Brachial vein transposition fistulas for hemodialysis are embloyed when the superficial veins in arms are not used. In our hospital, 28 patients have received brachial vein transposition fistula in the past 13 years. Post-operative complications were bleeding at the puncture sites in 2 patients, infection at the puncture site in 1, and aneurysm formation in the transposed vein in 1. Access related hand ischemia and venous hypertension were not recognized. For 3 patients of fistula stenosis, percutaneous catheter dilatation was performed. For 2 of 19 patients with fistula occlusion, surgical thrombectomy was performed. The primary patency rates were 76.8% at 1 year and 55.8% at 4 years. The secondary patency rates were 95.5% at 1 year and 66.3% at 4 years. The brachial vein transposition procedure is useful for long-term continuation of hemodialysis using autologous arm vessels.

During past 15 years 78 patients were operated for thoracic aortic aneurysm. Patients operated in emergency or dead within 24 hours after operation or with preoperative renal failure were excluded and remaining 65 patients were studied for factors affecting postoperative renal dysfunction. Postoperative renal dysfunction was based on the serum creatinine value which was within normal limit before operation and exceeded 1.5mg/dl after operation, or which increased by 1mg/dl and more from preoperative value. 23 patiens developed postoperative renal dysfunction and the incidence was 35.4%. As preoperative factors, old age, male and high value of preoperative serum creatinine were significantly (p<0.01) related with postoperative renal dysfunction. As intraoperative factor, decreased urine output per operative hour was significantly (0.01<p<0.05) related. Other preoperative factors; hypertension, diabetes, location of aneurysm, dissecting and nondissecting, intraoperative factors; operation time, volume of operative bleeding, minimum systolic blood pressure during operation, clamping time of aorta, minimum temperature of rectum, difference of adjuncts (temporary shunt or extracorporeal circulation), postoperative factors; systolic blood pressure at arriving ICU, urine output of first postoperative day were not significantly related. Between the operative procedures of graft replacement and extraanatomic bypass, no significant difference was recognized in occurrence of postoperative renal dysfunction, but patients with patch angioplasty etc. developed no renal dysfunction. In the complications within one week after operation, central nervous system dysfunction, infection and hemorrhage had a tendency to occur together with renal dysfunction. For prevention of postoperative renal dysfunction it is important to minimize the renal ischemia, to protect the kidney and to maintain urine output during operation, particularly in patients of preoperative decreased function of kidney and of old male with advanced arteriosclerosis. Also it is necessary to choose the less invasive procedure of operation for patients of severely decreased function of kidney and to consider about organ system relations in patients of postoperative renal dysfunction.

Transluminal angioplasty during vascular reconstructive procedures was performed to 18 lesions in 13 patients. Ages ranged from 57 to 81 years with a mean of 72.7 years, and all patients were men. Transluminal angioplasty during the thromboendarterectomy or bypass grafting was performed to 3 patients for inflow dilatation, 3 patients for outflow dilatation and 1 patient for renal artery dilatation. Transluminal angioplasty with thrombectomy for the anastomotic stenoses of EPTFE grafts was performed 11 times for 7 patients. The results of this method for arteriosclerotic lesions were as follows; patency was 100% at 1 year and 80% at 3 year. Four patients died during the follow-up periods and the dilated lesions were all patent at the time of death. The results of this method for anastomotic stenoses were as follows; patency was 34.6% at 6 month and 0% at 10 months. Graft infection occurred in 1 of 4 patients to whom transluminal angioplasty was performed 2 times. The patency of transluminal angioplasty during vascular reconstructive procedures for arteriosclerotic lesions was good. Transluminal angioplasty for anastomotic stenoses was noninvasive and easily performed with the thrombectomy, but the patency was not so good and there was the risk of graft infection by repeated operations.

Thromboexclusion method for thoracic aortic aneurysm was studied in 10 patients who had dissecting aneurysm in 7 and atherosclerotic aneurysm in 3. The aortic aneurysms extended from the left subclavian artery to the diaphragma or more widely. The operations were extraanatomic bypass and permanent aortic clamp proximal to the aneurysm in 9, and proximal and distal to the aneuysm in one. The follow up periods were 14 days to 80 months. Eight patients survived more than 3 months and 5 of them had thromboexclusion of aneurysm to the diaphragma. One with the aneurysms of incomplete thromboexclusion resulted in aneurysmal rupture 28 months after operation, and recovered by additional clamp distal to the aneurysm. Another had aneurysmal rupture, and died 63 months after operation. A patient had the penetration of the clamp to the pulmonary artery, and died 12 months after operation. Temporary paraplegia occurred in a patient 15 months after operation. Two patients developed constipation without ileus. Any difference of blood pressure between upper and lower extremities was not recognized, and no patient had deterioration of renal function. Indication of this method should be strictly selected, and careful follow up study is mandatory.

Ischemic heart disease (IHD) poses a major complicating factor for abdominal aortic aneurysm (AAA) repair. To identify patients with IHD, we evaluated patients scheduled to undergo AAA repair with dipyridamole-thallium scintigraphy (DTS) and coronary angiography (CAG). If indicated, coronary revascularization was performed. Finally, an assessment of the effectiveness of these preventive measures was made. One hundred and ten patients scheduled to undergo AAA repair were identified and treated accordingly over a 20-year period. As the pre-operative evaluation and prophylactic surgical revascularization strategies were instituted in 1983, the patients were divided into 2 groups: 25 patients between 1973-1982 (group A) and 85 patients between 1983-1992 (group B). The mean age of patients in group A was 65.3 years. The male/female ratio within this group was 21:4. One patient in the group had a history of IHD and 9 had hypertention. The mean age of patients in group B was 67.7 years. The male/female ratio within this group was 77:8. Fourteen patients in this group had a history of IHD and 27 had hypertension. Screening and treatment of IHD in group B was as follows. All patients with a history of IHD underwent CAG. Of the 32 patients with cardiac risk factors, including hypertension and hyperlipidemia, or ECG abnormalities who underwent DTS, 8 were referred for CAG. Thirty-nine patients with no risk factors and a normal ECG proceeded to AAA repair without further workup. Perioperative myocardial infarction occurred in 2 patients in grouzp A, leading to death in 1 patient. Coronary revascularization was performed in 5 patients in group B. No perioperative myocardial infarction occurred in this group. Pre-operative identification of high-risk cases with DTS, CAG, and coronary revascularization in patients with IHD may prevent cardiovascular complications in patients undergoing AAA repair.