Iliac artery stenosis associated with atherosclerosis after renal transplantation affects transplanted kidney function and graft kidney engraftment rate. We report a case of iliac artery revascularization for arteriosclerotic obliterans that improved renovascular hypertension and renal dysfunction. A 58-year-old male underwent a living donor renal transplant 20 years ago. He had experienced intermittent claudication in his right lower limb for 3 years. Computed tomography (CT) revealed severe stenosis of the right common iliac and femoral arteries because of a highly calcified plaque. The transplanted renal artery was anastomosed to the right external iliac artery. On admission, the patient had marked hypertension despite taking antihypertensive medication, and his plasma renin concentration was elevated to 126 pg/ml. Retrospectively, his serum creatinine concentration had increased from about one year earlier. Thus, the patient was diagnosed with renovascular hypertension and transplanted kidney dysfunction owing to reduced graft blood flow caused by proximal arterial stenosis. The patient underwent right common femoral artery thromboendarterectomy and endovascular treatment of both common iliac arteries resulting in a reduction in serum creatinine and plasma renin concentrations and blood pressure, in addition to an improvement in intermittent claudication. We hypothesized that iliac artery stenosis is an infrequent but important postoperative complication that should be considered when graft blood flow is suspected to decrease after kidney transplantation.

A 72-year-old man with a thoracoabdominal aortic aneurysm combined with an aberrant right subclavian artery, Kommerell's diverticulum, and angina pectoris during follow-up for peripheral arterial disease was successfully treated surgically by two-staged operation. First, we performed total arch replacement using cardiopulmonary bypass, systemic hypothermia, selective cerebral perfusion, and coronary artery bypass grafting. Secondly, we performed replacement of the thoracoabdominal aortic aneurysm using a partial cardiopulmonary bypass. The postoperative course was uneventful. This is apparently the first case of repair for the thoracoabdominal aortic aneurysm combined with an aberrant right subclavian artery and Kommerell's diverticulum.

A 71-year-old woman was admitted with sudden onset of abdominal pain. CT scan image and symptoms showed an impending ruptured suprarenal abdominal aortic aneurysm therefore we performed an emergency operation. The abdominal aorta was replaced with a trunk prosthetic graft with four branches for visceral and lumbar arteries. The post-operative course was uneventful. Pathological examination showed that the aorta had severe atherosclerotic changes. The fibrous tissues increased in the aneurysmal wall which was not consistent with the normal aorta. Intima and media of the aorta everted into the aneurysm. These findings suggested that aneurysm was caused by a penetrating atherosclerotic ulcer.

A high-risk abdominal aortic aneurysm patient with multiple complications was treated by a transluminally placed endovascular stent-graft. A tapered stent-graft composed of 3 units of self-expandable Z stents covered with ultra-thin woven Dacron was inserted through an 18 Fr sheath via the femoral artery. The stent-graft was deployed successfully, and endovascular exclusion of the abdominal aortic aneurysm was achieved. The endoluminal stent-graft treatment is an option for minimally invasive operation in comparison with conventional open surgery, and appears to be effective for aortic aneurysms in certain selected cases.

The stump pressure of the inferior mesenteric artery (IMA) was measured before and after aortic cross clamping during infra-renal abdominal aortic aneurysmal surgery in 50 cases. We analyzed the hemodynamics in IMA-supplied areas, and established an appropriate index to indicate intestinal ischemia. The IMA stump pressure after aortic cross clamping decreased significantly (p<0.0001), by 11% on an average. This means that the collateral blood supply from the internal iliac artery (IIA) is 11% of the total pressure and the collateral blood supply from the superior mesenteric artery (SMA) is 89%, therefore the SMA supply dominates that of the IMA. Intestinal ileus due to ischemia occurred in one patient who had the highest rate of pressure decrease after aortic cross clamping. The cause of ileus might be poor collateral blood supply from SMA and insufficient IIA blood flow preservation. The IMA stump pressure might be an index to predict intestinal ischemia. We analyzed the IMA stump pressure in 38 cases without IMA reconstruction who had no ischemia. The ratio of 0.6 in IMA stump pressure versus systemic pressure could be a safe index suggesting sufficient blood flow in IMA-supplied areas. IMA reconstruction and IIA preservation should be performed to maintain an IMA stump pressure ratio of 0.6.

Ten cases of pseudoaneurysms that developed after thoracic aortic surgery were treated with an endovascular technique using stent grafts for redo operations. All patients were treated under general anesthesia and the stent grafts were implanted through 18 Fr or 20 Fr sheath introducers via femoral arteries under fluoroscopic guidance. The stent graft was composed of several units of self-expanding stainless-steel Z stents covered with an ultra-thin polyester fabric. Stent graft deployment was technically successful in all patients and in 7 of 10 cases exclusion of the aneurysms with no endoleak was achieved within two weeks after the operation (initial success rate: 70%). Minor endoleak was found in 3 patients and one of those finally underwent conventional surgery because of stent graft migration 6 months after the stent graft repair. Two of ten patients died, 10 days and 18 weeks after the operation, due to hemoptysis, which had already been observed before the operation. Endovascular stent graft repair of pseudoaneurysms after thoracic aortic surgery is a minimally invasive operation in comparison with conventional redo surgery with extracorporeal circulation. These results and experiences suggest that stent graft repair can be a safe and useful redo treatment for pseudoaneurysms. However, careful long-term investigations are necessary to prove the value and effect of this endovascular treatment and a new strategy for cases with hemoptysis is required.

A 60-year-old woman with acute Stanford type A dissecting aneurysm underwent Dacron graft replacement of the total aortic arch combined with the modified elephant trunk technique. Follow-up CT and angiogram demonstrated blood flow into the false lumen from the distal anastomosis. In order to interrupt the blood flow, endovascular stent grafting was undertaken. She recovered uneventfully, and was discharged on the 14th postoperative day. Follow-up CT taken in the third postoperative month demonstrated exclusion of the blood flow into the false lumen of descending thoracic aorta. Aortic arch replacement followed by endovascular stent grafting of the descending thoracic component is a potential therapeutic option in patients with dissecting aneurysm.

A patient with mutiple aneurysms of the thoracic aorta in Behçet's disease was treated with transluminally placed endovascular stent grafts. Stent graft devices composed of several units of self-expandable Z stents covered with ultra-thin woven Dacron were inserted through 18 Fr sheaths via the femoral arteries. The stent grafts were deployed successfully and blood flow into the aneurysms was reduced immediately and no blood endoleak was found on aortography. However minor endoleak due to migrations of the stent grafts was recognized in two distal descending aortic aneurysms twenty days after the operation. Extra stent grafts were inserted to interrupt the endoleak and finally all aneurysms were thrombosed without any endoleak. Former surgical replacement of the aorta due to aneurysms associated with vasculo-Behçet's disease often causes anastomotic leakage and pseudoaneurysms. The endoluminal stent graft treatment is a minimally invasive operation in comparison with former surgical operations, and is useful for aortic aeurysms especially for inflammatory aneurysms in Behçet's disease because it requires no anastomotis. However, improvement of the stent graft devices, including components of the delivery system such as the dilator, sheath and pushing rod, and the development of better devices, is required to reduce delivery failure and to make stent graft treatment more reliable.

Prosthetic graft replacement for thoraco-abdominal aneurysm was performed in a 69-year-old man. Fever and CRP elevation developed 8 days after the operation. A subcutaneous abscess was found in the wound. The culture of pus and thoracic discharge revealed methicillin-resistant staphylococcus aureus (MRSA). Infected tissues were debrided and an omentopexy was performed without removing the prosthetic graft to avoid spinal cord ischemia. The thoracic cavity was irrigated continuously with 1% Povidone-iodine for three days. The infection subsided gradually and the patient was discharged. Graft infection due to MRSA has recently increased and we experienced such a case which we treated successfully by complete debridement, omentopexy and continuous irrigation.