In order to elucidate risk factors in arteriosclerosis obliterans (ASO), histories and physical and laboratory findings were reviewed in 163 patients with ASO, and the results were compared with ischemic heart disease (IHD) patients. Patients with ASO were much older and smoked more than patients with IHD. Such complications as hypertension, cerebrovascular disease were significantly more frequent in ASO patients than in IHD patients. On the other hand, the levels of serum total cholesterol, triglycerides, Apo A-II and Apo B were significantly lower in ASO patients than in IHD patients, although lipoprotein(a) tended to be higher in ASO. In ASO, remnant-like particles cholesterol tended to be higher when other presumable atherosclerotic risk factors were absent. The present results indicate that male gender, aging, smoking habit, hypertension and cerebrovascular disease are major risk factors in ASO patients. Although abnormal lipid metabolism may contribute to the development of ASO, we postulate that it plays a less significant role in IHD.

We determined cross sectional area of stent and lumen of iliac arterial lesions before and after deployment of Palmaz stents using intravascular ultrasound (IVUS). Stent deployment was performed in 43 patients with 47 lesions. Cross sectional images were recorded using IVUS in the proximal (P), center (C), and distal portion (D) of the stent in the iliac lesions before, immediately after, and 6 months after the deployment of stent. The initial success rate was 100%. Ultrasound images were analyzed for lumen, intra-stent and intimal proliferation area.The lumen area dilated significantly from 9.9±7.1mm² to 32.7±9.4 after the stent deployment. The intra-stent cross sectional area right after the treatment did not show any difference among the 3 portions. The mean stent area after 6 months was 32.8±8.4mm², without significant stent recoil. The lumen (=intra-stent) area after stent deployment were P: 338±9.7mm², C: 30.9±9.0, and D: 32.7±8.6. The lumen of the center portion had a tendency to be smaller than that of the proximal or distal portions. After 6 months, the intra-stent area was P: 33.5±9.2mm², C: 31.5±7.7, and D: 33.3±8.3 and the lumen area was P: 31.3±10.4mm², C: 28.2±8.9, and D: 29.4±10.5. Stent recoil was not observed but minimal dilatation was noted in the center and distal portions. The lumen area after 6 months became smaller than that immediately after the treatments due to intimal proliferation and stent deformation. The lumen area in the center portion had a tendency to be smaller than that of the proximal portion. The rates of change in the lumen area were P: -6.7±5.6%, C: -98±6.4% and D: -12.4±9.9. This showed a tendency for the lumen of the distal portion to be smaller than that of the proximal portion due to intimal proliferation. The intimal proliferation rates showed a tendency to be higher toward distal sites, but the narrowest portion in the stent was its center. The long-term patency diagnosed by angiography was 92.3% in 6 months and 89.5% in 12 and 24 months. IVUS is useful for evaluation of iliac stent deployment. The Palmaz stent was a very effective treatment for the iliac arterial lesions, protecting against vascular recoil.

Background: The glissonean pedicle approach was introduced by Couinaud and Takasaki in the early 1980s. The key of the glissonean pedicle approach is clamping the pedicle first, secondly confirming the territory, and finally dissecting the liver parenchyma. In this presentation, we introduced our recent refinements of glissonean pedicle approach for liver resection. “Approach to the glissonean pedicles at the hepatic hilus” Couinaud described three approaches to the hepatic hilus. 1) Intra-fascial access (Control method): The conventional dissection at the hilus or within the sheath is referred to as intrafascial access However, dissection performed under the hilar plate is dangerous and surgeons have to consider any variations of the hepatic artery and bile ducts. 2) Extra-fascial access (Glissonean pedicle approach): The glissonean pedicle is dissected from the liver parenchyma at the hepatic hilus before dissecting the liver parenchyma. This procedure prevents intrahepatic metastasis of HCC, which spreads along the portal vein and improves the overall survival after surgery. 3) Extra-fascial and transfissural access: If the main portal fissure or the left suprahepatic fissure is opened after dissecting the liver parenchyma, the surgeon can confirm the pedicles that arise from the hilar plate or the umbilical plate. “Operative techniques” 1) Preoperative 3D simulation of the precise anatomy of portal vein, hepatic artery and bile duct at hepatic hilus should be performed. 2) Right glissonean pedicle: The hilar plate is detached from the quadrate lobe. The assistant pulls the liver parenchyma cranially and the operator conversely pulls the hepatoduodenal ligament caudally. Mayo scissors are inserted along the liver parenchyma between the liver parenchyma and glissonean capsule (Fig.1). Then forceps are inserted in the same way and the right main pedicle is taped (Fig.2). The right anterior and posterior glissonean pedicles are taped as well. 3) Left glissonean pedicle: The hilar plate is detached from the liver parenchyma. Then, the Arantius duct is confirmed and the left pedicle is dissected along the left pedicle at the ventral side of the Arantius duct. “Pitfall of glissonean pedicle approach” The right pedicle should be dissected in the liver side as much as possible to prevent the injury of left hepatic duct. If possible, the right pedicle is recommended to be dissected at the level of the second branches separately (Fig.3). The right posterior hepatic duct sometimes branches from the left hepatic duct and the Arantius duct is confirmed and the left pedicle should be dissected along the left pedicle at the ventral side of the Arantius duct because the right posterior hepatic duct branches from the left hepatic duct at the dorsal side of Arantius’ duct. In addition, the intraoperative cholangiogram should be used in the case with the abnormal anatomy of bile duct. Conclusions: Any anatomical hepatectomy can be performed using “glissonean pedicle approach” which allows simple, safe and easy liver resection.