Treatment of an Isolated Superior Mesenteric Artery Dissection

PURPOSE: Isolated superior mesenteric artery dissection (SMA) is an uncommon event but is reported not infrequently recently because of the advancement of diagnostic imaging modalities. However, the etiology and therapeutic guideline are not yet established. The purpose of this study is to find a therapeutic guideline of isolated SMA dissection. METHOD: Between January 1997 and February 2007, we retrospectively reviewed 21 patients diagnosed with isolated SMA dissection. RESULT: All patients except one patient were male and mean age was 54 years old (39~68) at the time of the diagnosis. The most common symptom was diffuse abdominal pain (72.2%). Diagnosis was made by computed tomography and/or angiography. SMA thrombosis was noted in 16 patients (76.2%). Conservative treatments were performed in 14 patients (66.7%) and surgical treatments in 7 (33.3%). One of the patients who received conservative treatment underwent diagnostic laparotomy to assure viability of bowel. Of the 7 patients received surgical treatment, 2 patients (12.5%) with the preoperative diagnosis of bowel infarction received emergent laparotomy followed by resection of the small bowel, 4 thrombectomy with angioplasty, and 1 prosthetic graft bypass surgery. One patient who had short bowel disease died of septic shock. Otherwise, there was no recurrence of symptoms during the 15 months follow-up period. CONCLUSION: In patients with isolated SMA dissection, conservative treatment seems to be feasible if there is no evidence of bowel infarction.

Report of Nation-wide Questionnaire Survey for Abdominal Aortic Aneurysm Treatment in Korea

While endovascular aneurysm repair (EVAR) is prevailing for the treatment of abdominal aortic aneurysm (AAA) in modern vascular practice, PURPOSE: we conducted nationwide questionnaire survey to investigate the current status of AAA treatment and their results in Korea. METHOD: We reviewed the replies from 28 hospitals (33 departments) to the questionnaire inquiring annual number, clinical features, mode of treatment and results of AAA patients during the period from Jan. 2000 to Jul. 2004. Results: 980 AAA patients were reported including 292 ruptured AAA (29.8%) and 688 non-ruptured AAA (70.2%). For treatment of AAA, 834 (85.1%) surgical repairs (SRs) and 111 (11.3%) endovascualr aneurysm repairs (EVARs) were performed while 35 patients (3.6%) died of AAA rupture before operation. The locations of AAA were infrarenal in 889 (90.7%), juxtarenal in 62 (6.3%), and suprarenal in 29 patients (3.0%). Among 834 patients undergoing SR, 577 patients (69.2%) had non-ruptured AAAs and 257 patients (30.8%) had ruptured AAAs. Mean operative mortality rate was 4.1% after elective SRs, 30.7% after SR for ruptured AAAs, and 2.3% after EVARs. The reported brand name of stent graft devices were various including domestic custom-made in 56 (50.5%), imported brand in 18 (16.2%) while 37 (33.3%) stent grafts were not reported their brand name. The frequencies of type I and III endoleaks after EVAR were reported 5.8% and 5.8% respectively in 86 patients with an available data. CONCLUSION: SR has been used as a major treatment option in Korea for the treatment of AAA patients while EVAR is increasing. The mortality rate of SR of AAA was comparable to western multi-center trial reports but mortality or morbidity rates of EVAR were unable to know in this questionnaire survey.

Buerger's Disease in Korea

PURPOSE: Buerger's disease (Thromboangiitis obliterans, TAO) is characterized by non- atheromatous inflammatory disease, and segmental inflammatory thrombotic occlusions of the small & middle-sized arteries and veins of the upper or lower extremities. Any epidemiological study of Buerger's disease in Korea has not been carried out until now. This study was undertaken to investigate the incidence of Buerger's disease in Korea among the patients suffering with arterial disease. METHODS: We collected and analyzed the data on 11,128 patients who were admitted to or visited the participating 22 hospitals for chronic arterial diseases throughout the major region of the South Korea from January 1986 to December 2003. The clinical diagnostic inclusion criteria for Buerger's disease were the followings: (1) a history of smoking or tobacco abuse; (2) an age of onset less than 50 years; (3) infrapopliteal, segmental arterial occlusions with sparing of the proximal vasculature; (4) frequent distal upper extremity arterial involvement (Raynaud's syndrome or digital ulceration) or-superficial phlebitis; and (5) the absence of arteriosclerotic risk factors other than smoking. RESULTS: The incidence rate of Buerger's disease among the arterial disease (11,128 patients) was 93 patients (0.83%) when the strict criteria of Shionoya was applied. 699 male-patients (6.55%) and 30 female patients (4.12%) who met the less strict criteria (the extended clinical diagnostic criteria group) were also reviewed. The 4th and 5th decades were the most common ages with-249 patients (34.2%) and 222 patients (30.5%) respectively, being found at these ages. The mean age was 40.4+/-1.6 years (age range: 16~83 years) and this was similar in both the strict criteria group and the less strict criteria group. CONCLUSIONS: This study suggests there was a low incidence of Buerger's disease in Korea among the patients who visited the participating hospitals when the strict diagnostic criteria were used. The incidence was lower than expected even when the less strict criteria were used. The more accurate incidence of Buerger's disease among the general population can be obtained by performing careful prospective study that is participated in by not only vascular surgeons, but also the other medical specialists with utilizing the strict diagnostic criteria.

Arterial Involvement of Behcet's Disease: Clinical Experience of Seoul Asan Hospital

No abstract available.

Experience of an Abdominal Aortic Aneurysm in a Patient Having Crossed Ectopia with Fusion Anomaly of the Kidney

We report a case of surgically treated abdominal aortic aneurysm (AAA) in a patient having crossed ectopia with fusion anomaly of the kidney. One artery from the abdominal aorta above the aneurysm supplies the right kidney while three renal arteries (two from the aneurysm itself and one from the left common iliac artery) supply the crossed ectopic kidney. Preoperative imaging to define the arterial and collecting systems along with a detailed planning of the operation is essential to prevent ischemic renal injury as well as ureteral injury during AAA repair.

Spontaneous Rupture of the Left External Iliac Vein

Recently, we have experienced a case of spontaneous rupture of the left iliac vein in a 62-year-old woman, who had been suffering from hemiparesis and chronic constipation. An urgent laparotomy was performed for massive hemoperitoneum without knowing the bleeding point, and laceration on the left external iliac vein was repaired. Spontaneous rupture of the iliac vein is extremely rare. However, it should be included in differential diagnoses of the patient with massive hemoperitoneum who have no known pathology or any evidence of blunt trauma.

Metabolic Changes after Revascularization in a Patient with Innominate Artery Occlusion by Localized in vivo Proton Magnetic Resonance Spectroscopy

Localized in vivo proton magnetic resonance spectroscopy (1H-MRS) has been used to measure the metabolic status of the human brain in a non-invasive manner; thus, it is often called "a non-invasive biochemical assay". MRS is more sensitive than magnetic resonance imaging (MRI) in detecting ischemic damage by measuring the metabolic changes that occur prior to the anatomic changes. We report a patient who presented with innominate artery occlusion and symptoms of posterior circulation insufficiency and showed favorable metabolic changes by 1H-MRS after revascularization. He showed no visible lesion in brain MRI, but in 1H-MRS, decreased N-acetylaspartate (NAA) signal was noted in a resting state. After revascularization, both symptomatic improvement and recovery of NAA signal were observed. 1H-MRS may provide valuable clinical information in diagnosis and management of cerebral hypoperfusion at a much earlier stage prior to the anatomic changes.

Ruptured Renal Artery Stump Aneurysm in a Renal Autotransplanted Behcet's Disease Patient

A recurrent aneurysm at the anastomosis site or the remaining artery frequently occurs after the operative treatment of an aneurysm in Behcet's disease despite anti-inflammatory medication. Herein, a ruptured left renal artery stump aneurysm in a patient with Behcet's disease, who received a left nephrectomy, aorto-biiliac bypass and heterotopic autotransplantation of the right kidney for the treatment of an abdominal aortic aneurysm and renal hypertension one year prior to this admission, is reported. An aneurysm and rupture occurred despite the administration of anti-inflammatory medications while monitoring of the clinical findings, such as skin manifestations, erythrocyte segmentation rate (ESR) and C-reactive protein (CRP). Although there is no definite proven treatment modality to prevent recurrent aneurysms at the anastomosis site or a remote artery, close follow-up with anti-inflammatory medications, and surveillance with regular intervals are the only current methods for the prevention and/or to treatment of an arterial complication in patients with Behcet's disease.

Pararenal Leiomyosarcoma of the Inferior Vena Cava

A complete surgical resection is the only proven therapeutic modality that prolongs the survival in patients with leiomyosarcoma of the inferior vena cava (IVC). Reconstruction of the IVC is not always necessary but is often required to facilitate venous drainage of the kidney for the tumors at the pararenal area of the IVC. Controversy exists in postoperative adjuvant therapy. Recently, we experienced four cases of pararenal leiomyosarcoma of the IVC, of which treatment consisted of a complete resection of the tumor, ringed polytetrafluoroethylene (PTFE) graft interposition, and bilateral renal vein reconstructions in all patients. Postoperative radiation therapy was instituted in 3 of 4 patients. One patient who did not receive the postoperative radiation therapy was treated with adjuvant chemotherapy. The kidneys were preserved in all patients and no deep vein thrombosis (DVT) or venous insufficiency of the lower extremity veins developed. Distant metastasis to the lung was noted in one patient at 18 months after surgery, who was not received the postoperative radiation therapy but chemotherapy. In conclusion, a complete resection of the tumor, IVC reconstruction, and bilateral renal vein reconstruction followed by adjuvant radiation therapy is recommended for the treatment of pararenal leiomyosarcoma of the IVC.

Popliteal Entrapment Syndrome

Popliteal artery entrapment syndrome, capable of causing intermittent claudication or even critical ischemia of the lower leg, is a rare disease that usually affects young men. This syndrome arises due to an abnormally medially displaced popliteal artery which has been entrapped and/or occluded by the medial head of the gastrocnemius muscle, especially in knee hyperextension posture. This report summarizes our experience with popliteal entrapment syndrome in 6 limbs of 5 patients treated during a 3-year period. Popliteal entrapment syndrome is more prevalent than previously appreciated. On the basis of our experience, early surgical intervention is recommended in all cases of entrapment at the time of diagnosis to avoid occlusion as a result of continued arterial wall degeneration.

Clinical Analysis of Aortoiliac Occlusive Disease

PURPOSE: Aortoiliac occlusve diseases are common disease of chronic artherosclerosis in patients in lower extremities. We compared the operative results of anatomic reconstruction with those of an extraanatomic bypass to evaluate the true benefit of one over other procedure. METHOD: 115 patients who underwent surgery from January 1995 to May 2001 were retorspectively reviewed. The patients were classified in two group: a direct anatomic reconstruction group and an extraanatomic bypass group. Operative risk were analyzed by the scoring system recommended by the Subcommittee on Reporting Standards for Lower Extremity Ischemia of International Society for Cardiovascular Surgery(ISCVS). Risk factor, graft patency were analyzed between two group. RESULT: Graft patiency was better in anatomic reconstruction but it was not statistically significant. The important risk factors in deciding the extraanatomic bypass were age and degree of the organ injury, especially heart disease. CONCLUSION: Preoperative evaluation of the risk factors was important in decision making but statistically not significant. Patency of the deep femoral artery was sufficient for runoff and extensive profundaplasty prevented the femorodistal bypass.

Clinical Study of Abdominal Aortic Aneurysm Repair

PURPOSE: Ruptured abdominal aortic aneurysm still carries high operative mortality, but the operative mortality of elective operation for abdominal aortic aneurysm has been reduced to less than 5 percent due to an adequate management of severe influential factors:treatment of preventable coronary and carotid artery disease, intraoperative prevention of hypotension and reperfusion injury, and postoperative intensive surveilance of cardiopulmonary function. METHOD: Seventy-six AAAs patients who were treated in our vascular division between January 1996 to December 2000 were prospectively investigated in regard to clinical manifestations, operative finding, and other factors affecting the outcomes. RESULT: The male-to-female ratio was 65:11 and the mean age was 63.1 years. The ruptured AAA to unruptured AAA ratio was 30:46, and suprarenal to infrarenal AAA was 5:71. The mean maximal diameter was 6.8 (4~15) cm. The AAA associated with iliac artery aneurysm was observed in 56 patients and with occlusive arterial disease was observed 15 patients. All patients for elective surgery had a preoperative thallium myocardial perfusion scan and color duplex carotid scan, Nine of them had a coronary occlusive lesion and six of these nine patients had preoperative coronary angioplasty (3) or coronary bypass procedure (3). One of them who had carotid artery stenosis received a carotid endarterectomy after the AAA resection. The treatment were aorto-iliac bifurcation graft (80.2%), straight graft interposition of aorta (11.8%), aorto-bifemoral bypass (5.3%), and stented graft (2.6%). Two stented graft case were excluded from mortality and morbidity calculation. The postoperative complications were pulmonary complication (9.4%), renal complication (4.0%), wound infection (2.7%), small bowel obstruction (2.7%). The operative mortality of elective AAA resection was 14.5%, and elective was 2.3% (1/44). Mortality of ruptured AAA was 33.3% (10/30) in which intraperitoneal rupture (free rupture) was 85.7% (6/7) operative mortality and retroperitoneal contained rupture was 17.4% (4/23). Age was not a independent risk factor. CONCLUSION: Mortality of elective AAA resection has been reduced with careful pre-operative assessment of the patient and proper management of the risk factors. Intrapritoneal free rupture still carries unacceptably high mortality. Thus elective operation before the rupture of AAA is emphasized again.

Lumbar Sympathectomy in Patients with Threatened Limb Ischemia

PURPOSE: Lumbar sympathectomy has been performed in critical lower limb ischemia patients who have no reconstructable arteries. However, much controversy still persists over the its physiologic & clinical effects. This study was performed to determine the value of lumbar sympathectomy as a treatment modality. METHOD: A consecutive series of 35 patients who underwent lumbar sympathectomy during October 1995 and February 1999 were included in this study, and clinical, angiographic and postoperative results were evaluated. RESULT: The limb salvage rate was obtained in 85.7% (30/35) of the cases. Morbidity was 8.6% (3/35) and there were no mortality. Prevention of major amputation was achieved in a significant percentage of patients who received lumbar sympathectomy. Sympathectomy was carried out in long segment and was confirmed by frozen biopsy intraoperatively. CONCLUSION: Lumbar sympathectomy is a valuable procedure for prevention of major amputation in critical limb ischemia patients who have no reconstructable arteries.

AVF Creation Using Synthetic Graft

PURPOSE: Graft interposition arteriovenous fistula (GAVF) graft has been used for the chronic renal failure patients when autogenous arteriovenous fistular procedure is not feasible. Reported, mean first year primary patency rate of GAVF was 40~60%, and the secondary patency being 50~70%. The purpose of this study is to evaluate the patency rate of our AVF using synthetic graft, and factors influencing on the patency rate. METHOD: To evaluate the patency rate of GAVF and the causes of GAVF occlusion, we analyzed 430 cases of GAVF from January 1998 to December 2000. 430 graft interposition was performed on 357 patients, accounting 36.9% of the total 1163 AVF procedure. RESULT: The primary patency rate were 69.8% at the first and 66.6% at the second year. The mean occlusion free interval was 15.8 months. The secondary patency rate was 82.0% at the first year, and 71.2% at the second year. The mean secondary patency interval was 18.5 months. Early occlusion within 1month of surgery has been due to a misjudgement in evaluation of adequate artery and vein (11/16, 68.8%). Majority of the occlusion occurred after 5 months of surgery (37.8%). In late occlusion cases, the common causes were somewhat different. They were intimal hyperplasia at venous anastomosis site and improper hemostasis or sudden changes of hemodynamics during dialysis. CONCLUSION: These data lead us to conclude that a skilled judgement of a surgeon is still the most important factor for successful AVF graft surgery in early outcome. Intimal hyperplasia at venous anastomosis site remains to be the main cause of long term failure.

Clinical Evaluation of Argatroban in the Treatment of Chronic Arterial Occlusion Disease

PURPOSE: The main object of treatment in chronic occlusive arterial disease is to increase blood flow and to prevent progress of ischemic ulcer. In case of the symptoms and signs such as rest pain, ischemic ulcer and gangrene with poor angiographic distal run-off, conservative medical treatment is recommended. Argatroban (Novastan(R) ) has an arginine structure, is the first selective antithrombin in the world, showing the inhibitory effect of thrombin-induced fibrin formation, platelet aggregation and vasoconstriction. METHOD: From September 1995 to January 1999, 39 patients with chronic arterial occlusion as subjects, ulcers, resting pain and feelings of coldness participated in Novastan treatment in 3 institutions (Department of Surgery, Yeungnam University College of Medicine, Department of Surgery Vascular Division, Ulsan University College of Medicine and Asan Medical Center, Department of Surgery, Gachon Medical School) and 30 patients completed the study:thromboangitis obliterance (TAO) in 19 and atherosclerosis obliterans (ASO) in 11 cases. Administration dose was 20 mg (2 amples, q.d or b.i.d) and medicated for consecutive 4 weeks. To detect the changes of symptoms, ulcer size and occurrence of side effects, inquiries, photography and laboratory tests were checked at prior to medication and 2, 3 and 4 weeks after medication. RESULT: There were 29 men and 1 women, ranging in age from 18 to 80 years old with mean of 50 years old and in body weight from 44 to 86 kg with mean of 64 kg. Improvement rate on ulcer size and granulation appearance was 73.3% (22 cases/30) and 86.7% (26 cases/30) respectively. General improvement rates were 76.7% (23 cases/30), general safety rates were 97.4% (38 cases/39), and utility rates were 70.0% (21 cases/30). Side effects were observed in 3 cases (7.7%), and abnormal changes in laboratory tests were observed for 15 items in 9 cases. But there noted no significant side effects and abnormalities in laboratory tests. CONCLUSION: Argatroban had a beneficial effect in improving such clinical symptoms as ischemic ulcer, resting pain and the feeling of coldness, accompanying chronic arterial occlusion, it causes no serious side effects and it shows high clinical utility.

Leiomyosarcoma of the Inferior Vena Cava-experience of 2 Cases

Leiomyosarcoma of the inferior vena cava (IVC) is a rare malignant tumor originating in the smooth muscle of the media. Though only two hundred and eighteen cases have been reported in International Registry until 1994, it is the most common malignancy of the IVC. Various treatment including adjuvant chemotherapy has been advocated but controversy exists due to lack of a large series and of a long-term follow-up of the published cases. Radical resection with negative margins remains the only hope for cure. Two cases of well documented IVC leiomyosarcoma surgically treated at Asan medical Center are reported.

Clinical Experiences of Stented Graft

PURPOSE: Endovascular repair is a alternative treatment with favorable short-term result, but long term results are not available compared to standard operation. The authors have reviewed experiences of Asan Medical Center on stented graft, performed from Aug. 1998 to Feb. 2000, and the results as to age, operative indication, clinical condition, anatomic location, complication, follow-up are reported. METHOD: Seven patients who has received stented graft between Aug. 1998 and Feb. 2000 are reviewed retrospectively. RESULT: Of the seven patients, 6 were male and 1 was female. The mean age was 46.4 years (17~71). Indication for stented graft were two pseudoaneurysms, two iatrogenic arterio-venous fistulas, one thoracic aorta aneurysm, one abdominal aortic aneurysm, and one iliac artery occlusion with blue toe syndrome. Three different types of stented graft devices were utilized: Dacron-covered nitinol stented graft (made by the Asan Medical Center medical device team), Vanguard II (by Boston Scientific Corp.), and PTFE with nitinol stented graft (by Tae-woong). There was no perioperative mortality, and the technical success was achieved in five cases (71%). The patency at 14-month were 100% (5/5). Two immediate complications are hemorrhage due to iliac & femoral artery avulsion requiring emergency bypass grafting, and deployment failure of stented graft requiring removal of retained graft device. CONCLLUSION: Stented graft may be utilized even in complicated vascular situation but will need further development of device and more experience to prevent possible catastrophic complication. Indication should be decided by team approach and vascular surgeon should be prevent or participate during the procedure.

Factors Affecting Mortality Rate of Ruptured Abdominal Aortic Aneurysm

PURPOSE: Ruptured abdominal aortic aneurysm (RAAA) still carries high operative mortality, despite improvements in anesthesia, intensive perioperative monitoring, surgical methods. The authors reported on the factors affecting mortality rate of the RAAA providing clues for successful operations. METHODS: Charts of the patients, who received operations for RAAAs at Asan Medical Center from July 1990 to July 1998 were reviewed to find out whether there is a difference between survival group and fatal group. RESULTS: Multivariate statistical analysis of factors between survival group (12 patients) and fatal group (7 patients) showed that preoperative loss of consciousness, cardiopulmonary resuscitation, and intraperitoneal free rupture were the factors affecting poor prognosis. Improvement in survival was also noted in patients who were treated in latter period (since January 1997) when autotransfusion using the cell saver and circulatory monitoring with Swan-Ganz cathter were introduced. Other risk factors were similar between the earlier group (8 patients) and latter group (11 patients). CONCLUSION: Rapid and accurate diagnosis of RAAA and timely transfer to the operating room for laparotomy is cleary paramount, and this can decrease the mortality of RAAA.

Factors Affecting Mortality Rate of Ruptured Abdominal Aortic Aneurysm

PURPOSE: Ruptured abdominal aortic aneurysm (RAAA) still carries high operative mortality, despite improvements in anesthesia, intensive perioperative monitoring, surgical methods. The authors reported on the factors affecting mortality rate of the RAAA providing clues for successful operations. METHODS: Charts of the patients, who received operations for RAAAs at Asan Medical Center from July 1990 to July 1998 were reviewed to find out whether there is a difference between survival group and fatal group. RESULTS: Multivariate statistical analysis of factors between survival group (12 patients) and fatal group (7 patients) showed that preoperative loss of consciousness, cardiopulmonary resuscitation, and intraperitoneal free rupture were the factors affecting poor prognosis. Improvement in survival was also noted in patients who were treated in latter period (since January 1997) when autotransfusion using the cell saver and circulatory monitoring with Swan-Ganz cathter were introduced. Other risk factors were similar between the earlier group (8 patients) and latter group (11 patients). CONCLUSION: Rapid and accurate diagnosis of RAAA and timely transfer to the operating room for laparotomy is cleary paramount, and this can decrease the mortality of RAAA.

Percutaneous Placement of Bird's Nest Inferior Vena Cava Filter

PURPOSE: To describe clinical experiences of the use of Bird's Nest inferior vena cava(IVC) filter. MATERIALS AND METHODS: Between August 1991 and August 1997, IVC filter was percutaneously inserted in 51 patientswith pulmonary embolism(PE) and deep vein thrombosis of the lower extremities. Indications for the placement ofthis filter were contraindication to anticoagulation in 17 patients, prophylaxis of PE in 17, failedanticoagulation in 11, massive PE with residual floating thrombus in three and complications involvinganticoagulation in 3. In order to delineate the location of renal vein and extension of deep vein thrombosis intothe IVC, all patients under went inferior vena cavography before filter placement. Thirty filters were insertedthrough the right femoral vein, 19 through the right internal jugular vein and three through the left femoralvein. The patients involved were followed up for periods ranging from one week to six years (mean, 10 months). RESULTS: A Bird's Nest IVC filter was placed in the infrarenal IVC in 44 patients and in the suprarenal IVC in7. Certain complicatioins ensued. IVC penetration occurred in three patients(5.9%), and in seven(1.37%) the filterwire prolapsed. Except for transient pain, however, there were no serious IVC penetration-related complicationsand no evidence of recurrence of PE in the cases involving prolapse of the filter wire. During follow up,clinically suspected recurrent PE was noted in two patients(3.9%), but there was no evidence of newly developedocclusion of the IVC. CONCLUSION: In patients who under went follow up, Bird's Nest IVC filter effectivelyprevented the development and recurrence of PE, and there were no complications. To prevent of penetration of theIVC and prolapse of the filter, however, technical skill was needed.