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We report a case of concurrent saccular aneurysms caused by a penetrating atherosclerotic ulcer of the thoracic and abdominal aorta that were successfully treated by staged endovascular repair. Even though surgical open repair or endovascular repair is the treatment option, use of endovascular repair is now accepted as an alternative treatment to surgery in selected patients. To prevent contrast medium-induced nephropathy and spinal cord ischemia caused by a simultaneous endovascular procedure, a saccular aneurysm of the descending thoracic aorta was excluded by stent graft, followed by the placement of a bifurcated stent graft in the infrarenal abdominal aorta one month later.

Purpose: The aim of this study is to evaluate the results of aspiration thrombectomy (AT) in the endovascular treatment for iliofemoral deep vein thrombosis (DVT) through the comparison of catheter directed thrombolysis (CDT) alone group and CDT with AT group. Methods: From November 2001 to April 2011, 100 patients received endovascular treatment with CDT alone or CDT with AT for iliofemoral DVT at Yeungnam University Medical Center. We compared procedure, clinical outcomes and complications between the two groups. Results: The mean age of patients was 60.48 ± 14.57 years. The patients consisted of 41 men and 59 women. CDT alone and CDT with AT were performed in 29 and 71 patients, respectively. The mean procedural time of the CDT-alone group was longer than the CDT with AT group (P ＜ 0.001) and dose of urokinase used during the procedure significantly decreased in the CDT with AT group (P ＜ 0.001). There were no statistically significant differences in clinical outcomes between the two groups. Cases of pulmonary embolism was not noted in each group in our series, but entrapped thrombus during procedure was noted in 6 of 37 in the CDT with AT group and 0 of 9 in the CDT-alone group among 46 patients with prophylactic inferior vena cava (IVC) filter insertion. Conclusion: In conclusion, CDT with AT is safe and effective for the treatment of an acute iliofemoral DVT. In AT treatment, prophylactic IVC filter insertion should be considered for the prevention of pulmonary embolism by floating thrombi.

The incidence of concomitant carotid artery stenosis and unruptured intracranial aneurysm (UIA) has been reported to be between 3% and 5%. The rupture risk of UIA measuring7 mm is very low according to International Study of Unruptured Intracranial Aneurysm data. However, there may be a potential risk of aneurysm rupture after carotid artery revascularization because of increased cerebral blood flow. The aims of this study were to investigate the incidence of concomitant UIA in patients who needed carotid artery intervention and to survey the incidence of aneurysm rupture after treatment.Between October 2004 and December 2009, 114 patients with severe carotid artery stenosis were treated in our hospital (69 carotid endarterectomies and 45 carotid artery stentings). Cerebral angiography and medical records were reviewed retrospectively.Cerebral angiography revealed seven asymptomatic UIAs in six patients (5%, 6/114). Of them, four patients underwent carotid endarterectomy and two underwent carotid artery stenting. All patients were male, and the mean age of the patients was 72 years (range, 67-79 years). Aneurysm size ranged between 2.3 and 4.0 mm. Two patients had UIAs on the same side of the treated carotid artery, whereas others developed UIAs on the contralateral side. There was no periprocedural aneurysm rupture. During follow-up (mean: 18 months, 5-31 months), two patients died from other causes, and no rupture of aneurysm occurred in any of the patients.In our series, the carotid artery revascularization did not have an effect on the natural course of small-sized asymptomatic UIA.

Introduction L'incidence des stenoses carotidiennes associees a un anevrysme intracrânien non rompu (AINR) concomitant est comprise entre 3% et 5%. Le risque de rupture des AINR Methodes Entre Octobre 2004 et Decembre 2009, 114 patients presentant une stenose serree de l'artere carotide etaient traites au sein de notre hopital (69 endarterectomies carotidiennes et 45 stentings carotidiens). Les angiographies cerebrales et les dossiers medicaux etaient revus retrospectivement. Resultats Les angiographies cerebrales revelaient sept AINRs asymptomatiques chez six patients (5%, 6/114). Parmi eux, quatre patients avaient une endarteriectomie et deux avaient un stenting. Tous les patients etaient des hommes, et l'âge moyen des patients etait de 72 ans (range, 67-79 ans). La taille des anevrysmes etait comprise entre 2,3 et 4,0 mm. Deux patients avaient un AINR du meme cote que l'artere carotide traitee tandis que les autres developpaient un AINR du cote controlateral. Aucune rupture peri-operatoire n'etait notee. Au cours du suivi (moyenne : 18 mois, 5-31 mois), deux patients decedaient d'autres causes, et aucune rupture d'anevrysme ne survenait chez ces patients. Conclusion Dans notre serie, la revascularisation carotidienne n'avait pas d'effet sur l'histoire naturelle des petits AINRs asymptomatiques.

Purpose: This study aimed to investigate early and mid-term outcomes of carotid artery stenting (CAS). Methods: We retrospectively reviewed 111 patients who were treated for carotid stenosis between October 2004 and December 2009 (42 CASs and 69 carotid endarterectomies [CEAs]). Results: CAS group was older than CEA group (70 years vs. 67 years, P = 0.001). Coronary artery disease and high lesion above the 2nd cervical vertebral body were more common in CAS group (29% vs. 13%, P = 0.002; 4% vs. 24%, P = 0.004). The 30-days stroke rate was higher in CAS group (10% vs. 1% in CEA group, P = 0.067, Fisher’s exact test). New brain lesions on diffusion-weighted magnetic resonance imaging were more common in CAS group (48% vs. 20% in CEA group, P = 0.002, chi-square test). The 1-, 3-year freedom from stroke were 91%, 84% in CAS group and 99%, 99% in CEA group (P = 0.007, log-rank test). Univariate analysis showed that female gender and age ＞70 years were related with postprocedural neurological complications (P = 0.046 and P = 0.007, log-rank test). However, none were independent risk factors on multivariate analysis. Conclusion: In our series, the rates of peri-procedural neurological complications in CAS group were significantly high. These results suggest that more experience and restricted patient selection will be needed for CAS.

We reviewed surgically treated patients with intrahepatic cholangiocarcinoma to evaluate the clinical and pathologic features of intrahepatic cholangiocarcinoma that may affect long-term survival in Korean patients with the disease. Between 1990 and 1997, 28 patients with intrahepatic cholangiocarcinoma underwent laparotomy. Resection was performed in 25 patients, and wedge resection alone in 3 patients. The liver resections consisted of right lobectomy in 5 patients, right trisegmentectomy in 1, left lobectomy in 7, extended left lobectomy in 3, hepatopancreatoduodenectomy in 2, and segmentectomy in 7. Curative resection was performed in 15 patients. Histological sections of all resected specimens were immunohistochemically stained with p53 and Ki-67 monoclonal antibodies to assess the biological behavior of the tumor cells. Cumulative survival rate and clinicopathological factors that may influence the prognosis, including biological markers (p53, Ki-67), were analyzed statistically. Patients who underwent curative resection survived significantly longer than patients who underwent noncurative resection. The median survival time of the patients who underwent curative resection was 24 months (mean, 34 +/- 8 months), with 1-, 2-, and 3-year survival rates of 66.6%, 44.4%, and 35.6%, respectively. The median survival time of the patients who underwent noncurative resection was 3 months (mean, 8 +/- 3 months), with 1- and 2-year survival rates of 26.7% and 13. 4%, respectively. Univariate analysis showed that positive regional lymph nodes correlated significantly with poor outcome (P = 0.004) and that curative resection significantly correlated with better prognosis (P = 0.001). Age, sex, tumor size, degree of cell differentiation, gross type of tumor, and p53 and Ki-67 labeling index were not significantly correlated with outcome. Our findings support the concept that aggressive liver resection, along with regional lymph node dissection, be recommended for long-term survival. The validity of molecular biologic tumor markers (p53, Ki-67) as prognostic factors has not yet been clearly demonstrated.

Cilostazol is a selective inhibitor of phosphodiesterase 3 that increases intracellular cAMP levels and activates protein kinase A, thereby inhibiting vascular smooth muscle cell (VSMC) proliferation. We investigated whether AMP-activated protein kinase (AMPK) activation induced by heme oxygenase-1 (HO-1) is a mediator of the beneficial effects of cilostazol and whether cilostazol may prevent cell proliferation and reactive oxygen species (ROS) production by activating AMPK in VSMC. In the present study, we investigated VSMC with various concentrations of cilostazol. Treatment with cilostazol increased HO-1 expression and phosphorylation of AMPK in a dose- and time-dependent manner. Cilostazol also significantly decreased platelet-derived growth factor (PDGF)-induced VSMC proliferation and ROS production by activating AMPK induced by HO-1. Pharmacological and genetic inhibition of HO-1 and AMPK blocked the cilostazol-induced inhibition of cell proliferation and ROS production.These data suggest that cilostazol-induced HO-1 expression and AMPK activation might attenuate PDGF-induced VSMC proliferation and ROS production.

ObjectiveThis study is a review and evaluation of our 12-year experience of revascularization for critical limb ischemia (CLI) with angioplasty/stenting and bypass surgery to identify specific trends of procedure volume and outcomes in this particular group.MethodsEndovascular and open bypass procedures done for CLI by a single surgeon between 1993 and 2004 were evaluated retrospectively. Thrombolysis and thrombectomy procedures done as the only revascularization procedure were excluded from analysis. The data were divided into three groups by time periods: the first period, 1993 to 1996; the second period, 1997 to 2000; and the third period, 2001 to 2004. Outcomes were defined according to the reporting standards of the Society for Vascular Surgery/International Society for Cardiovascular Surgery. The study included 416 procedures done in 237 limbs in 192 patients. The mean follow-up was 23 months (range, 1 to 122 months).ResultsPrimary revascularization procedures for CLI were angioplasty in 153 limbs (65%) and bypass surgery in 84 (35%). Subsequent procedures were angioplasty in 102 limbs (57%) and open surgery (bypass and/or patch angioplasty) in 77 limbs (43%). The rates for technical and clinical success and complications in the entire group were 99%, 95%, and 4%, respectively. One patient died perioperatively (0.5%). Among the three periods, TransAtlantic Inter-Society Consensus lesion types were significantly more severe in patients in the first period (P < .05). Additionally, the complication rate was significantly higher and the mean hospital stay was significantly longer in the first period compared with the second and third periods (P < .05). Furthermore, between the first and third periods, the number of endovascular revascularization procedures done as primary and secondary procedures significantly increased from 15 to 84 (+460%) and from 13 to 57 (+340%), whereas the number of open surgical procedures done as primary and secondary procedures decreased from 39 to 20 (−49%) and from 35 to 18 (−49%), respectively (P < .0001). The assisted primary patency rates in the third period were significantly higher than those in the first and second periods (P = .012); otherwise, the long-term outcomes among the three periods were not statistically different. Multivariate analysis revealed that, while controlling for other factors, the third period showed improvement in the primary patency (P = .032) and assisted primary patency (P = .051), and the bypass group showed improvement in the primary patency (P = .008).ConclusionsIn our experience, open surgical procedures for the treatment of CLI have been largely replaced by angioplasty procedures without compromising outcomes. Angioplasty is a feasible, safe, and effective procedure and can be the procedure of choice for the primary and secondary treatment of CLI. Open surgical procedures can be reserved for lesions technically unsuitable for endovascular procedures and patients who do not demonstrate clinical improvement after angioplasty.

Recently significant neurotoxicity has been reported with the use of carcineurin inhibitors. An 11-year-old-girl had undergone a transplantation of kidney from her mother. On post-operative day 12, hypertension, headache, and left motor weakness (grade I) suddenly occurred. The brain-magnetic resonance imaging and magnetic resonance angiography showed acute cerebral infarction at subcortical white matter of the right hemisphere and multiple stenoses of both anterior cerebral artery and middle cerebral artery. While stopping tacrolimus treatment, we experienced clinical and radiological improvement. So, the neurological complications of this patient seem to have been caused by the use of tacrolimus.

Adventitial cystic disease (ACD) of venous system is an extremely rare condition. Very few reports of ACD in venous system have been described. In this report we discuss two cases of common femoral vein ACD that presented with a swollen leg by the obstruction of the vein. Ultrasound imaging showed the typical hypoechoic fluid filled cyst with a posterior acoustic window. Computed tomography scan and ascending venogram showed a stenosis to flow in the common femoral vein caused by an extrinsic mass. Trans-adventitial evacuation of cyst with removal of vein wall was performed for both cases. During operation we found the gelatinous material in the cysts arising in the wall of the common femoral vein and compressing the lumen. The patients were released after short hospitalization and have remained symptom free with no recurrence.