Although balloon angioplasty was initially limited to simple, focal lesions in peripheral arteries, the application of balloons in conjunction with stents, stent-grafts, laser-light, and advanced pharmacotherapies has allowed for widespread implementation of endovascular treatment, regardless of disease distribution or degree of ischemia. Further refinement of guidewires, sheaths, and adjunctive medications has allowed for traversal of even the longest lesions and has promoted technical success. In Korea, increasing numbers of endovascular therapies are being applied to iliac and femoral occlusive lesions by radiologists, vascular surgeons, and cardiologists. Although surgery remains the principal treatment for patients with lower limb ischemia, physicians must assess the benefits and risks associated with various treatment options, including endovascular therapy.
Angioplasty, Balloon ; Arteries ; Femoral Artery ; Humans ; Ischemia ; Korea ; Lower Extremity ; Risk Assessment ; Stents

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.
Adult ; Echocardiography, Transesophageal ; Female ; Heart ; Heart Atria ; Humans ; Hysterectomy ; Leiomyomatosis ; Ovary ; Renal Veins ; Uterus ; Veins ; Vena Cava, Inferior

An inferior vena cava (IVC) filter is a useful treatment to prevent a pulmonary embolism (PE) in patients with DVT. Since the introduction of IVC filters more than 30 years ago, there has been a steady improvement in the design, ease and safety of the delivery system. The use of a temporary filter has also increased as performing thrombolysis and thrombectomy has increased. Today all of the commonly used filters can be placed via a peripheral vein by using the standard percutaneous Seldinger (Ed note: check the spelling) technique. However this typically requires fluoroscopy, intravenous contrast agents, radiation exposure and transport of the patient to the interventional or operating suite. As the multiple trauma injured or critically-ill intensive care unit patients often require inotropic and ventilator support, transporting these patients to these facilities can be hazardous. The following report describes two cases of VTE patients who underwent percutaneous placement of an IVC filter with using duplex ultrasound guidance. Identification of the renal vein and artery is important to decide the infrarenal level. The first case was an 84 years female with right ilio-femoral DVT and pulmonary embolism. To prevent recurrence of PE, we decided to insert an IVC filter. The second case was a 47 years female with right femoral DVT together with left pulmonary embolism and infarction. She also had thrombocytopenia, which is a contraindication for anticoagulation. IVC filter insertion can be safely performed under ultrasound guidance. This technique will reduce the risk and complexity of inserting an IVC filter in selected multiple injured trauma patients.
Arteries ; Contrast Media ; Female ; Fluoroscopy ; Humans ; Infarction ; Intensive Care Units ; Multiple Trauma ; Pulmonary Embolism ; Recurrence ; Renal Veins ; Thrombectomy ; Thrombocytopenia ; Veins ; Vena Cava Filters ; Vena Cava, Inferior ; Ventilators, Mechanical

Citrobacter freundii is frequently isolated in antimicrobial-resistant nosocomial infections. Many strains of Citrobacter freundii are capable of producing an inducible broad-spectrum beta-lactamase. We report a case of an abdominal aortic aneurysm infected with Citrobacter freundii. A 55-year-old woman presented with acute lower back pain. Contrast enhanced computed tomography revealed a saccular aneurysm of the infrarenal abdominal aorta, with impending rupture. She underwent emergency surgery, during which a segment of aneurysmal aorta and infected tissue were completely removed and an in situ graft was placed for vascular reconstruction. The anastomotic site and inserted graft were wrapped with greater omentum. Citrobacter freundii was isolated by tissue culture from the resected aneurysmal wall.
Aneurysm ; Aorta ; Aorta, Abdominal ; Aortic Aneurysm, Abdominal ; beta-Lactamases ; Citrobacter ; Citrobacter freundii ; Cross Infection ; Emergencies ; Female ; Humans ; Low Back Pain ; Middle Aged ; Omentum ; Rupture ; Transplants

Takayasu arteritis (TA) is a chronic systemic inflammatory disease that most commonly affects the aorta and its major branches. TA-induced renal artery stenosis (TARAS) can result in malignant hypertension, severe renal dysfunction, cardiac decompression and premature death. Surgical management for TARAS has been proved to be effective and safe, especially in the medically or interventionally-intractable cases. We report here on a 39-year-old patient with recently deteriorating hypertension and renal function because of a recurred RAS, for which he underwent "y-shaped" aorto-birenal reconstruction surgery 20 years ago. CT angiography showed bilateral diffuse calcified stenosis in the previous renal graft and there was a partial rupture of a pseudoaneurysm in the suprarenal abdominal aorta segment between the celiac axis and the renal graft. We performed descending thoracic aorto-abdominal aortic bypass together with a graft-renal bypass and exclusion of the pseudoaneurysm. The renal function was normalized and the blood pressure became stable without any antihypertensive medication. He recovered and was discharged without any complications.
Adult ; Aneurysm, False ; Angiography ; Aorta ; Aorta, Abdominal ; Axis, Cervical Vertebra ; Blood Pressure ; Constriction, Pathologic ; Decompression ; Humans ; Hypertension ; Hypertension, Malignant ; Hypertension, Renovascular ; Mortality, Premature ; Renal Artery Obstruction ; Rupture ; Takayasu Arteritis ; Transplants

Endovascular aneurysm repair (EVAR) is used with increasing frequency in the management of high-risk abdominal aortic aneurysm (AAA) patients. We report a delayed open repair for a persistent type I endoleak after EVAR in a patient with co-morbidities. An infrarenal AAA with a transverse diameter of 9.86 cm was detected on CT angiography; it extended from 8 mm below the renal artery to both common iliac arteries. The infrarenal angle was 90 degrees. After insertion of a Zenith stent graft (COOK, USA), a type I endoleak was detected on aortography, and several balloon dilatations were performed. The procedure was finished with a sustained type I endoleak. The endoleak persisted after 5 days on Doppler ultrasound, so open repair was performed. Total operative time was 240 minutes, and the duration of supra-celiac aorta clamping was approximately 35 minutes. The patient suffered an acute myocardial infarction on postoperative day 7 and recovered with conservative management. The patient was discharged on postoperative day 29.
Aneurysm ; Aorta ; Aortic Aneurysm, Abdominal ; Aortography ; Constriction ; Dilatation ; Endoleak ; Humans ; Iliac Artery ; Myocardial Infarction ; Operative Time ; Renal Artery ; Stents ; Transplants

Endovascular aneurysm repair (EVAR) has become increasingly popular since Parodi reported the first endovascular repair in 1991. Aortobiiliac stent grafting has gained popularity as an endovascular technique for managing abdominal aortic aneurysms (AAA), but the use of aortouniiliac stenting with femorofemoral bypass increases the proportion of patients treatable by endovascular techniques. The Zenith AAA Endovascular Graft Converter is used to convert a bifurcated graft to an aortouniiliac graft. We report successful EVAR using an aortouniiliac stent graft and converter in a 66-year-old man with an AAA and right common iliac artery occlusion. The preoperative CT angiography showed an infrarenal AAA 78 mm in diameter and right common iliac artery occlusion with recanalization by a collateral epigastric artery. The converter was deployed after placement of the main body, and the iliac leg extension was placed in the left external iliac artery. No postoperative complications occurred, and no endoleak was seen on follow-up CT angiography.
Aged ; Aneurysm ; Angiography ; Aortic Aneurysm, Abdominal ; Arteries ; Endoleak ; Endovascular Procedures ; Epigastric Arteries ; Follow-Up Studies ; Humans ; Iliac Artery ; Leg ; Postoperative Complications ; Stents ; Transplants

Cross femoro-femoral venous bypass (the Palma operation) is one way of treating iliofemoral venous occlusion in patients with deep vein thrombosis (DVT). We reviewed five patients (four men and one woman, two right legs and three left legs) who underwent the Palma operation. Three patients underwent surgery secondary to severe suprapubic and scrotal varicosities; one patient underwent surgery for symptomatic pain and swelling; and one patient underwent surgery for acute severe DVT. Four patients showed good patency and flow through the venous bypass during follow-up. The suprapubic and scrotal varicosities disappeared after surgery. Our results suggest that the Palma operation is an effective treatment for selected cases of DVT.
Female ; Femoral Vein ; Follow-Up Studies ; Humans ; Leg ; Male ; Transplants ; Varicose Veins ; Veins ; Venous Thrombosis

No abstract available.
Genetic Therapy*

Intimal hyperplasia is a frequent cause of failure of vascular surgery and angioplasty including endarterectomy, bypass surgery, angioplasty and atherectomy. Some author reported 50% of late failure identified in 5000 arterial reconstructions, including both endarterectomy and bypass operations, were attributed to this hyperplastic intimal response. Clearly this response is a significant cause of morbidity in patients undergoing vascular procedures and investigations on methods to control this process are of great importance. The precise patholphysiologic pathways leading to the development of intimal hyperpllasia have not been characterized.The initial event is thought to be damage to the vascular endothelium. Intimal thickening is the characteristic fibromuscular cellular response of intimal injury and some author advanced the "response-to-injury" hypothesis of atherogenesis and intimal hyperplasia. The response of the medial smooth muscle cell (SMC) to vascular injury can be devided into four distinct stages: (1) an initial medial proliferative response, (2) migration from the media across the internal elastic lamina and into the intima, (3) subsequent proliferation within the neointima, and (4) synthesis and deposition of extra-cellular matrix. Ross and Gomset suggested that a high local concentration of growth factors, particularly platelet-derived growth factor (PDGF), releaed from degranulating platelets could stimulate SMC proliferation. But Clowes and Reidy concluded from their research result that platelet factors do not play a substantial role in the initial wave of proleferation after injury but do influence migration from the media to the intima. From the observation of response to the balloon injury of carotid artery, Lindner and Reidy concluded that damaged SMC might be releasing some kind of intracellular factor. A logical candidate is now basic fibroblast growth factor (bFGF) Currently the only available option for the treatment of intimal hyperplasia is mechanical intervention with revision or angioplasty of the affected vessel. The ability of several agents to suppress the development of intimal hyperplasia has been investigated and some drugs have been shown to be at least partially successful in this regard: antihypertensive drugs, antiplatelet agents, antiimflammatory agents, anticoagulants, antilipid agents, and other substances including angiopeptin, and porphyrin compounds. The variety of agents attests to the complexity of the pathways which responsible for the development of this lesion and suggests that no single agent will likely be entirely effective. Although the usefullness of pharmacologic therapy to prevent myointimal hyperplasia remains unclear, if effective pharmacologic therapy and thus prevent the assoiciated recurrent arterial stenosis, this would be major impact on the durability of vascular procedures and lower their associated morbidity, mortality and cost. Gene transfer methods are providing important information about the biology of vascular cells. The most gene transfer techniques involves the introduction of new genetic information into the genome of specific vascular cells. These genetically altered cells subsequently express individual proteins or traits for which they have been engineered. Most investigators have considered endothelial cells the ideal recipient for human gene therapy. Ths is because their location makes them easily accessible to recombinant vectors and allows for any produced products to be secreted directly into the bloodstream. In vitro experiments have already been performed that have documented the ability to transfer specific genes into cultured endothelial cells. Genes coding for neomycin resistance, b-galactosidase, growth hormone, prostacyclin, and tPA, have all been successfully transferred. More recently, expression of recombinant gene products, by transduced endothelial cells, has also been achieved in vivo. The potential of genetically engineered vascular cells to modify the vessel wall and interfere with the development of intimal hyperplasia is obvious and research into this possibility is developing rapidly. Intimal hyperplasia will continue to be a major cause of vein graft and native artery with resultant loss of life and limb. To prevent the problem successfully further understanding of the mechanism of intimal hyperplasia will be required so that treatment can be tailored to the key steps in the pathologic process. As we enter the 21st century, gene transfer, somatostatin, photodynamic theapy and brachytherapy, intravascular irradiation following angioplasty and stent insertion will be the importanat focus for research on intimal hyperplasia.
Angioplasty ; Anticoagulants ; Antihypertensive Agents ; Arteries ; Atherectomy ; Atherosclerosis ; Biology ; Blood Platelets ; Brachytherapy ; Carotid Arteries ; Clinical Coding ; Constriction, Pathologic ; Endarterectomy ; Endothelial Cells ; Endothelium, Vascular ; Epoprostenol ; Extremities ; Fibroblast Growth Factor 2 ; Gene Transfer Techniques ; Genetic Therapy ; Genome ; Growth Hormone ; Humans ; Hyperplasia* ; Intercellular Signaling Peptides and Proteins ; Logic ; Mortality ; Myocytes, Smooth Muscle ; Neointima ; Neomycin ; Platelet Aggregation Inhibitors ; Platelet-Derived Growth Factor ; Research Personnel ; Somatostatin ; Stents ; Transplants ; Vascular System Injuries ; Veins