Stepwise angioplasty and catheter directed thrombolysis for budd-Chiari syndrome complicated with floating thrombus in inferior vena cava.

Recently, we experienced a rare case of Budd-Chiari Syndrome. The case was a 57-year-old female patient. Venous return had been severely disturbed by the membranous occlusion of the IVC and a giant floating thrombus. After catheter directed thrombolysis combined with stepwise percutaneous angioplasty, the IVC was recanalized sufficiently and the thrombus was completely resolved.

Initial experience with proximal ligation for profunda femoris artery aneurysms: report of three cases.

Profunda femoris artery aneurysms (PFAAs) are rare and difficult to diagnose in the early stage. They are often found due to the presence of complicated conditions, such as rapid expansion, rupture, or acute lower limb ischemia. Surgical procedures such as aneurysmectomy and endoaneurysmorrhaphy tend to be technically challenging because of the patient status and the extent of the aneurysm. We experienced three cases of PFAAs that were treated by proximal ligation (PL) without complete control of the distal branches. The exclusion of PFAAs was confirmed by duplex ultrasound or angiography at the end of the operation. There was no mortality in the perioperative period. During a 12-month follow-up, all cases exhibited complete exclusion of aneurysms with marked size reduction. Based on these findings, we propose that PL, with a careful follow-up for PFAA exclusion and distal limb circulation, could be an alternative treatment for complicated PFAAs.

Thromboembolic complications after endovascular repair of abdominal aortic aneurysm with neck thrombus.

OBJECTIVE: To evaluate outcomes after endovascular aneurysm repair (EVAR) for abdominal aortic aneurysm (AAA) with neck thrombus. METHODS: We retrospectively reviewed patients who underwent EVAR for AAA at our institution from 2007 to 2011. Patients with ruptured AAA, chronic renal failure, or hostile neck characteristics other than thrombus were excluded. Patients were divided into 2 groups: group T (with neck thrombus) and group N (without neck thrombus). We compared complications and mid-term outcomes. RESULTS: There were no differences in success rates between the groups, but there were higher rates of thromboembolic complications such as distal embolization (20% vs 0%, P = .02) and renal dysfunction (36.8% vs 11.1%, P = .03) in group T than in group N. Suprarenal thrombus and suprarenal fixation in the presence of suprarenal thrombus were associated with postoperative renal dysfunction (P = .01). CONCLUSION: The EVAR for AAA with neck thrombus is associated with thromboembolic complications.

[Successful endovascular repair with chimney graft technique and carotid artery bypass for ruptured aortic arch aneurysm].

An 83-year-old man with a decreasing level of consciousness was carried to the emergency room. Computed tomography (CT) revealed a ruptured aortic arch aneurysm. He was deemed a high risk candidate for conventional surgical repair. The case was treated by a hybrid approach. Endo-exclusion of thoracic aortic aneurysm (TAA) was obtained by implanting stentgrafts from the ascending to descending aorta. The brain circulation was maintained by right to left carotid and to left subcravian artery bypasses combined with" chimney endo-debranching graft" of the innominate artery. This could be a method of choice for the acute patients under similar circumstances.

Preservation of aortic arch branches using chimney and sandwich stent grafts.

PURPOSE: To share our hybrid endovascular experiences using chimney or sandwich stent grafts for acute aortic arch pathologies. METHODS: Hybrid procedures for a distal aortic arch aneurysm and an ascending anastomotic aortic aneurysm rupture were reported. Right to left common carotid and left axillar artery bypasses were located. Covered stents were inserted into the inominate artery, with the flow-proximal end located in the ascending (standard chimney) or the descending aortic stent graft (retrograde sandwich). RESULTS: Both cases had no signs of brain ischemia. Aneurysms are decreasing in size. CONCLUSION: Chimney and sandwich techniques were technically feasible in the complex and acute situations.

Usage of external shunt in hybrid approach for aortic arch aneurysm to restore cerebral oxygenation.

A hybrid approach, combining open and endovascular procedures, may be a less invasive substitute to correct aortic arch pathologies in high-risk patients. We describe an 82-year-old male patient with an atherosclerotic aortic arch aneurysm, which was treated with proximal transposition of all arch branches and endovascular aortic arch repair. During the left common carotid artery reconstruction, oxygen saturation level of the left cerebral hemisphere decreased lower than the safety limit. To re-establish brain perfusion, we installed an external shunt from the right common femoral artery to the left common carotid artery. The oxygen saturation was restored to an acceptably safe level, and the patient tolerated the procedure without any signs of postoperative ischemic stroke.

Ultrasonographic character of carotid plaque and postprocedural brain embolisms in carotid artery stenting and carotid endarterectomy.

OBJECTIVE: To investigate ultrasonographic character of carotid plaques, and incidences of brain embolism in carotid angioplasty and stenting (CAS) and carotid endarterectomy (CEA). MATERIALS AND METHODS: CEA (22/25 symptomatic lesions) and CAS (17/20 symptomatic lesions) between 2007 and 2010. Embolic protection devices (15 occlusion and 5 filtering devices) were used during CAS. Carotid plaques were classified into three categories (I: calcificated, II: intermediately echogenic, III: echolucent). Magnetic resonance imaging (MRI) was used to investigate brain emboli. RESULTS: Ultrasonographic character of the plaques in CEA cases (I: 4%, II: 88%, III: 8%) was different from the one in CAS cases (I: 10%, II: 90%, III: 0%). The incidence of brain embolism in the CAS cases was 52.6% while 0% in the CEA cases (p = 0.00037). CAS had high incidences of brain embolism in any plaques (I: 100%, II: 43.8%). In the most recent 9 procedures of CAS using occlusion devices, averaged number of embolic lesion was 1.0 (0 post operative day; 0 POD). The number increased as 1.4 (1 POD) and 2.0 (7 POD). CONCLUSION: CEA should be currently the first choice for most patients with a high-grade and symptomatic carotid artery stenosis.

[Hybrid endovascular repair with reconstruction of superior mesenteric and celiac arteries for thoracoabdominal and abdominal aortic aneurysms].

A 79-year-old woman presented with sustained thoracolumbar back pain. Contrasted computed tomography (CT) showed a thoracoabdominal aortic aneurysm (TAAA: type I of Crawford classification) and an abdominal aortic aneurysm (AAA) that were not ruptured. Considering her age, the placement of an endovascular stent graft was performed for TAAA at the possible sacrifice of the celiac (CA) and superior mesenteric arteries (SMA). In order to prevent ischemic events, it was necessary that blood supply to the CA and SMA was maintained by placing a graft to each artery from the Y-shaped graft for replacement of AAA. Actually, only CA was sacrificed and coil embolization of CA was needed because of type 2 endoleak. The patient was discharged 17 days after surgery. A hybrid technique, endovascular repair with reconstruction of abdominal branches for TAAA and AAA, can be an alternative procedure for such high-risk operation with multiple aortic aneurysms including TAAA.

[Simultaneous endovascular aortic aneurysm repair and coronary artery bypass grafting in a patient with abdominal aortic aneurysm and left main trunk lesion].

To patients with severe coronary artery disease (CAD) and expanding large abdominal aortic aneurysm (AAA), simultaneous coronary artery bypass grafting (CABG) and AAA repair has been recommended. A 68-year-old woman had a CAD and an AAA 71 mm in diameter which was enlarging. Coronary angiography showed severe stenoses in the left main trunk (LMT), the left anterior descending artery and the circumflex artery. On-pump beating CABG and AAA repair with endovascular aneurysm repair (EVAR) were performed simultaneously, because intraaortic balloon pumping (IABP) might be needed due to severe stenoses of LMT. Just after EAVR, on-pump beating CABG was performed. The patient was discharged 15 days after the operation. It was suggested that a simultaneous operation of CABG and EVAR might be safe and effective for high risk patients with CAD and AAA.

[Endovascular repair of primary aortoenteric fistula].

Aortoenteric fistulas are a rare, but often fatal cause of gastrointestinal bleeding. This report describes the use of endovascular aneurysmal repair (EVAR) for the initial treatment of gastrointestinal bleeding possibly related to an aortoenteric fistula. A 69-year-old man with an abdominal aortic aneurysm was admitted to our hospital because of melena. He initially underwent EVAR. Upper and lower endoscopic examination failed to detect a bleeding site. Twenty-five days later, a fever of 38 degrees C developed, and endograft infection was diagnosed. The patient underwent an extra-anatomic bypass and total endograft explantation. He remains well 9 months after EVAR

[Dissecting aneurysms at the bases of the brachiocephalic artery and the left common carotid artery due to localized dissection of the aortic arch; report of a case].

A 43-year-old male lost consciousness immediately after archery practice, and was brought to our hospital by ambulance. Angiography showed dissecting aneurysms at the bases of the brachiocephalic artery and the left common carotid artery, causing compression of these arteries. Under cardiopulmonary bypass with selective cerebral perfusion, the blood supply to these arteries was restored with a bifurcated graft. Surgical specimen showed localized dissection of the aortic arch at the bifurcation to the brachiocephalic artery and the left common carotid artery, with the formation of dissecting aneurysms at the bases of both arteries. The aneurysms were filled with thrombi. In addition to these dissecting aneurysms, there were arterial dissections involving the brachiocephalic artery and the bilateral common carotid arteries. Histopathological examination of the vessel wall showed no evidence of atherosclerosis or vasculitis, and no abnormalities in the arrangement of elastic fibers.