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Background Primary infected aneurysms of the abdominal aorta and iliac arteries are potentially life-threatening. However, because of the rarity of the disease, its pathogenesis and optimal treatment strategy remain poorly defined. Methods A nationwide retrospective cohort study investigated patients who underwent surgical treatment for a primary infected abdominal aortic and/or common iliac artery (CIA) aneurysm between 2011 and 2017 using a Japanese clinical registry. The study evaluated the relationships between preoperative factors and postoperative outcomes including 90-day and 3-year mortality, and persistent or recurrent aneurysm-related infection. Propensity score matching was used to compare survival between patients who underwent in situ prosthetic grafting and those who had endovascular aneurysm repair (EVAR). Results Some 862 patients were included in the analysis. Preceding infection was identified in 30.2 per cent of the patients. The median duration of postoperative follow-up was 639 days. Cumulative overall survival rates at 30 days, 90 days, 1 year, 3 years and 5 years were 94.0, 89.7, 82.6, 74.9 and 68.5 per cent respectively. Age, preoperative shock and hypoalbuminaemia were independently associated with short-term and late mortality. Compared with open repair, EVAR was more closely associated with persistent or recurrent aneurysm-related infection (odds ratio 2.76, 95 per cent c.i. 1.67 to 4.58; P Conclusion In patients undergoing surgical intervention for primary infected abdominal aortic and CIA aneursyms, postoperative survival rates were encouraging. Eradication of infection following EVAR appeared less likely than with open repair, but survival rates were similar in matched patients between EVAR and in situ graft replacement.

Objective A nationwide survey was conducted in Japan to determine the incidence of venous thromboembolism (VTE) after endovenous thermal ablation for varicose veins and to investigate its pathogenic background. Methods The survey targeted all cases of endovenous thermal ablation between January 2011 and December 2013. Based on this survey, a retrospective study of patients who developed endovenous heat-induced thrombosis (EHIT) of classes 2 to 4, no EHIT-related deep venous thrombosis (DVT), and pulmonary embolism (PE) was conducted. Lower extremity venous ultrasound was performed within 72 hours and at 1 to 3 months postoperatively in all institutions. We investigated factors associated with the occurrence of complications and the usefulness of postoperative ultrasound. Results Survey responses were collected from 213 institutions. Endovenous laser ablation was performed for 43,203 patients (EHIT 2 in 318 patients, EHIT 3 in 50 patients, EHIT 4 in 7 patients, other DVTs in 24 patients, and PE in 3 patients). The incidence of VTE complications was 1.0% for EHIT 2, 0.11% for EHIT 3, 0.013% for EHIT 4, 0.063% for other DVTs, and 0.0067% for PE based on the adjusted population. Sex, age, obesity, origin of the varicose vein, vein diameter, and preoperative Caprini score were not strong indicators of VTE complications. Of 50 patients with EHIT 3, there were 35 patients who had EHIT 3 during the first postoperative ultrasound session. In one patient, EHIT 3 progressed to EHIT 4 despite initiation of anticoagulant therapy. Of seven patients with EHIT 4, only one patient had EHIT 4 at the first postoperative ultrasound examination. Because ultrasound performed before the occurrence of EHIT 4 revealed that three patients had EHIT 2 or EHIT 3, EHIT 4 could have possibly been predicted by ultrasound. Of three patients with PE, two developed PE before ultrasound, and EHIT was not detected by ultrasound in one of those patients before PE developed. Anticoagulant therapy was administered in most patients with EHIT 3 and all patients with EHIT 4 and PE, with favorable outcomes. Conclusions The incidence of VTE complications after endovenous laser ablation was low. Furthermore, the value of performing postoperative ultrasound for VTE management seems to be low because the occurrence of severe VTE complications could not be predicted by lower extremity venous ultrasound. Although the perioperative detection of VTE complications by this modality resulted in the early administration of anticoagulant therapy and may have contributed to improved prognosis, the number of those patients was limited.

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.

Surgical strategy for significant carotid artery stenosis complicated with severe aortic valve stenosis is still controversial. Herein, we report a case of 80-year-old female in whom 78% stenosis by the NASCET criteria in left internal carotid artery was pointed out during preoperative checkup for symptomatic severe aortic stenosis. Carotid endarterectomy was done concomitantly with aortic valve replacement. No neurological complication occurred perioperatively.

Refractory esophageal ulcerations occur rarely after cardiovascular surgery, occasionally leading to perforation. There is little consensus on their optimal management. Herein, we present a case of refractory esophageal ulceration after cardiovascular surgery. A 62-year-old woman with Marfan’s syndrome was referred to our hospital with cardiac failure due to aortic regurgitation. She underwent root replacement by the modified Bentall method. Refractory esophageal ulceration developed 3 months later and persisted for 3 months despite conservative therapy. With the patient’s informed consent, Kirschner bypass surgery was performed. A jejunostomy using a 20 Fr. Nelaton catheter was made in the Roux-en-Y loop of the jejunum for postoperative endoscopy. The postoperative course was uneventful and transjejunostomal endoscopy revealed excellent healing of the ulceration. Esophageal bypass surgery and transjejunostomal endoscopy were very effective in this patient with refractory esophageal ulceration.

要 旨：閉塞性動脈硬化症の患者に対し，近赤外線分光法(NIRS)にて測定された運動負荷試験後の下肢虚血の回復時間(RT)と，心血管予後との関連性を検討した。観察期間は9.2±2.1年であった。心血管イベント発症群と発症しなかった群とで比較すると，患者の両下肢のうち回復が遅かったほうの肢のRTは，有意差はなかったもののイベント発症群で長かった。NIRSで測定されたRTは，心血管予後に関連する可能性がある。

Staged repair of extensive thoracic aortic aneurysms is complicated, with a high incidence of interval rupture between stages. We describe the systematic staged hybrid procedure of a previous endovascular repair of a descending aortic aneurysm and open surgical repair of an aortic arch aneurysm. In the second-stage arch repair, the stent graft was easily retracted and fixed, without dissection, around the aortic arch aneurysm distal side. Extensive thoracic aortic aneurysms were managed without interim rupture or neurologic deficits. This approach avoided the potential for interim rupture because recovery from the first-stage endovascular repair was shorter than that from open repair.

Objectifs La revascularisation des branches de la crosse aortique a ete associee a une reparation endovasculaire de l’aorte thoracique (TEVAR) pour preserver la zone d'atterrissage de l'endoprothese chez 19 patients a haut risque. Methodes La procedure utilisee etait un pontage ou une transposition des arteres carotides communes et sous-clavieres. Des stentgrafts fenetres sur mesure, deployes dans la zone d’ancrage 0, etaient employes pour TEVAR. Resultats Toutes les lesions etaient traitees sans endofuites. Aucun deces perioperatoire ne s'est produit ; sept patients ont eu des complications postoperatoires. Un patient presentant un syndrome de detresse respiratoire aigu a du etre reopere pour changer le trajet du pontage et permettre une tracheotomie. Un patient est mort de pneumonie 2 mois apres traitement, apres un faux anevrysme anastomotique, un infarctus cerebral et une reintervention pour hemostase. La mortalite liee au geste etait de 5,3%. Conclusion La revascularisation de la crosse aortique avant TEVAR peut permettre une chirurgie moins invasive, mais le choix rigoureux des patients est essentiel.

To minimize surgical invasiveness for extensive aortic aneurysms and expand the indications for thoracic endovascular aortic repair (TEVAR), we evaluated outcomes of hybrid procedures combining conventional surgical aortic repair and TEVAR for thoracic aortic aneurysms.The following hybrid procedures were performed: second-stage TEVAR after total aortic arch replacement using the elephant trunk as the landing zone in 17 patients; and for multiple aortic aneurysms, vascular graft replacement and TEVAR in 13 patients, vascular graft replacement and TEVAR with bypass in 2 patients, and TEVAR with bypass in 23 patients.There were three (5.3%) hospital deaths, from serious complications including stroke, paraplegia, paraparesis, and aspiration pneumonia; and eight late deaths. There was only one aneurysm-related death, of a patient who underwent emergency surgery for an esophageal fistula resulting from enlargement of a residual false lumen of a thoracoabdominal aorta after second-stage TEVAR.Hybrid procedures minimize surgical invasiveness in thoracic aortic aneurysm repair, but further evaluation of a larger number of patients is necessary.

Obstructive sleep apnea (OSA) is not only a cause of hypertension; it also possibly affects the pathogenesis and progression of aortic disease because an inspiratory effort-induced increase in negative intrathoracic pressure generates mechanical stress on the aortic wall. The objective of the present study was to examine the incidence by location of OSA as a complication in patients with aortic aneurysm and patients with aortic dissection (AD). An overnight sleep study was conducted in the following study groups: the aortic disease group (n = 95) consisting of patients with thoracic aortic aneurysm (TAA, n = 32), patients with abdominal aortic aneurysm (AAA, n = 36), and patients with AD (n = 27); and a control group (n = 32), consisting of patients with coronary risk factors who were matched with the aortic disease group for age, gender, and body mass index (BMI). The 3% oxygen desaturation index (ODI) was significantly higher in all the TAA, AAA, and AD groups (P = 0.045, P = 0.003, and P = 0.005, respectively) than in the control group. The incidence of moderate to severe OSA [apnea hypopnea index (AHI) ≥15 events/h] was significantly higher in the first three groups (P = 0.026, P = 0.001, P = 0.003, respectively) than in the control group, while no significant difference was found between the TAA group and the AAA group with respect to these variables. Furthermore, no significant differences were found between the thoracic AD subgroup and the abdominal AD subgroup with respect to AHI and 3% ODI, as well as with respect to the incidences of moderate to severe OSA. Patients with TAA, patients with AAA, and patients with AD showed high incidences of moderate to severe OSA. Although this result suggests that OSA may be one of risks for aortic disease, unelucidated mechanism(s) other than negative intrathoracic pressure may be involved in the pathogenesis of aortic disease.

Aim: To assess the utility of skin perfusion pressure (SPP) measurement in evaluating the outcome of vascular constructions for critical limb ischemia (CLI) patients. Methods: We retrospectively studied 19 lower limbs in 18 patients who underwent arterial reconstruction for CLI from whom SPP measurements had been obtained pre- and postoperatively between 2008 and 2010. Six limbs whose ulcers had healed postoperatively were classified into group H, 7 limbs whose ulcers had not healed into group U, and 6 limbs without ulcers into group N. SPP values were compared among these groups. Results: The preoperative SPP values in all groups were

Background: The results of paramalleolar distal bypass for critical limb ischemia in patients with peripheral arterial disease were reviewed to determine the factors affecting the long-term patency of this procedure in Japanese subjects. Methods and Results: A total of 65 legs from 60 consecutive Japanese patients with critical limb ischemia who underwent distal bypass to the ankle were retrospectively reviewed. Postoperative graft patency, morbidity and mortality were analyzed. All patients were monitored during a mean follow-up period of 2.2±1.7 years (median, 1.7 years). The accumulated primary and secondary patency rates were both 81.0% at 1 year and 78.7% at 3 and 5 years. The amputation-free rates and survival rates at 1 year, and 3 and 5 years were 94.5% and 82.6%, 82.6% and 88.1%, and 76.7% and 69.7%, respectively. The Cox proportional hazard model was used to determine factors contributing to long-term results. Age (odds ratio, 1.1; P

Objective The Japanese Committee for Stentgraft Management (JACSM) was established with the aim of ensuring the safe and proper reach of commercial stent grafts following their regulatory approval. This study examines the validity of the practice standards developed by JACSM. Methods JACSM comprises 10 associations related to endovascular treatment. Based on the practice standards developed by JACSM, the status of practising institutions, practising surgeons, supervising surgeons and the results of follow-up surveys were analysed. Results In the 2.5 years following the establishment of JACSM, 298 institutions have fulfilled the practice standards. The number of practising surgeons reached 493, and the number of supervising surgeons reached 177. There were 3089 registered cases up to June 2009. The present study analysed 1570 cases registered in the 2 years from July 2006 to June 2008. The hospital mortality rate was low (0.4%) in the follow-up surveys. Conclusions Early results following the introduction of stent grafts were generally good. The procedure spread safely without the learning curve seen in the initial stages following introduction of new medical materials, indicating that the practice standards were appropriate.

Ehlers-Danlos syndrome is a rare inherited disease of connective tissue. Patients with type IV Ehlers-Danlos syndrome are likely to present with arterial disorders such as aneurysm or dissection. We report a 20-year-old man with type IV Ehlers-Danlos syndrome in whom a subclavian arterial rupture was successfully treated with transcatheter coil embolization.

Although the presence of coronary heart disease (CHD) was the major determinant of perioperative mortality and long-term prognosis in patients with aortic aneurysm (AA) and peripheral artery disease (PAD), the prevalence and severity of CHD in patients with individual vascular diseases was unknown. Adenosine triphosphate-loading myocardial single-photon emission computed tomography therefore was performed in 788 patients with vascular diseases of the aorta and peripheral arteries, with AA in 500, PAD localized in the lower-limb arteries in 183, and combined AA and PAD in 105. Patients with known CHD, such as those with previous myocardial infarction or revascularization procedures, were excluded. Myocardial single-photon emission computed tomography was analyzed using a 20-segment model, and summed stress scores and summed difference scores were calculated. Stress-induced myocardial ischemia was defined as a summed difference scoreor=2. The presence of myocardial ischemia was highest in patients with combined PAD and AA (73%), followed by PAD (55%; p = 0.005), and the lowest in patients with AA (37%; p0.0001). Summed stress score was also the highest in patients with combined PAD and AA (11.6 +/- 9.9), followed by PAD (7.8 +/- 8.8; p0.0001), and the lowest in patients with AA (4.0 +/- 6.2; p0.0001 for both). Similarly, summed difference score was the highest in patients with combined PAD and AA (6.4 +/- 6.1), followed by PAD (4.4 +/- 5.7; p = 0.001) and AA (2.3 +/- 4.0; p0.0001 for both). In conclusion, the prevalence of CHD in patients with PAD was50%, and although myocardial ischemia was observed in only (1/3) of patients with AA, its prevalence not only doubled, but also indicated extensive myocardial ischemia when combined with PAD. Thus, cardiac evaluation was particularly important in patients with combined AA and PAD.

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

A celiacomesenteric trunk (CMT) aneurysm is extremely uncommon in splanchnic aneurysm, accounting for less than 0.5% of the population. We report a case of CMT aneurysm that led to surgical treatment. The patient underwent excision of the aneurysm with successful vascular reconstruction. Only eight cases of CMT aneurysm have been reported so far. Awareness of congenital vascular anomalies and grasp of embryologic development are necessary for adequate surgical intervention.

動脈硬化に起因した複数の併存症を有する腹部大動脈瘤症例に対し, 手術侵襲を軽減する目的でステントグラフト内挿術を施行した. 極薄ダクロン人工血管に自己拡張型金属ステントを縫着したテーパー (先細り) 型ステントグラフトを作製し, これを透視下にカテーテルを用いて腹部大動脈より左総腸骨動脈に留置固定し, 大腿-大腿動脈交叉バイパスを設置することで瘤内血流を遮断し, 良好な結果を得た. 本法は外科的手術と比較して侵襲が少なく有用な治療法となり得る.

症例は60歳女性. 突然の胸背部痛で発症した早期閉塞型 Stanford A型大動脈解離と診断され, 保存的治療を行っていた. 発症後約2カ月で再び胸背部痛が出現し, 解離腔の再開通と診断され, elephant trunk を併用した弓部全置換術を行った. 術後のDSAにて, 人工血管末梢吻合部より解離腔へ造影剤の漏出を認め, 1カ月後にステントグラフト内挿術を施行した. 解離腔は血栓化し早期離床が可能であった.

胸部大動脈手術後に発生した仮性大動脈瘤10例を対象として, ステントグラフト内挿術の有用性と問題点について検討を加えた. 手術は全例全身麻酔下に総大腿動脈より経血管的にシースを介してステントグラフトを内挿した. 術後2週間以内に瘤内が血栓化したものは10例中7例 (70%) であり, これを初期成功とした. 残り3例では瘤内に少量の血流 (minor endoleak) を認め, このうち1例は6カ月後にステントグラフトが移動し外科的修復を要した. また, 2例を大量喀血により失った. 胸部大動脈手術後の人工血管吻合部に発生した仮性瘤に対する再手術は, 全身管理や手術手技に困難を伴うことが多く, 低侵襲治療であるステントグラフト内挿術の有用性は高いと考えられる. しかし, 喀血例への対策, および遠隔期成績については, 今後の十分な検討が必要である.

Aortic aneurysm due to BehCet's desease has a high risk of abrupt enlargement causing rupture. Fot this, operative procedure in often the treatment of choice, but complications at anastomosed portion occur in a relatively high frequency and the operative results are poor. This paper deals with our successful attempt of omental flap coverage for such an abdominal aortic aneurysm. A 56-year-old man originally diagnosed as complete type Behcet's disease in 1967, was admitted to our hospital because of an aortic abdominal aneurysm disclosec by CT and DSA. The aneurysm consisted of a large thrombus, and a punched-out lesion was found on the aorta (φ 20mm) beneath the thrombus. The aneu-rysm was replaced by an 16×8mm woven dacron graft and the graft was wrapped in omental pedicle flap to prevent potential anastomotic complications of development of false aneurysms at the site of anastomoses, in-fection, delayed healing, and graft occlusion. Pathologic examination revealed that the patient had vasculo-Behcet's syndrome. The patient has been followed for over 5 years and has had no further complications either from his un-derlying disease or from his aortic dissection and aneurysm. Omental flap coverage is essential for effective treatment of abdominal aortic aneurysm in Behget's disease.

待機手術を行った腎動脈下腹部大動脈瘤50例を対象として, その手術中に腹部大動脈の遮断前後で下腸間膜動脈 (IMA) の断端圧測定を行い, 各動脈支配領域の血行動態変化を解析した. 大動脈血流の遮断前におけるIMA断端圧体血圧比は, その遮断後に有意に減少した (p

Multiple aortic aneurysms in Behçet's disease were repaired with transluminaly placed endovascular stent grafts. Before deploying the stent graft device for permanent implantation for the saccular aneurysm located in the descending thoracic aorta, from which feeding arteries for the spinal cord possibly branched, a retrievable stent graft was inserted and evoked spinal cord potential (ESP) were monitored in order to predict spinal cord ischemia. The original retrievable stent graft, constructed of a self-expandable Z-shaped stainless steel stent covered with e-PTFE, can be easily withdrawn into a 18 Fr. sheath after deployment. Blood flow into intercostal arteries branching from that part of the descending aorta where the permanent stent graft is planned to be implanted, is intercepted by the retrievable stent graft. A change of ESP during the temporary implantation of the device indicates that spinal cord ischemia would be caused by permanent implantation of the stent graft. In this case, no change of ESP was observed and the patient showed no postoperative paraplegia. The retrievable stent graft was useful for prediction of spinal cord ischemia before endoluminal stent graft repair of the descending aortic aneurysm. However, the device is not flexible enough to fit a severely tortuous aorta, therefore we are obliged to select patients to some extent. Further improvement of the device is required to make prediction of spinal cord ischemia with the retrievable stent graft possible in all cases.

We studied changes in blood coagulation and fibrinolytic system in 18 cases of thoracic aortic aneurysm and 5 cases of aortic dissection treated with stent grafts. The mean operation time was 259 +/- 67 minutes and the amount of blood loss during operation was 472 +/- 456 ml. Although blood transfusion of 220 +/- 360 ml was performed in 7 cases, 16 of 23 cases (70%) received no homologous blood transfusion. Consequently, the endoluminal stent graft treatment was minimally invasive compared with the conventional surgical procedure. On the 1st postoperative day, platelet counts and AT-III decreased and TAT increased. The promotion of blood coagulability was found in these patients on the 1st day after the operation. Changes in the fibrinolytic system were less marked than that in coagulation. These results suggest that the thrombosed aneurysm was excluded from systemic blood flow by the stent graft. There was no consumption coagulopathy in any case with aneurysm excluded by stent graft deployment. Stent-graft treatment for thoracic aortic aneurysm can be successfully performed without consumption coagulopathy when the aneurysm is completely excluded.

症例は50歳の男性で, ベーチェット病の診断後, 上行大動脈拡張および大動脈弁閉鎖不全症をきたし Bentall 手術を施行. 術後経過観察中に胸部近位下行および胸部下行に計3個の嚢状動脈瘤を生じたため, 血管内治療の一つであるステントグラフト内挿術を施行し, 瘤内血栓化および減圧に成功した. 本疾患に対する外科手術は術後の人工血管縫合不全や吻合部仮性瘤の発生などその治療成績は不良であることから, 手術侵襲が低く, 吻合が不要という利点をもつステントグラフト治療は有用性が高いことが示唆された. 今後さらに長期にわたる経過観察が必要である.

We present two cases of severely calcified thoracoabdominal aortic aneurysm treated by means of endografting with a retrograde aortomesenteric bifurcated bypass graft reconstructing the celiac axis and superior mesenteric artery. To avoid spinal ischemia, we monitored evoked spinal cord potential and performed an occlusion test of the intercostal arteries using a retrievable stentgraft. No change in evoked spinal cord potential was noted, and no endoleaks or complications, including paraplegia, were observed. This procedure is a feasible and less-invasive treatment for severely calcified thoracoabdominal aortic aneurysms. (J Vasc Surg 2002;35:397-9.)

When operating on patients with type B aortic dissection, the preoperative hemodynamics and malperfusion of visceral organs should be considered. We report a 70-year-old man with dissecting distal arch aneurysm following type B aortic dissection, whose celiac artery arose from a false lumen and who was successfully treated with total arch replacement and ascending graft-celiac artery bypass.

From November 1986 to January 1993, 97 wrinkled ePTFE prosthetic vascular grafts were implanted in 90 peripheral arterial reconstructions for 87 patients with arteriosclerosis obliterans (ASO) (79 men and 8 women). Grafts used in this series were 54 Vitagraft and 33 Technograft. Initial results for a period of as long as 6 years are summarized here. Forty-four (45.3%) grafts were implanted anatomically, and the remaining were extra-anatomically routed. The mean age of patients in the anatomic bypass group was 64.7 years, and that of patients in the other group was 71.4 years. Twenty-three (43.3%) grafts in the extra-anatomic group were anastomosed sequentially. Mean follow-up periods for each group were 32.4 months and 30.9 months, respectively. None of nine late deaths during the follow-up period was graft related. There was one primary obstruction in the anatomic group; in the extra-anatomic groups, primary graft occlusion occurred in four grafts. In addition, one perigraft seroma and one pseudoaneurysm requiring surgical repair were seen. Cumulative event free ratio for this group was 80.8% at 72 months. These results reveal that the wrinkled ePTFE graft is clinically applicable to arterial reconstruction for ASO with satisfactory long-term patency, even in extra anatomic sequential bypasses.

The surgical reconstruction of intrahilar renal artery aneurysms (RAAs) is a difficult surgery because of complex anatomy. We present a case of right intrahilar RAA diagnosed in a 67-year-old man. We performed ex vivo reconstruction using an organ preservation solution to prevent postoperative renal failure. We assessed graft patency and blood perfusion was assessed by laser-assisted indocyanine green angiography using the SPY system after autotransplantation. Postoperative renal insufficiency was not observed. The results demonstrate that ex vivo reconstruction of intrahilar RAAs using an organ preservation solution, and graft patency and blood perfusion evaluation using the SPY system are effective methods for preserving renal function.

Background Revascularization of aortic arch vessels was performed with thoracic endovascular aortic repair (TEVAR) to preserve the endoprosthesis landing zone in 19 high-risk patients. Methods The operative procedure used was a bypass or transposition involving the common carotid and subclavian arteries. Homemade fenestrated stent-grafts, deployed in landing zone 0, were used for TEVAR. Results All lesions resolved without endoleaks. No perioperative deaths occurred; seven patients had postoperative complications. One patient with acute respiratory distress syndrome required reoperation to change the bypass route and permit tracheostomy. One patient died of pneumonia 2 months after treatment, after an anastomotic pseudoaneurysm and cerebral infarction developed and an operation was performed to obtain hemostasis. The procedure-related mortality was 5.3%. Conclusion Aortic arch vessel revascularization before TEVAR may permit less invasive surgery, although careful patient selection is essential.

Because extracorporeal circulation is used in thoracic aortic surgery, artificial vascular grafts that does not leak blood in the presence of heparin is required, and artificial vascular grafts covered with biological components are mostly used. They are prepared by soaking Dacron grafts in bovine collagen or gelatin, and they possess the following characteristics: 1) zero porosity, 2) no need for preclotting, and 3) knitted Dacron grafts can also be used. In recent years, various surgical materials have also been developed and clinically used ; grafts with a branch for revascularization of the aortic arch or the thoracoabdominal aorta, composite grafts for aortic root reconstruction, and Valsalva grafts. Recent advances in endovascular therapy have been remarkable, and various stent grafts have been developed and used worldwide. In Japan, Gore TAG (stent grafts for the thoracic aorta) was finally covered by insurance in July 2008 for the treatment of true aneurysms in the thoracic descending aorta. In Europe and USA, stent grafts with a branch are already being used clinically, while in Japan, a clinical study is being conducted on fenestrated stent grafts, and their indications for endovascular therapy may be expanded.

Aortic anomaly in which a right-sided aortic arch associated with Kommerell's diverticulum and aberrant left subclavian artery is rare. The present report describes a patient with type-B aortic dissection accompanying aortic anomalies consisting of right-sided aortic arch and the left common carotid and left subclavian artery arising from Kommerell's diverticulum. As dissecting aortic aneurysm diameter increased rapidly, Single-stage surgical repair of extensive thoracic aorta was performed through median sternotomy and right posterolateral fifth intercostal thoracotomy, yielding favorable results. Our surgical procedures are discussed.

As far as the indications for revascularization in the abdominal aortoiliac region are concerned, endovascular therapy is recommended for TASC II type A and type B lesions, and surgical bypass is recommended for TASC II type C and type D lesions. As stents have been developed and used more frequently in recent years, the results for endovascular therapy have dramatically improved, and its indications are beginning to be expanded. Endovascular therapy is the first-live therapy for stenotic lesions smaller than 10 cm in length or bilateral common or external iliac artery occulusion (type A and type B lesions). For highly skilled surgeons, endovascular therapy is the first-line therapy for type C and type D lesions exclude aorta and common femoral artery lesions. Therefore, when performing endovascular therapy for type C and type D lesions, it is necessary to sufficiently evaluate not only the skill of the surgeon, patient risk and QOL, but also revascularization. Furthermore, it is imperative to consider therapeutic options when endovascular therapy ends in failure.

We herein present a 60 years old woman with Takayasu arteritis and an extensive thoracic aortic aneurysm who initially underwent a total aortic arch replacement. Then, in the second stage, thoracic endovascular aortic repair was performed using the elephant trunk graft as the proximal landing zone at four weeks after aortic arch repair. The postoperative course was relatively uncomplicated, but a type II endoleak was noted. Currently, about 5 years postoperatively, the slight type II endoleak from intercostal artery persists, but aneurism dilatation has not been noted, so the patient is being followed up.

We investigated the surgical results of secondary thoracic endovascular aneurysm repair (TEVAR) using the elephant trunk graft after total aortic arch replacement (TAR) for extensive thoracic aortic lesions. The subjects comprised 16 patients who underwent TEVAR as a staged procedure following TAR at our institution between 1997 and 2007. Long-term results were retrospectively surveyed (mean observation period 68.4 months). We performed TEVAR with the elephant trunk graft as a proximal landing zone for the descending thoracic repair, the mean duration between TAR and TEVAR was 4.7 weeks for the staged operations and 18.3 months for the nonstaged operations. Early results were good in all cases, with no deaths and no noteworthy complications. For the seven patients without dissection, long-term results were also good. Among the nine patients with dissection, the false lumen in the thoracoabdominal area enlarged in three during follow-up. We performed thoracoabdominal repair in two, but one died of an aneurysm-esophageal fistula. There was only one long-term aneurysm-related death. Second-stage TEVAR using the elephant trunk graft after TAR allows less invasive surgery for extensive aortic lesions and achieves good long-term results. However, enlargement of the false lumen was a long-term concern in patients with aortic dissection, and careful follow-up is essential.

Popliteal artery entrapment syndrome (PAES) is rare congenital anomaly that occurs due to compression of the popliteal artery by adjacent musculotendinous structures. We report a 54-year-old woman with PAES of total popliteal arterial occlusion was successfully treated by release of the muscle bundle and reconstruction of the popliteal artery. Pathologic examination revealed that the extracted portion of the popliteal artery had chronic total occlusion with fibrosis and destruction of internal elastic membrane. We should deliberate whether we reconstruct the popliteal artery in addition to release of the aberrant muscle bundle due to the preoperative examination to prevent the reoperation.

No generally accepted treatment of multiple mycotic aortic aneurysms of the thoracic and abdominal aorta has yet been established. We report a 67-year-old man with widespread mycotic aortic aneurysms previously treated for malignant lymphoma and interstitial pneumonia. He was successfully treated by a two-stage hybrid surgical procedure comprising open and endovascular methods. This is apparently the first report of repair of multiple mycotic aortic aneurysms using a hybrid procedure.

Since its introduction in the 1990s, the number of thoracic endovascular aortic repairs is increasing rapidly. However, data on the operative method for reoperation after failed thoracic endovascular aortic repairs are still scanty. We describe the surgical technique of total arch replacement with partial stent removal and the elephant trunk procedure for failed thoracic endovascular aortic repair.

Malignancy can cause deep vein thrombosis(DVT)through: extrinsic compression; venous stasis due to intravenous invasion; secondary factors such as prolonged bed rest; and malignancy-induced abnormal coagulation and fibrinolysis. Various factors secreted from malignant tumors can reportedly cause systemic hypercoagulation, and tumor cells activate monocytes and macrophages to release tumor necrotic factor(TNF)-a and interleukin(IL)-6, which damage endothelial cells. Of the various onset factors for DVT, malignancy accounts for 15.6% in Japan, but discovery of malignancy at the onset of DVT or during follow-up is not rare, and malignancy is often involved with recurrent DVT or idiopathic DVT without a clear onset factor. Thorough testing must therefore be performed in patients with idiopathic or recurrent DVT while keeping malignancy in mind. As cancer patients are at risk for DVT, preventative management including hemorrhagic complication prevention is also required during surgery, chemotherapy, hormone therapy or prolonged bed rest.

Purpose: We evaluated the operative results of our treatment for multiple aortic aneurysms by means of a hybrid procedure consisting of a combination of conventional surgical maneuvers and simultaneous or sequential endovascular aortic repair (EVAR). Materials and Methods: From August 1998 to April 2007, a total of 15 patients, 11 men and 4 women, ranging in age from 62 to 78 years, were treated with hybrid procedures for multiple aortic aneurysms. The pathology of these patients were, atherosclerotic aneurysm in 12 patients, atherosclerotic aneurysm associated with chronic dissection in 2 and type III chronic dissection in 1 patient. The distribution of aneurysmal locations were as follows: 5 patients had aneurysms at the arch and descending aorta, 1 had at the arch and thoracoabdominal aorta, 6 at the descending and abdominal aorta. Two patients with chronic dissection had simultaneous abdominal aortic aneurysms. In all except 1 of the 7 patients who had abdominal aortic aneurysm, we performed abdominal aneurysmectomy and EVAR simultaneously. In 7 patients, EVAR was performed sequentially after graft replacement surgery. In 2 patients, EVAR was the initial procedure followed by conventional surgery. The mean interval between first and second stage procedures was approximately 4 months. Results: One patients died of methicillin resistant Staphylococcus aureus pneumonia 3 months after the simultaneous procedure, all others were discharged and survive. In particular, no major EVAR linked complication was observed in the follow-up period (range 3 to 91 months, mean 46 months). Conclusion: The hybrid procedure for the treatment of multiple aortic aneurysmal disease is less invasive compared to conventional staged surgery and the outcome in terms of mortality and morbidity in hospital as well as long-term follow-up are satisfactory.

症例は69歳, 男性. Crawford III型の胸腹部大動脈瘤に対して人工血管置換術を行った. 術後8日目より炎症所見が著しくなり, 創部皮下膿瘍を形成した. 排膿および胸腔ドレーン排液よりMRSAが検出され創部から胸腔内への感染と診断し, 再開胸術を施行した. 感染組織を掻爬した後, 人工血管除去による再建術を選択せず大網充填術を行い, 術後3日間は1%イソジン液による持続胸腔内洗浄を行った. 炎症は鎮静化し, 軽快退院した. 近年, MRSAによる人工血管感染は増加し治癒例も散見されるが, 本例のごとく胸腹部における人工血管を温存しえた例は稀であることから, 文献的考察を加えて報告した.

Objective: We tried to experimentally clarify the flow dynamic differences under flow competitive conditions between the internal thoracic artery (ITA) and gastroepiploic artery (GEA) as in-situ arterial bypass conduits. Methods: The ITA and the GEA were anastomosed close together to the left anterior descending artery (LAD) in 8 pigs. Flow characteristics of the ITA and the GEA were analyzed using a transit time flow meter under the following flow competitive conditions; condition A: the ITA, GEA and LAD were left open, condition B: either of the ITA or GEA were clamped and the LAD was left open, condition C: the ITA and GEA were open but the proximal LAD was clamped, condition D: either of the ITA or GEA were clamped and the proximal LAD was also clamped. Results: The flow volume of the ITA was significantly (p

Background Aortic surgery is an invasive, high-risk noncardiac procedure and the patients who require it have a high prevalence of coronary artery disease. Therefore, preoperative risk stratification for this subset is essential. Methods and Results To assess the perioperative risk for aortic surgery, pharmacologic stress single-photon emission computed tomography (SPECT) was performed in 302 patients: aortic dissection in 56, thoracic aortic aneurysm in 124, and abdominal aortic aneurysm in 122. Not only was the presence or absence of perfusion defects analyzed, but also the 20-segment model. Pharmacologic thallium SPECT revealed negative findings in 210 patients and positives in 92. Perioperative cardiac events occurred in 9 patients: 7 occurred in patients with positive SPECT, and in only 2 of those with negative SPECT (2/210 vs 7/92; p