Abdominal aortic aneurysm (AAA) is considered to be a potent life-threatening disorder in elderly individuals. Although many patients with a small AAA are detected during routine abdominal screening, there is no effective therapeutic option to prevent the progression or regression of AAA in the clinical setting. Recent advances in molecular biology have led to the identification of several important molecules, including microRNA and transcription factor, in the process of AAA formation. Regulation of these factors using nucleic acid drugs is expected to be a novel therapeutic option for AAA. Nucleic acid drugs can bind to target factors, mRNA, microRNA, and transcription factors in a sequence-specific fashion, resulting in a loss of function of the target molecule at the transcriptional or posttranscriptional level. Of note, inhibition of a transcription factor using a decoy strategy effectively suppresses experimental AAA formation, by regulating the expression of several genes associated with the disease progression. This review focuses on recent advances in molecular therapy of using nucleic acid drugs to treat AAA.

For the treatment of patients with critical limb ischemia (CLI), the angiosome concept is essential in revascularization and wound treatment. In this article, we describe how we use the angiosome concept for surgically treating CLI wounds and review some essential reports. For wounds in patients with CLI to heal, both successful revascularization and wound management are crucial. In order to preserve the blood supply as much as possible intraoperatively, surgeons should always consider the angiosome concept.

Critical limb ischemia (CLI) is a severe blockage of the arteries to the lower limbs characterized by poor prognoses for both salvage of the lower limb and patient survival. Accordingly, CLI must be diagnosed and treated appropriately from the earliest possible stage. To do so, multidisciplinary treatment not only by vascular surgeons but also by many other doctors and medical staff is necessary. Accurate diagnosis is indispensable to appropriate treatment of CLI; thus, the definitions in the recently issued new guidelines for CLI treatment are reviewed. The multidisciplinary treatment of CLI should be recognized as three elements: namely, multidisciplinary treatment to salvage the lower limb, to improve of survival prognosis, and to prevent CLI occurrence. In all of these events, team medicine administered by expert staff is indispensable. The specialist must have not only profound knowledge of his/her field of specialty but also professional skills and the ability to cooperate with other departments. A multidisciplinary treatment approach that combines the abilities of many specialists for treating severely ischemic limbs in patients with peripheral arterial disease is expected to improve both limb salvage and patient survival and should be promoted in daily clinical settings. (This is a translation of Jpn J Vasc Surg 2018; 27: 507–512.)

While surgical treatment for abdominal aortic aneurysm (AAA) is a standard operation, prevention of complication is important. Intestinal ischemia of the sigmoid colon and/or rectum after AAA surgery is severe and has a high mortality rate although occurrence frequency is low. The most important thing to prevent is the preoperative and intraoperative evaluation of the left hemicolon and rectal circulation. Measurement of inferior mesenteric artery stump pressure is also useful. From the viewpoint of prevention of buttock claudication, it is desirable that internal iliac artery (IIA) blood flow is preserved, but aggressive IIA reconstruction adaptation is considered to be low. For erectile function, it is important that the antegrade blood flow from the IIA to the internal pudendal artery on at least one side is preserved or reconstructed. To prevent retrograde ejaculation, it is important to preserve the superior hypogastric plexus and one side of the lumbar splanchnic nerve, and the hypogastric nerve. Understanding and mastering local anatomy and pathophysiology is important in preventing complications, and we must also remember that we always keep watchful surgical operations in mind in order to prevent tissue damage. (This is a translation of Jpn J Vasc Surg 2019; 28: 99–103.)

Treatment of thoracoabdominal aortic aneurysm (TAAA) remains a challenging pathology. Technologies and innovations of endovascular treatment, in particular the evolution of fenestrated and branched stent graft for complex aortic pathologies such as TAAA have provided excellent short-term results. However, the mid-term and long-term results of endovascular treatment for TAAA including endoleaks and branch patency are still unclear. This article provides an overview of available devices and results of endovascular treatment for TAAAs. (This is a translation of Jpn J Vasc Surg 2019; 28: 67–74.)

Objectives: To evaluate the outcomes of the E-ventus BX balloon-expandable stent graft system (Jotec, Hechingen, Germany) implanted as bridging stent grafts during fenestrated endovascular aortic repair (FEVAR) and the iliac branch device (IBD) of complex aneurysms.

Methods: This was a single centre retrospective analysis prospective study including all consecutive patients treated by FEVAR and the IBD performed with E-ventus BX stent grafts as bridging stents. Demographics of patients, the diameter and length of the bridging stent grafts, technical success, reinterventions, occlusions, post-operative events, and imaging (computed tomography [CT] scan and ultrasound) were prospectively collected in an electronic database. Follow-ups were performed with clinical assessment and a CT angiogram scan at four weeks after discharge followed by a duplex ultrasound every six months for two years and then a yearly duplex scan afterwards.

Results: Between June 2015 and October 2017, 40 consecutive patients (three females) were treated with custom made fenestrated endografts and the iliac branch device for complex aneurysms, using the E-Ventus BX stent graft. All 82 E-Ventus BX stent grafts were successfully delivered and deployed. There was no in-hospital mortality. The early bridging stents patency rate was 97.6% (80 out of 82). The two-target vessel post-operative occlusion was secondary to kink of the renal stents and failure for re-lining of the renal artery. Of the two patients, only one needed permanent dialysis. On the late follow-up (after 30 days), two other patients demonstrated a renal stent occlusion, with one treated successfully with re-lining of the stent and the other patient treated conservatively. Neither of them needed permanent dialysis. A follow-up was maintained for 36 patients until April 2018 with a median follow-up of 18 months. All bridging stents E-Ventus BX stent grafts remained patent (78 out of 82, 95.1%).

Conclusion: E-Ventus BX stent grafts used as bridging stents during FEVAR and the IBD are associated with favourable outcomes at the mid-term follow-up. Long-term follow-up is required to confirm these promising results.

Objective: To assess mechanisms underlying aneurysm formation using a simple electronic circuit model.

Materials and Methods: We created a simple circuit model connecting the celiac artery (CA) to the superior mesenteric artery via the pancreaticoduodenal arcade. We retrospectively reviewed 12 patients with true pancreaticoduodenal artery aneurysms (PDAAs) who received open or endovascular treatment between 2004 and 2017. We set the resistance of each artery and organ voltage and calculated flow volume and rate in response to degrees of simulated CA stenosis from 0% to 99.9%.

Results: Flow volume rates of the anterior pancreaticoduodenal artery and posterior pancreaticoduodenal artery decreased to zero when CA stenosis increased from 0% to 50% and then increased drastically, at which point flow direction reverted and the flow was up to three times the initial rate. The gastroduodenal artery (GDA) also showed reversed flow with severe CA stenosis. In 12 patients with PDAA, eight presented with a CA lesion, and the other patients presented with comorbidities causing the arteries to be pathologically fragile, such as Marfan syndrome, Behçet’s disease, and segmental arterial mediolysis. All four GDA aneurysms were not accompanied by CA lesions.

Conclusion: The mechanism underlying CA-lesion-associated PDAA formation may be partially explained using our model.

Objective: This multicenter observational study was conducted in order to investigate the incidence of cancer in patients with critical limb ischemia.

Materials and Methods: We prospectively investigated the incidence of cancer in 68 patients with critical limb ischemia over a two-year period. Patients underwent an intensive examination at enrollment, which included tumor marker levels and chest and abdominal computed tomography, as well as one- and two-year follow-up examinations. We compared the observed incidence of cancer with the expected incidence calculated from national cancer rates by the standardized incidence ratio (SIR).

Results: The majority (83.6%) of the patients were men, and 92.5% of the patients had a peripheral arterial disease that was classified as Fontaine stage III or IV. During enrollment, newly diagnosed cancers were detected in seven patients. Four additional cancers were detected during the follow-up period. All of the detected cancers were asymptomatic. We observed an increased risk of cancer (SIR, 4.04; 95% confidence interval, 1.31–9.42) in patients with critical limb ischemia.

Conclusion: This study suggests that critical limb ischemia is associated with an increased risk of cancer. Our findings should be taken into serious consideration by future investigators considering the use of therapeutic angiogenesis.

Objective: Aortic dissection (AD) is a fatal disease that is caused by the rapid destruction of the aortic wall. Although recent studies in animal models indicate an important relationship between inflammation and tissue destruction, activation status of inflammatory signaling and its relation to the inflammatory cell infiltration are poorly characterized in human AD.

Materials and Methods: We examined the activation of inflammatory signaling molecules NFκB and STAT3, and neutrophil infiltration in AD tissue samples that were obtained during the surgical repair within 24 h after AD onset.

Results: Activation of NFκB was observed mainly in the intima both in AD samples and in aortic samples without AD. Activation of STAT3 was observed in AD samples, but not in the aortic sample without AD. Neutrophil infiltration was observed predominantly in the adventitial layer of AD samples. Histological analysis revealed that STAT3 was activated in cells other than neutrophils. Notably, STAT3 activation and neutrophil infiltration showed positive correlation in adventitial layer of AD tissue.

Conclusion: These findings demonstrated that adventitial STAT3 activation was associated with neutrophil infiltration, suggesting their importance in AD pathogenesis.

Objective: Open revascularization of the lower extremity in patients with chronic limb-threatening ischemia (CLTI) does not guarantee limb salvage. Due to the high prevalence of frailty among these patients, we hypothesized that sarcopenia negatively affects limb prognosis.

Methods: Seventy-five CLTI patients who underwent open revascularization between 2011 and 2015 were retrospectively reviewed. The lumbar psoas index, which is the ratio of the cross-sectional area of the psoas major muscles to the patients’ height squared, was used as a surrogate marker for sarcopenia. Male and female patients were stratified separately according to lumbar psoas index values. The lower two-thirds of the population for each sex were defined as the sarcopenia group, with the higher third defined as the non-sarcopenia group.

Results: Comorbidities and ambulatory status did not differ between the sarcopenia (n=50) and non-sarcopenia (n=25) groups. The sarcopenia group had significantly lower overall survival rates than the non-sarcopenia group (60% vs 87% at 3 years, P<0.05). Moreover, the limb salvage rates were significantly lower in the sarcopenia group than in the non-sarcopenia group (73% vs 100% at 2 years, P<0.05).

Conclusion: Sarcopenia, as measured by the lumbar psoas index, may predict poor limb prognosis in CLTI patients undergoing open revascularization.

Objective: The purpose of this study was to evaluate safety and effectiveness of endovenous radiofrequency ablation (RFA) for elderly patients.

Materials and Methods: We enrolled 140 patients (194 limbs) who underwent RFA for varicose veins of lower extremities. Patients were divided into two groups; elderly patients (more than 75 years old, E-group, n=36) and young patients (under 75 years old, Y-group, n=104), and perioperative data were analyzed and compared between two groups.

Results: In E-group, there were more than patients with hypertension, ischemic heart disease, malignant tumor, and cerebrovascular disease. A partial recanalization was observed in only one limb (0.6%) in Y-group. Endovenous heat induced thrombosis (EHIT) was identified four limbs (2.8%) in Y-group and two limbs (4.1%) in E-group. All EHITs were class 1 by Kabnick classification, and they disappeared within one month after interventions, without antithrombotic therapy. No other major complications were observed. There were no significantly differences for preoperative mean venous clinical severity scores (VCSS) (Y : E=4.84 : 4.47) and postoperative VCSS (Y : E=1.16 : 1.19, 0.35 : 0.58, 0.15 : 0.06, 0.05 : 0.06 at 1, 3, 6, 12 months after) in both groups.

Conclusion: RFA for elderly patients is a safe and effective strategy for varicose veins of lower extremities.

Objective: Venous thromboembolism (VTE) includes deep vein thrombosis (DVT) and pulmonary embolism (PE). VTE affects all races, age groups, and genders. The objective of this registry was to analyze the patient characteristics, clinical outcomes, management strategies, and temporal trends in VTE at a single center.

Materials and Methods: Consecutive medical records of inpatients between January 2007 and March 2018, meeting the inclusion criteria (confirmed diagnosis of DVT by Doppler ultrasound scan and/or PE by chest computed tomography) were identified and collected. A total of 1,024 patients were reviewed.

Results: Eight hundred and twelve patients with VTE were enrolled into the study; 37.4% were referrals from outside hospitals, 33.1% of the total patients had no risk factors, hence classified as unprovoked VTE and the rest of the patients had single or multiple risk factors which may have provoked the VTE, 68.8% presented with swelling and pain, and 88.5% had proximal DVT.

Conclusion: VTE is no longer a rare phenomenon in the Indian population, as believed earlier. The knowledge of VTE, prophylaxis, and treatment strategies is minimal among small institutes, nursing homes, and among general practitioners who are not affiliated with teaching institutes. Therefore, educating primary care physicians/surgeons on VTE is paramount, as this would reduce the incidence of VTE in India as well as associated morbidity and mortality rates.

Objective: The purpose of this study is to investigate morphologic changes of the femoropopliteal arterial segment (FPAS) with knee flexion after endovascular therapy (EVT).

Methods: From July 2012 to January 2015, EVT was performed on 12 limbs in 12 consecutive patients who had obliterative lesions in the FPAS. After the implantation of nitinol stents, angiography was performed with the knee in both extension and flexion to investigate morphologic changes of the FPAS.

Results: On angiography, the distal end of the implanted stent was placed at various distances (5–10 cm in two cases, 10–15 cm in nine cases, and 15–20 cm in one case) above the knee joint line with the knee in extension. In all cases, although the popliteal artery was highly bent with the knee in flexion, the FPAS morphology was highly variable. However, the most proximal bending point of the FPAS was about 10 cm above the knee joint line. In one case, the artery was occluded at the distal part of the stent 16 months later, probably due to EVT.

Conclusion: In EVT of the FPAS, it is important to consider the characteristics and position of the stent to prevent complications.

Objective: To present a new and easy technique for performing endarterectomy in patients with peripheral arterial occlusive disease (PAD) having dollop calcification at the common femoral artery (CFA).

Materials and Methods: We developed a procedure for angioplasty for PAD using a supersonic surgical suction device, based on the new concept of “to create a new lumen to dig tunnel in calcification.” Ultrasonic surgical aspiration device was inserted into the intravascular space from outside the area of the target lesion and only internal calcification was removed.

Results: We performed this technique in three patients who had PAD with dollop calcification at CFA. We succeeded in performing endarterectomy easily and safely. This method does not require vascular wall closure suture at calcified lesion or intimal fixation suture of dollop calcification.

Conclusion: We address the technical difficulty in treating highly calcified lesions that could not be dealt with conventional endarterectomy. Our new method is one of the options for revascularization of heavily calcified lesions.

Isolation selective cerebral perfusion (ISCP) technique is reportedly an effective method for preventing brain complications during the treatment of arch aneurysms. Here we present the case of a patient with intracardiac disease complicated by mobile atheroma in the proximal aorta. In this patient, not only the arterial cannulation of the ascending aorta might have posed a high risk of brain stroke but also the original ISCP technique could not be applied. We applied the ISCP technique for non-aortic disease without using circulatory arrest to prevent aortogenic brain embolism. The patients who underwent treatment using this technique were discharged without neurologic complications.

We describe the case of a 71-year-old woman presenting with abdominal angina with an intra-aortic mass at the thoracoabdominal aorta that restricted blood supply to the organs. Initially, the intra-aortic mass was suspected to be a mural thrombus; thus, endarterectomy was performed. However, postoperative histopathological examination revealed an intimal sarcoma, which relapsed locally within a few months. Additional en bloc resection of the aorta with graft interposition was performed. Despite surgical therapy, splenic metastasis was detected a few months after the second surgery; therefore, palliative care was selected for the patient.

A right-sided aortic arch, associated with an aberrant left subclavian artery and a Kommerell’s diverticulum, is a rare congenital anomaly. Case 1: A 53-year-old man, complaining of dysphasia, underwent a two-stage hybrid operation. Total arch replacement with the reconstruction of supra-aortic vessels was performed via a median sternotomy. Thoracic endovascular aortic repair was subsequently completed with the femoral approach. Case 2: A 81-year-old man, complaining of syncope and dizziness, underwent thoracic endovascular aortic repair after endovascular aneurysm repair for a common iliac artery aneurysm. Treatment strategies for Kommerell’s diverticulum should be individually determined depending on the clinical situation and anatomical features.

Spinal cord ischemia (SCI) is a devastating complication following thoracic endovascular aortic repair (TEVAR). A man with a ruptured thoracic aortic aneurysm (TAA) was transferred to our hospital. Emergency TEVAR, with left subclavian artery (LSA) coverage, was performed for the ruptured TAA. On postoperative day two, the patient had incomplete paralysis in his legs, presumably caused by SCI. We performed LSA revascularization (LSAR) to provide blood supply to the spinal cord; his paralysis improved and almost resolved after surgery. To our knowledge, this is the first report on LSAR’s efficacy for delayed paraplegia due to SCI.

The impact of blood disorders on fibromuscular dysplasia is unknown, and cardiovascular surgery results are also unclear. Furthermore, there are only a few case reports about the association between fibromuscular dysplasia and blood disorders. We report a case of a coronary bypass surgery and an aortic root replacement for a patient who is hypereosinophilic with multisite vasculopathy of fibromuscular dysplasia, including that of the coronary artery and saphenous vein, which was diagnosed by a histopathologic examination after an autopsy was performed 5 months after surgery. The outcome of cardiovascular surgery can be unfavorable for fibromuscular dysplasia. Blood disorders may also have an impact on the outcome.

The radial artery access site laceration is rare. We hereby described a case of radial artery access site laceration during retrieval of a cutting balloon. The bleeding site was not responsive to hemostatic maneuvers such as application of an external blood pressure cuff, balloon inflation, and an external compression bandage and was eventually coil embolized. Sacrifice using endovascular coiling averted surgical ligation which was the alternative.

Retroperitoneal tumors (RTs) are frequently found as large masses upon diagnosis. Within the differential diagnosis of RTs, one of the most important are germ cell tumors. We report here the case of a 30 year old man with a recurrent RT involving the inferior vena cava (IVC). Once discussed, he underwent a tumor resection with a primary IVC reconstruction maintaining vessel patency. On histopathology, a mixed germ cell tumor was reported. The patient recovered well and he was discharged from the hospital without complications.

Mesenteric ischemia is an infrequent, but potentially dangerous, complication of aortic or mesenteric artery dissection. Severe mesenteric ischemia presenting as a malperfusion syndrome, caused by aortic dissection or isolated mesenteric dissection, should be treated immediately by central aortic repair or angioplasty. However, treatment of non-critical, symptomatic mesenteric ischemia without narrowing true lumen of the aorta or localized mesenteric artery dissection was difficult. We treated two distinctly different cases of non-critical, symptomatic mesenteric ischemia superior mesenteric artery ischemia needing intensive care and mesenteric blood flow was determined by quantification with cine-phase contrast magnetic resonance imaging.

Multiple giant splenic artery aneurysms (>10 cm in diameter) are rare. We report a patient presenting with these aneurysms who had also associated portal hypertension and massive splenomegaly. Almost all the aneurysms were sealed by endovascular means at the first stage. Later, for the residual aneurysms at splenic hilum and enlarged spleen, splenectomy was performed. She made an uneventful recovery.

Bronchial artery–pulmonary artery arterio–venous malformation, previously known as “bronchial artery primary racemose hemangioma” is a rare vascular malformation. The literature surrounding the imaging findings and treatment is currently limited. We hereby describe the imaging findings and a novel endovascular approach of utilizing bi-directional embolization from both the pulmonary and bronchial artery to occlude the malformation, leading to thrombosis and resolution of symptoms. This strategy represents a potential treatment option of non-surgical patients in this rare malformation.

The diagnosis of pulmonary artery sarcoma (PAS) is challenging, and its definitive diagnosis is mainly confirmed using specimens obtained during surgery or autopsy. Endovascular catheter biopsy was performed in five patients with suspected PAS to establish a definitive diagnosis. Aspiration biopsy was performed in all patients, and forceps biopsy was performed in one patient. Three patients were diagnosed with PAS, and no definitive diagnosis was obtained in two patients with squamous cell lung carcinoma with pulmonary artery infiltration. Endovascular catheter biopsy is helpful in the diagnosis of PAS and should be performed when a tumor is suspected.

Objectives: This is an annual report indicating the number and early clinical results of annual vascular treatments performed by vascular surgeons in Japan in 2012, as analyzed by database management committee (DBC) members of the JSVS.

Materials and Methods: To survey the current status of vascular treatments performed by vascular surgeons in Japan, the DBC members of the JSVS analyzed the vascular treatment data provided by the NCD vascular surgery data analysis team, including the number of treatments and early clinical results such as operative and in-hospital mortality.

Results: In total 95,979 vascular treatments were registered by 1,043 institutions in 2012. This database is composed of 7 fields including treatment of aneurysms, chronic arterial occlusive disease, acute arterial occlusive disease, vascular injury, complication of previous vascular reconstruction, venous diseases, and other vascular treatments. The number of vascular treatments in each field was 19,600, 13,141, 4,600, 1,623, 1,973, 30,725, and 24,332, respectively. In the field of aneurysm treatment, 15,745 cases with abdominal aortic aneurysms (AAA) including common iliac aneurysms were registered, and 47.6% were treated by stent graft. Among AAA cases, 1,704 (10.8%) cases were registered as ruptured AAA. The operative mortality of ruptured and non-ruptured AAA was 17.8%, and 0.8%, respectively. Regarding chronic arterial occlusive disease, open repair was performed in 7,859 cases, including 1,173 distal bypasses to the crural or pedal artery, whereas endovascular procedures were performed in 5,282 cases. Venous treatment including 30,088 cases with varicose vein treatments and 395 cases with lower limb deep venous thrombosis were registered. Regarding other vascular operations, 22,654 cases of vascular access operations and 1,390 amputation surgeries were included. The number of lower limb amputations was still increasing and the mortality rate of amputation surgery was also still high; both of these issues require improvement.

Conclusions: The number of vascular treatments increased since 2011, and the proportion of endovascular procedures increased in almost all fields of vascular diseases, especially endovascular aneurysm repair (EVAR) for aneurysms and endovenous laser ablation (EVLA) for varicose veins. (This is a translation of Jpn J Vasc Surg 2018; 27: 437–456.)