Purpose: The aim of this study is to review the 5-year outcome of femoral above-knee popliteal artery (AKFP) bypass with an externally supported knitted Dacron prosthesis (EXS), and to evaluate the role of EXS by prospective comparison of EXS versus expanded polytetrafluoroethylene (ePTFE). Methods: The clinical records of 184 patients with arteriosclerosis obliterans (ASO), who underwent AKFP bypass in 206 limbs from January 1982 to December 2003, were retrospectively reviewed. The outcome in terms of the graft, limb, and life up to 5 years after surgery, as well as early operative complications, were evaluated. The graft patency rate, limb salvage rate, and the survival rate of patients were calculated by the Kaplan-Meier method. The risk factors affecting the graft patency adversely were elucidated by a multivariate analysis. In addition, the primary graft patency of EXS was compared with that of ePTFE in a prospective nonrandomized study performed since 1998. Results: The operative mortality was zero. The cumulative primary and secondary patency rates of 206 EXS were 82% and 74%, and 88% and 79% at 2 and 5 years, respectively. The limb salvage rate of 42 critical ischemic limbs was 94% at 5 years. The survival rates of 184 patients were 88% and 63% at 2 and 5 years respectively after bypass surgery. The significant risk factors of graft failure were operative indications (limb salvage) and a history of ischemic heart disease. A prospective study revealed that the cumulative primary patency rates of 33 EXS and 33 ePTFE were 79% and 73% at 3 years, respectively with no statistically significant difference. Conclusions: Although AKFP bypass using EXS is an acceptable procedure in ASO patients, EXS is not always recommendable as a first choice prosthesis for AKFP bypass.

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Thirty-one cases of graft infection after vascular reconstructive surgery over a 21-year period (1984 to 2004) were reviewed. Initial indications for surgery included peripheral arterial disease (n=18), abdominal aortic aneurysm (n=7), and thoracic aortic aneurysm (n=3), among others (n=3). The graft implantation sites were the thoracic aorta (n=3), abdominal aorta (n=13), or an extracavitary artery (n=15). All initial surgeries of the three cases with thoracic aortic graft infection were emergencies. Two were graft replacements and one was an endograft with concomitant abdominal aortic surgery. One patient was saved by intercostal muscle flap rotation, and two died following conservative treatment. Aortoenteric fistula (AEF) developed in five of 13 patients with abdominal aortic infection. The removal of the graft was total in three of five patients, subtotal in one, and partial in one. AEF recurred in two patients. Four patients were saved and one died. Of the other eight patients without AEF, graft removal with extraanatomic bypass was performed in six patients, muscle flap rotation was performed in one and omental flap rotation was performed in one patient. Six patients were saved and two died. In 15 cases of extracavitary arterial graft infection, five patients underwent graft removal with vascular reconstruction: three were saved and two died. Six patients underwent graft removal without vascular reconstruction: three of them were saved, one required amputation and two died. Four patients did not undergo graft removal: three required amputation and one died. In the treatment of graft infection, it is critical to completely remove the infected graft and to extensively debride the surrounding infected tissue, while considering the extent of the infection and the general condition of the patient.

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A 39-year-old man was referred to Hirosaki University Hospital because of recurrent pulmonary embolism (PE) in spite of post insertion of a Greenfield inferior vena caval (IVC) filter with an anticoagulant agent. Although many examinations were performed in order to confirm the pathophysiology, we could not clarify the cause of PE. We decided on implanting an additional vena caval filter (Simon nitinol IVC filter) above the renal vein in this patient and administered oral anticogulants (Warfarin potassium, beraprost sodium, and sarpogrelate hydrochloride). We maintained an international normalized ratio (INR) of 2.5-3.0 and reduced the intravenous administration of heparin and he was discharged without recurrent PE. We think that further examination of thrombophilic tendency, including gene abnormality, will be necessary.

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We surgically treated a popliteal artery pseudoaneurysm in a 59-year-old woman who complained of a painful tumor behind her left knee four months after iatrogenic vascular injury sustained during orthopaedic surgery. She had severe ischemic damage and reperfusion injury to the left lower leg, causing compartment syndrome and permanent damage to the tibial nerve. Preoperative digital subtraction angiography revealed that the popliteal artery was occluded, but good collaterals had developed. We performed the operation by excising the aneurysm using the posterior approach and bypassing the popliteal arteries of the knee joint with a lesser saphenous vein graft. Intraoperative findings revealed a popliteal artery pseudoaneurysm with a 5-cm width and 10-cm length. The postoperative course was uneventful. We concluded that aneurysms of popliteal arteries should be treated as soon as possible because they may cause severe ischemic damage and development of aneurysm.

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Epithelioid hemangioendothelioma (EHE) is an extremely rare vascular tumor of intermediate or “borderline” malignancy. Generally it develops from the soft tissue, the lung or the liver and occasionally is known to metastasize. We report a case of EHE of a remnant and atrophic femoral vein associated with a persistent sciatic vein (PSV), that developed in a 69-year-old woman. She complained of a solitary painful mass on the right groin. She underwent complete resection of the tumor and the segments of the iliac-femoral artery and vein involved. The defect of the iliac-femoral artery was reconstructed with a prosthetic graft, but the iliac-femoral vein was not reconstructed because of the patency of the PSV. The pathological examination revealed EHE with low mitoses and bone formation. Radiation and chemotherapy do not improve survival or prevent recurrence, so that the need for complete excision is emphasized. To the best of our knowledge, this is the first case report of EHE arising from the femoral vein in such an unique situation in Japan.

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Neuropathy of the lower limbs is very rare as a chief complaint of ruptured abdominal aortic or iliac aneurysms, and there are even fewer cases that reach the level of an exercise disorder of the lower limbs. We encountered a case of ruptured abdominal aortic and iliac aneurysms presenting as an exercise disorder of the left lower extremity. The patient was a 68-year-old man. Though the exact origin of the symptom is not clear, he had back fatigue in October and December 2003. One day in February 2004 he could not walk because of weakness in the left lower limb, and was admitted to our emergency room. His consciousness was clear. Bilateral dorsal pedal arteries pulsated well. Disorder of the femoral nerve was revealed by manual muscle test. Computed tomography showed contained ruptures of abdominal aortic and left iliac aneurysms that had spread into the retroperitoneal space. We concluded that the disorder of the nerves of the left lower extremity had occurred owing to the rupture of the left iliac artery aneurysm. Emergency aortoiliac reconstruction was performed with a prosthetic graft. The case had transient renal failure postoperatively and hemodialysis was needed. The renal function and the neuropathy of the left lower limb gradually improved, and the patient was discharged on the 47th postoperative day. Because ruptured aneurysm cases like this may be diagnosed as an orthopedic disease at the time of first examination, we should be careful not to delay treatment.

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Two patients complaining of visual loss and hemorrhage were given a diagnosis of ocular ischemic syndrome (OIS) due to extracranial carotid artery disease by visual loss and hemorrhage of the fundus. OIS is defined as a disease with chronic ocular ischemic change, which can be diagnosed based on retinal tone and fluorescein fundus angiography. One patient underwent carotid endarterectomy (CEA) and the other underwent subclavian artery-common carotid artery bypass using the greater saphenous vein graft. Both patients recovered their eyesight in the early postoperative period. Patients with OIS also have general comorbid diseases; however, surgical treatment was thought to be effective unless a patient was at high risk. Because postoperative brain hemorrhage and high eye pressure could be critical, they should be monitored and controlled in consultation with ophthalmologists. The two patients with OIS achieved sufficient blood flow restoration to the ocular region, resulting in a good outcome. CEA or carotid artery reconstruction was effective for these two patients with OIS due to extracranial carotid artery disease.

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We conducted 2 cases of total aortic arch replacement with an isolated left vertebral artery (ILVA). A 71-year-old woman who had distal aortic arch aneurysm with chronic dissection (Stanford B), and a 70-year-old man had sacral arch aneurysm. Their preoperative computed tomography or angiogram could not identify ILVA. In both, surgery was done using 4-branched arch grafts with moderately hypothermic selective cerebral perfusion and systemic circulatory arrest. We perfused all cerebral branches including ILVA with small tubes. Selective cerebral perfusion times were 186 and 162 minutes respectively. All reconstructed ILVA anastomosed to the graft branch with the native left subclavian artery showed good patency. Neither of our patients had cerebral complications and they were discharged on the 20th and 11th postoperative days in good condition.

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A 30-year-old man suddenly suffered severe pain and cyanosis on the right lower leg. Analgesic drugs were not effective. We diagnosed acute arterial occlusion of his right foot. Emergency arterial thrombectomy was carried out successfully. Afterward, he was found to also have polycythemia vera by blood test and scintigraphy. Polycythemia vera could cause acute limb ischemia even in young patients.

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A case of thoracic outlet syndrome complicated by occlusion of the right subclavian artery and distal arterial embolism of the right upper extremity was reported. A 45-year-old man was admitted due to sudden onset of pain at rest, and mobility disturbance of the right upper extremity. An emergency arteriography demonstrated occlusion of the right subclavian artery and thromboembolism of the right brachial, radial and ulnar arteries. Occlusion of the right subclavian artery due to thoracic outlet syndrome accompanied by distal arterial thromboembolism was suspected. Left axillary-right axillary crossover arterial bypass and thrombectomy of the brachial, radial and ulnar arteries were successfully performed, and the patient's symptoms were completely relieved. Postoperative computed tomography scan demonstrated an abnormal fusion of the hypertrophic first rib and the second rib. No cervical rib was observed. Upper extremity ischemia is not a common clinical feature of thoracic outlet syndrome, however, in cases of acute arterial embolism following chronic upper limb ischemia, early diagnosis and aggressive treatment are necessary to avoid disastrous outcome of major upper extremity amputation.

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