The Results of Simultaneous Bilateral Internal Iliac Artery and Inferior Mesecteric Artery Ligation during Open Abdominal Aortic Aneurysm Surgery

PURPOSE: Bilateral internal iliac artery (IIA) ligation with inferior mesenteric artery (IMA) ligation has been performed during open abdominal aortic aneurysm surgery and endovascular aneurismal repair (EVAR). We reviewed both the acute and long term effects of bilateral IIA ligation with IMA ligation. METHODS: A retrospective cross sectional review was performed on 315 patients who underwent open aneurysmal repair and EVAR between 1997 and 2008. Both IIAs of all the patients' were patent before aortic reconstruction. The patency of the IIAs and the presence of bowel ischemia was evaluated by the medical records on the operative findings, the sigmoidoscopy and the computed tomography. Telephone interviews were performed to assess buttock claudication. RESULTS: The mean age was 68.4 years and 259 patients were male. Unruptured aneurysm was found in 233 patients, ruptured aneurysm was found in 72 patients and impending rupture was found in 10 patients. Unilateral ligation of the IIA was required in 78 patients (24.8%), and bilateral ligation was performed in 43 patients (13.7%). Sigmoid colon ischemia occurred in 8 patients (2.5%), and the IIA was patent in 7 patients. Buttock claudication occurred in 10 out of 178 patients who were contactable on telephone, and the IIA was patent in 8 of these 10 patients. Bowel ischemia and buttock claudication were not significantly associated with the patency of the IIA (P>0.05). CONCLUSION: Bilateral IIA ligation with IMA ligation was able to be performed without significantly increasing the incidence of bowel ischemia and buttock claudication. Performing endovascular aneurysmal repair may be considered when bilateral graft extension to the external iliac artery is required.

TEE-guided Excision of Intravenous Leiomyomatosis with Right Atrium Extension through an Abdominal Approach: A Case Report

Intravenous leiomyomatosis (IVL) is a rare, benign tumor that originates from the uterus. IVL is usually confined to the pelvic venous system, but it travels into the inferior vena cava (IVC) in 10% of cases and even into the heart in 3% of cases. We present a case of successful resection of recurrent IVL with right atrium extension. We used only an abdominal incision and transesophageal echocardiography (TEE) guidance. A 40-year-old female patient visited our hospital with recurrent IVL. She had a history of total abdominal hysterectomy and right salpingo-oophorectomy due to IVL performed one year prior. On computed tomography (CT) and ultrasonography, IVL was found to involve both ovarian veins, the left renal vein, and the IVC extending to the right atrial junction. Using intraoperative TEE monitoring, we could see that IVL was not attached to the vascular wall. After creating a midline abdominal incision, we removed the tumor through the enlarged ovarian vein and ovary. The patient had an uneventful recovery and was discharged home on the ninth postoperative day.

Surgical Treatment for Cerebrovascular Disease in Takayasu's Arteritis

PURPOSE: Takayasu's arteritis is a chronic disease characterized by nonspecific inflammation of the aorta and its branches, and cerebral ischemia has been considered to be the most life-threatening complication of this disorder. METHOD: We performed a retrospective review of 13 patients who underwent 16 procedures between 1996 and 2006 secondary to cerebrovascular symptoms in Takayasu's arteritis (median follow-up=52.5 months). RESULT: Study subjects included 10 females and 3 males, with a median age of 36.5 years. Procedures included 7 bypasses (2 aorto-bicarotid artery, 1 axillo-axillary artery, 2 subclavian-common carotid artery, 1 common carotid-internal carotid artery, and 1 axillo-vertebral artery), 4 carotid endarterectomies (CEA), and 5 stents (4 common carotid artery [1 for the treatment of re-stenosis of CEA] and 1 vertebral artery). All patients were relieved of their cerebral ischemic symptoms and remained stroke-free during the follow-up period. Re-stenosis was seen in two cases of stenting. Occlusion or stenosis of arterial reconstruction occurred more frequently in patients who had elevated erythrocyte sedimentation rates (ESR) preoperatively (P<0.05). CONCLUSION: Surgical treatment was effective in stroke prevention and elimination of cerebrovascular symptoms. The patency of the reconstruction was related to the progression of the disease as indicated by elevated ESR and [18F]fluorodeoxyglucose positron emission tomography, which are useful tools for evaluating disease activity.

Abdominal Aortic Aneurysm in Behcet's Disease: Clinical Experience with 12 Patients

PURPOSE: An aneurysm identified in a patient with Behcet's disease should be repaired because of the high risk of rupture. However, recurrent aneurysms are commonly seen following the treatment of an aneurysm in Behcet's disease. In addition, the success rate for surgical management has not been high. We report our experiences with abdominal aortic aneurysms (AAA) in patients with Behcet's disease. METHOD: Between September 1998 and June 2006, we performed 21 procedures for an AAA in 12 patients with Behcet's disease. The diagnosis of Behcet's disease was based on the criteria of the International Study Group for Behcet's Disease (1990). Retrospective analysis of the outcomes was carried out. RESULT: There were nine men and three women and the mean age was 34. Six patients had an infrarenal aneurysm, five had a suprarenal aneurysm and one had double lesions both infrarenal and suprarenal. A contained rupture was the most common clinical manifestation (75%). Recurrent aneurysms were noted in six (50%) patients during the median follow-up of 46 months. For the treatment of the original lesions, resection of the AAA and graft interposition was performed in six patients, patch closure in six and a stent-graft insertion in one. Recurrent aneurysms were treated by a stent-graft insertion in four patients, patch closure in two and graft interposition in one. The overall recurrence rate for each procedure was 38.1%. The recurrence rate was 14.3% for the resection and interposition graft, 62.5% for patch closure and 40% for the stent-graft insertion. CONCLUSION: Resection of an AAA with an interposition graft showed the lowest recurrence rate in this study. Endovascular techniques for the treatment of these patients require further evaluation with prospective randomized trial and long-term follow up.

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.

Deep Venous Thrombosis of the Lower Extremity Associated with Protein C and/or S Deficiencies

PURPOSE: Protein C and S deficiencies are frequently described as causes of the hypercoagulable states. The aim of this study was to evaluate the clinical features and prognosis of deep venous thrombosis associated with protein C and/or S deficiencies and to determine an adequate treatment modality for such cases. METHOD: A total of consecutive 42 patients with deep venous thrombosis of the lower extremity were seen in our hospital between September 2000 and August 2002. Hypercoagulability studies were done before systemic anticoagulation therapy, and the diagnosis of protein C and/or S deficiencies was confirmed if antigenic protein C and/or S levels were less than 60%. RESULT: Seven patients (16.7%) were diagnosed with deep venous thrombosis associated with protein C and/or S deficiencies. Of these, 5 patients with acute iliofemoral deep venous thrombosis were treated with catheter-directed thrombolysis therapy, and 2 with systemic anticoagulation therapy. There were no major complications or clinically detectable pulmonary emboli. CONCLUSION: Protein C and/or S deficiencies are one of the common causes of deep venous thrombosis. Considering that patients with deep venous thrombosis and protein C and/or S deficiencies should be treated with life-long anticoagulation for the prevention of recurrence, patients presenting with deep venous thrombosis without evidence of other risk factors should be evaluated for hypercoagulable states.