-ICDs showed an intimal flap and 3 had intramural hematomas. Six patients underwent emergent stenting for acute stroke within 6 hours (n=2) or crescendo-type stroke within 24 hours (n=4), while 2 patients had stenting for recurrent ischemia on dual antiplatelet and/or anticoagulation after the initial attack. The mean dissection-related stenosis improved from 93.1% to 20.3% after stenting (P

Ethanol sclerotherapy has shown favorable short-term efficacy in managing head and neck arteriovenous malformation (AVM) which is well known for high recurrence rate after treatment. The purpose of this study was to report immediate treatment results and long-term follow-up results of ethanol sclerotherapy in patients with head and neck AVMs.We performed a retrospective review of 45 patients with head and neck AVMs treated between April 1997 and December 2013 by using ethanol sclerotherapy with or without adjunctive surgery. The degree of AVM eradication was analyzed, and complications per treatment session were recorded. Long-term treatment effectiveness was assessed with clinical and imaging follow-up.In total, 132 sclerotherapies were performed in the 45 patients, with a total angiographic eradication rate of 17.8% (n = 8). Partial resolution was achieved in 34 patients, and three patients showed no response. Mean follow-up period was 56.6 months (range, 13-144 months). The long-term recurrence rate was 11.1% (5/45), and all recurrences occurred more than 3 years after the treatment with interval disease-controlled period. The major complication rate was 3.8% (5/132), and 34 minor complications (25.8%) occurred.Ethanol sclerotherapy is effective for achieving long-term durable cure of head and neck AVMs. In patients with non-curable disease, it is also effective for symptom palliation and long-term disease control. However, given recurrence after interval disease-controlled period, long-term follow-up should be required to detect recurrence in patients with any residual lesion after treatment.

Objective This study was designed to examine postoperative venous hemodynamic changes at 1 and 6 months after endovenous laser ablation (EVLA) and phlebectomy for primary great saphenous varicose veins. Methods We retrospectively analyzed 116 limbs from 102 patients who were treated with EVLA from 2011 to 2013 at Samsung Medical Center. Venous hemodynamic changes were evaluated by air plethysmography preoperatively and at 1 month and 6 months postoperatively. The measured hemodynamic changes included venous volume (VV), venous filling index (VFI), residual volume fraction (RVF), and ejection fraction (EF). Results The study included 52 limbs from men (44.8%) and 64 limbs from women (55.2%; male/female ratio, 1:1.23). The mean age of the patients was 54.8 ± 12.3 years. The preoperative median values were VV of 99.1 mL, VFI of 3.6 mL/s, RVF of 39.2%, and EF of 55.5%. The 1-month and 6-month postoperative median values were VV of 77.6 and 75.5 mL, VFI of 1.4 and 1.5 mL/s, RVF of 32.5% and 26.4%, and EF of 60.5% and 66.2%, respectively. The postoperative reduction rates between preoperative and 1-month measurements for VV, VFI, and RVF were 18.6%, 63.9%, and 22.2%, and the increase in EF was 7.9%. ( P P P P = .043). Comparing 1-month and 6-month measurements, the reduction rates of VV and RVF were 1.9% and 15%, and the increase rates of VFI and EF were 3.2% and 7.6%, respectively. EF was significantly increased at 6 months compared with 1 month after EVLA ( P = .013), but the other parameters showed no statistically significant differences between 1 month and 6 months after EVLA. Conclusions This study demonstrated that the venous hemodynamic parameters of primary varicose veins improved after performance of EVLA and phlebectomy.

Purpose Venous thromboembolism (VTE) is a common life-threatening illness with significant morbidity and mortality rates. In recent years, the incidence of VTE has gradually increased in Korea. In this study, we evaluated the current trends in the management of acute deep vein thrombosis (DVT) in Korea. Materials and methods A 20-item questionnaire was prepared and sent to 48 members of the Korean Society for Vascular Surgery. Each member worked in a different hospital. Twenty-two members participated in this study. Results The vascular surgery departments were primarily responsible for managing DVT. Ultrasound and computed tomography (CT) venography were chosen as the most common initial diagnostic tools. Eighty-two percent of participants routinely used the coagulation factor assay. Thrombolysis and inferior vena cava (IVC) filter insertion were performed mainly in the radiology departments. Seventy-seven percent of participants performed thrombolysis only if the thrombus age was less than 21 days. During thrombolysis, IVC filter was routinely inserted by 50% of respondents and removed within 14 days by 64% of respondents. Nearly all participants followed the 2012 American College of Chest Physicians guidelines for anticoagulation therapy. Conclusion The majority of Korean vascular surgeons followed the guidelines. However, CT was frequently used. Thrombolysis and IVC filter insertion were more frequently performed than recommended by the guidelines.

Objective Optimal treatment of spontaneous isolated celiac artery dissection (SICAD) is not well established because the natural history of this rare disease is poorly understood. We analyzed the natural history of patients who underwent conservative treatment. Methods The study included 28 patients with SICAD from December 2008 to January 2017. Our institutional policy of first-line treatment for SICAD patients was conservative, and invasive procedures were reserved for unstable complications such as severe persistent pain, significant organ malperfusion, rapid aneurysmal change, and rupture or concealed rupture. Demographics, clinical features, morphologic characteristics on computed tomography, treatment modalities, and follow-up results of these patients were retrospectively reviewed. Results Mean age was 52 years, and 89% of patients were male; 86% presented with pain, mostly abdominal, and 14% of cases were detected incidentally on abdominal imaging. None of these patients had unstable complications on admission, and all underwent initial conservative treatment. During the follow-up period (22 ± 20 months), aneurysmal change and propagation of thrombosis were noted in one patient and two patients, respectively, all of whom were managed conservatively without adverse clinical events. No difference in clinical and morphologic outcomes was noted between patients who were treated with antihypertensive therapy and those who were not. Patients with intramural hematoma on initial images showed dynamic vascular remodeling (partial to complete resorption) during the follow-up period compared with patients who had dominant intimal flap on initial images. Conclusions The clinical course of patients with SICAD was benign. Even progressive vascular changes during follow-up did not require invasive treatment. Antihypertensive therapy might not modify the clinical course. The short-term results of conservative management are encouraging, but further evaluation with long-term follow-up in a large population is needed.

Objective/Background Despite randomised evidence, the debate continues about the preferred treatment strategy for carotid stenosis in routine clinical practice. The aim of this study was to compare early outcomes and restenosis rates after carotid endarterectomy (CEA) and carotid stenting (CAS) in unselected patients using propensity score matching (PSM). Methods The 30 day incidence of major adverse clinical events (MACE; defined as stroke, transient ischaemic attack, myocardial infarction, or death) and procedure related complications, as well as restenosis rates during follow-up were compared between unselected patients undergoing CEA or CAS between January 2002 and December 2015 at a single institution. PSM was used to balance the following factors between the CEA and CAS cohorts: age, sex, hypertension, diabetes, dyslipidaemia, smoking, atrial fibrillation, previous percutaneous coronary intervention or coronary artery bypass grafting, valvular heart disease, contralateral carotid occlusion, degree of carotid stenosis, and symptomatic status. Statistical comparisons of outcomes were based on logistic regression analysis and log rank test. Results Of 1184 patients (654 CEA and 530 CAS), 452 PSM pairs of CEA and CAS patients were created. The CAS group showed a relatively higher 30 day incidence of MACE (7.5% vs. 2.4%; odds ratio [OR] 3.261, 95% confidence interval [CI] 1.634–6.509; p = .001) but a lower incidence of procedure related complications (1.5% vs. 5.3%; OR 0.199, 95% CI 0.075–0.528; p = .001). During a mean follow-up of 49.1 months (range 1–180 months), restenosis rates were higher after CAS than after CEA (1.5% vs. 1.0% at 12 months and 5.4% vs. 1.2% at 24 months, respectively; p = .008). Conclusion This PSM based observation reconfirmed previous trial results in both asymptomatic and symptomatic patients with carotid artery stenosis in routine clinical practice: CEA showed lower 30 day MACE and mid-term restenosis rates than CAS.

In the past, surgical excision is the only treatment, if there are secondary changes, without pathophysiological correction. But contemporary therapeutic concept is focused on pathophysiological correction and effective when performed before secondary histological changes. An obstructive factor is that lymphatics is very thin. Thus, development of microsurgery is crucial. Also because various conservative therapeutic options, such as extremity elevation, compressive therapy, complex decongestive therapy, and compressive pump therapy, outweighed the surgery, physicians take account for what surgery to do and when to do.

Purpose: The aim of study was to review the results of open surgical repair (OSR) of chronic juxtarenal aortic occlusion (JRAO). Materials and Methods: We retrospectively reviewed the results of OSR performed in 47 patients (male, 92%; mean age, 59.9±9.3 years [range, 44–79]) with chronic JRAO during the past 21 years. In order to reduce intraoperative renal ischemic time (RIT), we excised a portion of the occluded segment of the infrarenal aorta without proximal aortic clamping. We then performed suprarenal aortic clamping with both renal arteries clamped, removed the proximal aortic thrombus cap, confirmed both renal artery orifices, and moved the suprarenal aortic clamp to the infrarenal aorta to allow renal perfusion and standard aortoiliac reconstruction. We investigated early (

Background The primary goal of endovascular aneurysm repair (EVAR) is to prevent death from aneurysm rupture. Regression of aortic sac size is believed to be a marker for success after EVAR. This study analyzes the changes in aneurysm sac size and the factors affecting sac regression after EVAR. Patients and Methods We retrospectively reviewed 121 patients with abdominal aortic aneurysm (AAA) who underwent elective treatment with EVAR at our institution from January 2005 to December 2011. In this study, 17 of the 121 patients were excluded due to loss during follow-up or for not having undergone a postoperative computed tomographic (CT) scan, and 3 patients were excluded due to an isolated iliac artery aneurysm. CT scans were scheduled at months 1, 6, and 12, and annually thereafter. Aneurysm size was defined by the minor axis on the largest axial cut of the aneurysm on a two-dimensional CT scan. Sac regression was defined as a reduction in the diameter of more than 5 mm. Results Sac regression was observed during follow-up in 39 of the 101 patients. There was 1 regression in 87 patients (1%) at 1 month, 18 in 62 patients at 6 months (29%), 26 regressions in 44 patients (59%) at 12 months, and 18 regressions in 34 patients (53%) at 24 months. After multivariate analysis, the absence of endoleaks was the only factor associated with sac regression (hazard ratio, 3.620; confidence interval, 1.692–7.747; p = 0.001). Conclusion Sac regression over 5 mm is associated with current or previous endoleaks after EVAR. Continued surveillance is necessary in all patients after EVAR to prevent late complications.

BACKGROUND AND PURPOSE Coil packing density (PD) can be calculated via a formula (PDF) or software (PDS). Two types of PD can be different from each other for same aneurysm. This study aimed to evaluate the interobserver agreement and relationships between the 2 types of PD relative to aneurysm size. METHODS Consecutive 420 saccular aneurysms were treated with coiling. PD (PDF, [coil volume]/[volume calculated by formula] and PDS, [coil volume]/[volume measured by software]) was calculated and prospectively recorded. Interobserver agreement was evaluated between PDF and PDS. Additionally, the relationships between PDF and PDS relative to aneurysm size were subsequently analyzed. RESULTS Interobserver agreement for PDF and PDS was excellent (Intraclass correlation coefficient, PDF; 0.967 and PDS; 0.998). The ratio of PDF and PDS was greater for smaller aneurysms and converged toward 1.0 as the maximum dimension (DM) of aneurysm increased. Compared with PDS, PDF was overestimated by a mean of 28% for DM < 5 mm, by 17% for 5 mm ≤ DM < 10 mm, and by 9% for DM ≥ 10 mm (P < 0.01). CONCLUSIONS Interobserver agreement for PDF and PDS was excellent. However, PDF was overestimated in smaller aneurysms and converged to PDS as aneurysm size increased.

Background Overwide and undertall small intracranial aneurysms remain a challenge for coil embolization. The purpose of this study is to evaluate the feasibility and results of intrasaccular double microcatheter endovascular coil embolization of overwide and undertall small intracranial aneurysms.

Background and Objectives We investigated the prognostic value of qualitative lymphoscintigraphy in gynecological cancer-related lymphedema, which is a common complication after treatment. Methods All 152 patients underwent 99mTc tin-colloid lymphoscintigraphy before complex decongestive therapy (CDT). We analyzed the uptake patterns of the inguinal lymph nodes, main lymphatic vessel and collateral lymphatic vessels, as well as dermal back flow. We compared these lymphoscintigraphic findings and other clinical variables between good and poor therapeutic responders using Pearson's Chi-squared test, Fisher's exact test and multiple logistic regression analysis. Results Eighty-nine patients (58.6%) had a poor therapeutic response to CDT. In univariate analysis, there were significant differences between good and poor responders in clinical stage (P

BACKGROUND AND PURPOSE The purpose of this study was to compare clinical outcomes and treatment-related complications between coiling and clipping for ruptured distal anterior cerebral artery (DACA) aneurysms. METHODS Eighty-four consecutive patients (M:F = 36:48; mean 53.8 years) with ruptured DACA aneurysms were treated by either clipping (n = 46, 54.8%) or coiling (n = 38, 45.2%). The clinical outcomes and procedure-related complications were evaluated and compared between the two groups. RESULTS Procedure-related complications tend to occur more frequently in the clipping (n = 6, 13.0%) than coiling group (n = 1, 2.6%) (P = .121). At discharge, 51 patients (60.7%) had favorable outcomes (Glasgow outcome scale [GOS], 4 or 5). There was no significant difference between the two groups in favorable outcome (63.2% vs. 58.7%; P = .677). Hunt and Hess (HH) grade (P < .001; 95% CI, 3.354-29.609) and treatment modality (P = .044; 95% CI, 1.039-16.325) were independent risk factors for poor outcome (GOS, 1-3). CONCLUSIONS Coiling was more favorable to clipping in clinical outcomes and incidence of treatment-related complications for ruptured DACA aneurysms.

ObjectiveTo review initial clinical presentation, treatment course, and results of ethanol embolotherapy for foot arteriovenous malformations (AVMs) and to analyze prognostic factors for treatment results.MethodsTwenty-nine patients (mean age, 31.3 years; range, 9-59) who underwent ethanol embolotherapy between 1999 and 2012 were retrospectively reviewed. Initial clinical manifestation, medical history, treatment results of ethanol embolotherapy, and major and minor complications were reviewed in detail. Two radiologists analyzed the extent of AVM involvement, modified angiographic classification by Cho et al, presence of feeding artery aneurysm, degree of devascularization after embolotherapy, and treatment results. From the analysis, prognostic factors for final outcome were assessed.ResultsThe most common symptom was pain (83%; 24/29), followed by ulcer (52%; 15/29), mass (48%; 14/29), varicosity (38%; 11/29), and swelling (31%; 9/29). On baseline angiogram, lesion extent 25% having 55%. There was no correlation between angiographic type and outcome (P > .05; ρ = 0.143).ConclusionsEthanol embolotherapy for foot AVMs can be as effective and safe as for other body parts. From the analysis of angiographic findings, foot AVMs that involve

There is currently a lack of evidence regarding the optimal revascularization method for Takayasu arteritis (TA). This study compares outcomes between endovascular treatment and surgical therapy in TA patients requiring revascularization.From September 1994 to January 2011, 235 patients were diagnosed with TA according to the diagnostic criteria of the 1990 American College of Rheumatology, and of these, arterial revascularizations were performed in 65 (27.7%). Symptomatic or angiographic recurrence and peri-operative use of immunosuppressive drugs were investigated by retrospectively reviewing medical records.A total of 111 arterial lesions in the 65 (27.7%) patients were revascularized during the follow-up period (median 3.2 years, range 0.01-12.7 years). At the 2-year follow-up, the symptomatic recurrence rate was significantly higher in the endovascular treatment group (32.3% vs. 11.5%, p = 0.016), as was the incidence of angiographic recurrence (32.1% vs. 11.1%, p = 0.026). The symptomatic recurrence rate was not influenced by the need for peri-operative immunosuppressive drugs (20% vs. 34.1%, p = 0.34).In TA patients, surgical revascularization seems to be superior to endovascular treatment with regard to patency. Further investigation to identify novel and optimal arterial revascularization methods for TA patients should be undertaken.

Object The purpose of this study was to evaluate the incidence, radiographic findings, relationship between presenting symptoms for treatment and drainage pattern, and treatment outcomes of hypoglossal canal dural arteriovenous fistula (HC-dAVF). Methods During a 16-year period, 238 patients underwent endovascular treatment for cranial dAVF at a single center. The incidence, radiographic findings, relationship between presenting symptoms for treatment and drainage pattern, and treatment outcomes of HC-dAVF were retrospectively evaluated. Results The incidence of HC-dAVF was 4.2% (n = 10). Initial symptoms were tinnitus with headache (n = 6), tinnitus only (n = 1), ocular symptoms (n = 1), otalgia (n = 1), and congestive myelopathy (n = 1). Presenting symptoms requiring treatment included ocular symptoms (n = 4), hypoglossal nerve palsy (n = 4), aggravation of myelopathy (n = 1), and aggravation of tinnitus with headache (n = 1). While the affected HC was widened in 4 of 10 patients, hypersignal intensity on source images was conspicuous in all 7 patients who underwent MR angiography (MRA). All ocular symptoms and congestive myelopathy were associated with predominant drainage to superior ophthalmic or perimedullary veins due to antegrade drainage restriction. All patients who underwent transvenous coil embolization (n = 8) or transarterial N-butyl cyanoacrylate (NBCA) embolization (n = 1) improved without recurrence. One patient who underwent transarterial particle embolization had a recurrence 12 months posttreatment and was retreated with transvenous embolization. Conclusions The incidence of HC-dAVF was 4.2% of all cranial dAVF patients who underwent endovascular treatment. Source images of MRA helped to accurately diagnose HC-dAVF. More aggressive symptoms may develop as a result of a change in the predominant drainage route due to the development of venous stenosis or obstruction over time. Transvenous coil embolization appears to be the first treatment of choice.

a Neurology, b Biostatistics, and Background and Purpose Widespread use of thrombolytic treatments, along with improved chances of survival after an initial ischemic stroke, increases the possibility of repeated thrombolysis. There are few reports, however, regarding repeated thrombolysis in patients who have suffered acute ischemic stroke. We explored the number and outcome of patients with repeated thrombolytic therapy in the era of multimodal thrombolytic treatments. Methods We investigated patients with acute ischemic stroke who had received thrombo- lytic treatments for a period of 10 years. Number of thrombolysis was determined in each patient. Recanalization was defined as Thrombolysis in Cerebral Infarction grading ≥ 2a. Symptomatic hemorrhagic transformation was defined as any increase in the National Insti- tutes of Health Stroke Scale score that could be attributed to intracerebral hemorrhage. A good outcome was defined as a modified Rankin scale score ≤ 2. Results Of the 437 patients who received thrombolytic treatments, only 7 underwent re- peated thrombolysis (1.6%). The median age at the time of repeated thrombolytic therapy was 71 years old; 4 of the patients were female. All patients had 1 or more potential sources of cardiac embolism. Recanalization was achieved in all patients, in both the first and the second thrombolysis. No symptomatic intracranial hemorrhage occurred after repeated thrombolytic treatments. Five patients (71.4%) showed good outcomes at 3 months. Conclusions Repeated thrombolysis for recurrent acute ischemic stroke appears to be safe and feasible. Among patients who experience recurrent acute ischemic stroke, thrombolytic therapy could be considered even if the patient has had previous thrombolytic treatments.

Background Intracranial atherosclerotic stenosis (ICAS) is responsible for 9% to 37% of ischemic strokes. Objective To evaluate the clinical outcome and risk factors for in-stent restenosis (ISR) after treatment of ICAS with a Wingspan stent. Methods Seventy-seven patients with 79 total target ICAS > 60% (mean, 79.9 ± 8.4%; symptomatic ICAS, 96.2%) underwent attempted treatment with Wingspan stenting between March 2010 and March 2011. A retrospective review of the prospectively registered data was conducted to assess the risk factors for ISR and the clinical outcomes of these patients. Results The 30-day transient ischemic attack/stroke and death rates were 5.3% (95% confidence interval [CI], 0.1-10.5) and 0%, respectively. All patients but 1 were followed up clinically for a mean of 18.9 months (range, 12-23 months). During the period, cumulative transient ischemic attack/stroke and death rates were 8.1% (95% CI, 1.7-14.5) and 0%, respectively. Only 1 patient suffered a disabling stroke (subarachnoid hemorrhage), which was associated with retreatment of an ISR with a drug-eluting balloon-expandable stent. Follow-up angiography was available in 69 treated vessels (89.6%) at 3 to 24 months (median, 12 months). Binary ISR rate was 24.6%, of which 17.6% (3 of 17 cases) was symptomatic. Rapid balloon inflation (95% CI, 5.490-530.817) and longer length of stenosis (95% CI, 1.093-1.891) were independent risk factors for ISR. Conclusion Wingspan stenting may be effective for appropriately selected ICAS patients. Rapid balloon inflation and longer lengths of stenosis were independent risk factors for ISR.

The purposes of this study are to review the results of endovascular and surgical interventions and to evaluate clinical appearances of recurrent arterial involvement in patients with peripheral arterial Behcet disease (BD). A total of 28 patients with peripheral arterial BD were identified. There were 24 males (85.7 %), with mean age of 40.0 ± 9.0 years (range 21–59). Arterial involvements were confirmed with computed tomography angiography, magnetic resonance image angiography, or ultrasound. Immunosuppressive agents were administrated to all patients. Indications of intervention were acute symptoms due to arterial occlusion and aneurysmal changes with or without rupture. Among 28 patients with peripheral arterial BD, 10 endovascular and 24 surgical interventions were performed in 21 patients. All 21 patients who underwent endovascular and surgical intervention were followed up for a mean duration of 78.7 ± 52.5 months (range 0–182 months). There was one mortality due to the rupture of pseudoaneurysm in patient who underwent stent-graft insertion for abdominal aortic aneurysm. New arterial involvements of BD occurred in 10 patients. All patients were male, and median age was 33.5 years (range 29–59 years). Mean time of onset of the new arterial lesion was 32.7 ± 32.1 months. In conclusion, the result of endovascular and surgical interventions is satisfactory in patients with acute peripheral arterial BD. Accurate diagnosis with immunosuppressive therapy is mandatory to prevent recurrence and activation of peripheral arterial BD.

Purpose: The superiority of autogenous vein conduits is well known in lower extremity arterial bypass (LEAB). Among various alternative conduits for LEAB, long-term results of arm vein grafts were investigated in this study. Materials and Methods: We retrospectively reviewed clinical characteristics of 28 patients who underwent infrainguinal LEAB with autogenous arm vein grafts at a single institute between January 2003 and December 2015. All procedures were performed in the absence of adequate saphenous veins. Graft patency was determined by periodic examinations with duplex ultrasonography. Results: Autologous arm vein grafts were implanted for 28 patients (mean age, 60.4±16.8 years; range, 20–82 years; male, 92.9%; atherosclerosis, 19 [67.9%]; and non-atherosclerotic disease 9 [32.1%] including 5 patients with Buerger’s disease). Source of arm vein were basilic 13 (46.4%), cephalic 4 (14.3%) and composition graft with other veins in 11 (39.3%) cases. The level of distal anastomosis was distributed as popliteal in 5 (17.9%), tibio-peroneal in 21 (75.0%) and inframalleolar artery in 2 (7.1%) cases. Mean duration of follow-up was 41.5±46.9 months (range, 1–138 months). Cumulative primary patency rates at 1, 3, and 5 years were 66.5%, 60.9% and 60.9%, respectively. Assisted-primary patency rates at 1, 3 and 5 years were 66.5%, 66.5% and 66.5%, respectively. Secondary patency rates at 1, 3 and 5 years were 70.8%, 70.8% and 70.8%, respectively. There was one limb amputation during the follow-up period. Conclusion: Arm veins are a useful alternative conduit when great saphenous veins are not available during LEAB.

PURPOSE Directional atherectomy (DA) was introduced for the management of infrainguinal arterial stenosis or occlusive lesions. The procedure success rate in the DEFINITIVE LE study was determined using radiologic imaging. The aim of our study was to determine the usefulness of intraoperative ultrasonography (USG) during DA for evaluating the early results of this procedure. METHODS Patients who underwent DA from January to December 2014 were reviewed retrospectively. Twenty lesions from 14 patients with femoral artery stenosis (>70% stenosis) with short segment occlusive lesions (

Objective To determine the incidence and risk factors of carotid stenosis progression in patients with asymptomatic moderate carotid artery stenosis (CAS). Methods Patients with asymptomatic moderate CAS in duplex ultrasound (DUS) were identified from 2003 to 2008, and only those with more than 1 DUS were included during a 5-year follow-up after index DUS. Study end-points were carotid stenosis progression to severe stenosis ≥70%, development of ipsilateral neurologic symptoms (INS), and death. Results One hundred twenty-nine carotid arteries in 124 patients were included in the study. Carotid stenosis progression occurred in 41 (31.8%) arteries, and 4 (3.2%) patients developed INS during a mean follow-up of 49 months (range, 2–128 months). The 5-year freedom from carotid stenosis progression and development of INS were 63.5% ± 5.3% and 98.1% ± 1.4%, respectively, with no difference from those of statin. There was no significant predictor of carotid stenosis progression, and it was not significantly associated with development of INS. The 5-year actuarial patient survival and symptom-free survival were 95.3% ± 2.7 and 93.4% ± 3.0%, respectively, with no difference from those of statin. The only independent predictor of death and INS/death was a remote history of INS (hazard ratio 18.166, P = 0.021, hazard ratio 4.840, P = 0.046). Conclusions The incidence of carotid stenosis progression in asymptomatic moderate CAS was high even in popular use of aspirin and statin. Although development of INS was not associated with carotid stenosis progression, it was a risk factor of long-term morbidity and survival.

Purpose To find a significant predictive factor for the efficacy of endovascular treatment of peripheral arteriovenous malformations (AVMs). Materials and Methods One hundred seventy-six patients (73 male patients and 103 female patients; mean age, 29.4y) who underwent treatment for AVMs in the body or extremities were included. Per Schobinger classification, lesions in 31 patients (18%) were stage II, those in 136 (77%) were stage III, and those in nine (5%) were stage IV. AVMs were located in the extremities in 130 patients (74%) and in the trunk in 46 patients (26%). AVMs were angiographically classified as type I (n=1), type II (n=36), type IIIa (n=6), type IIIb (n=91), or complex type (n=42). Demographic factors, clinical data, and imaging data were analyzed to determine a statistically significant relationship with overall clinical outcomes. Results Overall, 68 patients (39%) were cured, 91 patients (52%) showed a partial response, nine patients (5%) showed no response, treatment failed in seven patients (4%), and treatment aggravated the condition in one patient (1%). The overall complication rate was 45% (79 of 176 patients). Minor complications developed in 62 patients (35%) and major complications developed in 17 (10%). Statistically, the extent of AVMs (odds ratio, 0.199) and angiographic classification (odds ratio, 0.162) were significant predictive factors for overall clinical outcome. Conclusions Endovascular treatment of peripheral AVMs, planned with consideration of anatomic extent and angiographic subtypes, is likely to yield good clinical results with low complication rates.