Klippel–Trenaunay syndrome (KTS) is a rare slow-flow combined vascular malformation characterized by capillary-lymphatic-venous lesions with soft tissue overgrowth of the limbs. We report the case of a 37-year-old female KTS patient with a deep femoral arterial aneurysm. We finally diagnosed that the aneurysm had resulted from a fundamental defect in the arterial wall structure. We discuss whether the use of “aneurysm associated with KTS” is accurate and how to better classify this type of capillary-venous lesion in 17 reported KTS patients with arterial aneurysms. In this review, we describe nosological problems of arterial aneurysms associated with KTS.

Objective: The objective of this study is to share our experience of early surgical excision of highly vascular carotid body tumor (CBT) and to correlate it with current literature.

Materials and Methods: Data of all consecutive patients diagnosed with CBT from September 2011 to September 2018, who underwent surgical excision, was analyzed.

Results: Of the 22 cases with mean age of 42±standard deviation (SD) 6 years and female to male ratio of 1.2 : 1, 68.1% (n=15) of the tumors were on the right side. There were 13.6% (n=3) Shamblin I, 77.2% (n=17) Shamblin II, and 9% (n=2) Shamblin III tumors. Complete excision without vascular reconstruction was achieved in 63.6% (n=14), while patch plasty with Dacron graft was noted in 29.4% (n=5) and interposition Dacron grafting 13.6% (n=3). Peroperative vascular shunt was deployed in 13.6% (n=3) of cases. Transient neuropraxia of the hypoglossal nerve was noted in 13.6% (n=3) of cases, while permanent drooping of the lower lip was noted in 4.5% (n=1). There was no ischemic stroke. The mortality rate was zero, and no recurrence was recorded in mean follow-up of 24±SD 3 months.

Conclusion: Complete surgical excision of CBT at an early stage, regardless of size, is associated with the best outcome.

Objective: This study aims to evaluate the efficacy and safety of direct oral anticoagulants (DOACs) after unfractionated heparin (UFH) bolus for the treatment of intermediate–high-risk pulmonary embolism.

Materials and Methods: On the basis of initial treatment, 81 patients were divided into two groups: DOAC after UFH bolus infusion group (group D; n=32) and conventional therapy group (group C; n=49). The frequency of recurrence of venous thromboembolism (VTE) and bleeding within 6 months were compared. In addition, hospitalization length and thrombus reduction rate in the pulmonary artery on computed tomography (CT) at the chronic phase were assessed.

Results: Recurrence of VTE was found in one (3.1%) and three patients (6.1%) (P=1.00) in groups D and C, respectively, whereas no bleeding events was found in group D and 8.2% of patients in group C (P=0.15). Group D showed shorter hospitalization (7.2±2.3 days) than group C (15.7±9.9 days; P<0.001). In the subset of patients with serial CT assessment (group D, n=20; group C, n=38), almost all thrombus of pulmonary artery were disappeared and the thrombus reduction rates were similar between the two groups (group D, 99.5%; group C, 97.1%; P=0.59).

Conclusion: DOAC administration immediately after UFH bolus treatment has the same efficacy and safety, whereas hospitalization days were significantly shorter than the conventional treatment group.

Objective: Endovascular treatment (EVT) for lower-limb peripheral artery disease patients reduces blood pressure (BP) and improves prognosis. This study retrospectively examined hemodynamics during EVT to clarify the mechanism.

Materials and Methods: Systemic vascular resistance (SVR) was measured using a noninvasive continuous cardiac output monitoring system during EVT. Furthermore, ankle brachial index was measured before and after EVT.

Results: The study included 88 lesions of 56 patients (hypertension in 98%). SVR significantly decreased from 2409.1±746.8 dynes·s·cm⁻⁵ to 2033.7±635.0 dynes·s·cm⁻⁵ (p<0.0001). The difference in SVR before and after EVT was significantly greater in the Fontaine IV group than in the Fontaine IIa group (554.7±406.6 dynes·s·cm⁻⁵ vs. 312.9±245.7 dynes·s·cm⁻⁵, p=0.0151). The change in SVR was correlated with a change in mean BP in the upper limb (p=0.0026). When the change in pressure gradient between the upper limb and the diseased lower limb was large, mean BP of the upper limb significantly decreased (p=0.0022).

Conclusion: EVT can reduce SVR and BP by canceling the pressure gradient between central BP and diseased lower-limb BP.

Objective: The treatment for arch aneurysms by endovascular repair is often difficult. This study evaluated the long-term outcomes of thoracic endovascular aortic repair for aortic arch aneurysms treated with the Najuta stent-graft system.

Materials and Methods: From January 2009 to December 2019, 37 patients underwent treatment for aortic aneurysms with the Najuta stent graft system at two institutes, including our hospital. We retrospectively analyzed the short- and long-term clinical outcomes.

Results: Of all 37 cases, the technical success rate was 97.3% (36 of 37). The mean proximal neck length was 20.1±5.3 mm. The postoperative results revealed 10 patients with type Ia endoleaks (27.8%), 6 with stroke (16.7%), and one with paraplegia (2.8%). In the chronic phase, the overall survival rates and the rates of freedom from aorta-related events at 7 years were 71.3% and 50.7%, respectively. Between two groups divided based on the proximal neck diameter of 20 mm, the <20-mm group had significantly higher rates of aorta-related events in terms of freedom from aortic events (P=0.046).

Conclusion: The fenestrated stent graft can be a less invasive option for the treatment of high-risk patients with aortic aneurysms.

Objective: This paper documents our experience using the Cleaner XT™ device (Argon Medical Devices, Plano, TX, USA) for pharmacomechanical thrombolysis (PMT) of thrombosed haemodialysis arteriovenous grafts (AVG) and fistulas (AVF).

Materials and Methods: This was a retrospective case series (n=17) over six months at Singapore General Hospital. We evaluated demographics, procedural data, technical and procedural success, patency rates and complications.

Results: There were 8 (47%) males and the patients’ mean age was 66 (± 5.7) years. The mean age of AVF/AVG was 1605 (± 1099) days. All procedures were performed under local anaesthetic. PMT was performed within a mean time of 40 (±34.3) hours from the presentation. Technical, clinical and procedural success was 15/17 (88%). The thrombolysis agents used were tissue plasminogen activator (52.9%) and urokinase (41.2%). Mean primary patency time was 114 (± 116) days, with a 65% 1-month and 47% 3-month primary patency rates. The mean secondary patency time was 155 (±132) days, with 76% one-month and 65% three-month secondary patency rates, respectively. AVF rupture occurred in 3/17 (18%) cases but did not involve loss of the access circuit.

Conclusion: The Cleaner XT™ device is a safe, minimally invasive endovascular tool for PMT in thrombosed AVF/AVG, with relatively high success and low complication rates.

Objective: Devices that can noninvasively measure central and peripheral venous pressures with relative ease and in a short time were developed, but the resolution of the data that can be recorded with these devices is limited to 50 mmHg.

Materials and Methods: We aimed to develop a system that could overcome this limitation. We used an innovative noninvasive controlled compression sonography device that could theoretically measure pressures higher than 200 mmHg. First, to validate the accuracy of our device, an in vitro study was conducted. Then, the values measured by our system were compared to conventionally obtained measurements of central venous, peripheral venous, and brachial artery pressures. Finally, regression analyses were used to determine the correlations between measurements obtained from different devices.

Results: With our device, the measurement of venous and arterial pressures required only 3 to 15 sec. All regression analyses revealed a significant statistical correlation between measurements, although the correlation coefficient was relatively low for arterial pressure.

Conclusion: For venous pressure, our system can provide measurements that could not be measured noninvasively with conventional methods. Regarding arterial pressure, although our system could measure systolic pressure, further studies are needed to confirm the clinical efficacy of our device.

Objectives: This study aimed to evaluate early- and long-term outcomes in patients who undergo muscle flap coverage (MFC) for prosthetic graft infections (PGIs) at the groin or thigh.

Materials and Methods: We retrospectively retrieved and analyzed data on infected wound cures, recurrence, graft and limb salvage, and survival of patients who underwent MFC for PGI at the groin or thigh between 2000 and 2018.

Results: There were eight patients in our cohort: six had groin PGIs and two had thigh PGIs. Moreover, of these patients, seven were treated from sartorius muscles and one from a gracilis muscle. The indicated wounds healed in all eight patients, but two patients died during hospitalization. Three patients suffered recurrence within 8 months, one of which overcame the infection and achieved wound cure without graft removal, with negative pressure wound therapy. No patients lost their limbs during the follow-up term (mean, 24 months; range, 1–60 months). Finally, four patients (50%) survived without removal of the infected graft for longer than 2 years.

Conclusion: MFC can be a curative treatment for PGI, but there remains a possibility of a recurring infection thereafter.

Objective: We sought to clarify the interface pressure (IP) when using a tubular elastic bandage (TEB) and examine the possibility for TEBs to provide IPs comparable to those provided by anti-thrombotic stockings.

Materials and Methods: In 40 healthy patients, IPs were measured at the level of calf at its maximum diameter (C) and transition of the medial gastrocnemius muscle into the Achilles tendon (B1) while a single or double layer of TEBs (17.5 cm in circumference) were applied with the patient in a supine position.

Results: Including both the C and B1 levels, circumferences and IPs showed a good correlation (single layer; r=0.72, double layer; r=0.75). The IP obtained with a single layer of TEB at the C level (median, 17 mmHg [range, 12–23 mmHg]) was higher than that at the B1 level (14 mmHg [11–18 mmHg], p<0.001). When double-layer TEB was used, the IP at B1 level increased to 18 (14–23) mmHg (p<0.001 vs. single layer).

Conclusion: Considering the characteristics of TEBs and using a single or double layer appropriately, creating a pressure profile mimicking that of an anti-thrombotic stocking seemed to be feasible when using a TEB.

We herein report a case of a 20-year-old man with aortic regurgitation (AR), coarctation of the aorta (CoA), and patent ductus arteriosus (PDA). The preoperative ankle–brachial pressure index was 0.56 in bilateral extremities. Enhanced computed tomography revealed CoA-postductal type. We decided to perform a two-stage surgery: thoracic endovascular aortic repair (TEVAR) for CoA and PDA and then open surgery for AR. TEVAR was successfully performed with deployment of the stent graft at a 31-mm diameter subsequent to balloon dilation. At 8 days after TEVAR, the patient underwent aortic valve replacement via median sternotomy and was discharged without a complication.

Although rare, superior mesenteric artery aneurysms (SMAAs) are life-threatening due to their high rupture rate. We herein report a case involving an 80-year-old man who presented with acute cholecystitis and who was incidentally found to have a 36-mm peripheral SMAA. A surgical intervention was performed, involving resection of the SMAA and reconstruction of the superior mesenteric artery (SMA) using an autologous vein graft. Intraoperative and histological findings indicated an inflammatory aneurysm, and the postoperative course was uneventful. We believe that resection of the aneurysm and reconstruction of the SMA is the preferred procedure for SMAAs to maintain adequate mesenteric circulations.

Report on total endovascular repair for a diseased aortic valve and the ascending aorta is few. Therefore, we report a case of prosthetic aortic valve stenosis and internal bovine pericardial flap after ascending aortic replacement complicated by congestive heart failure and hemolysis. Because the patient had high surgical risk and was anatomically suitable to undergo ascending endovascular repair, simultaneous transcatheter aortic valve-in-valve implantation and ascending endografting were performed. Her symptoms of heart failure and hemolysis resolved postoperatively. Thus, a simultaneous transcatheter procedure for a diseased aortic valve and the ascending aorta is a feasible option for appropriately selected patients.

An 83-year-old woman was referred to our hospital under a diagnosis of acute aortic dissection. Contrast-enhanced computed tomography revealed no intimal flap in the mid-ascending aorta, and the intimal flap was found from the distal ascending aorta to the aortic arch. Operative findings showed that the intima of the mid-ascending aorta was circumferentially dissected and was inverted into the aortic arch. An emergent replacement of the ascending aorta was successfully performed; however, she died of a global intestinal ischemia on the fourth operative day.

Hepatic artery aneurysm has been considered as a rare, life-threatening disease. In this study, we report on a patient requiring surgical treatment for a giant hepatic artery aneurysm by aneurysmectomy without revascularization. A 70-year-old woman who complained of epigastric pain was referred to our hospital. Enhanced computed tomography scan has revealed a giant (11×9 cm) common hepatic artery aneurysm. She then underwent emergency surgery; the intra-aortic balloon occlusion technique was applied in order to control the blood inflow into the aneurysm. The aneurysm was then incised, and direct closure of the inflow and outflow orifices was performed safely without evidence of ischemic change in the liver.

A 72-year-old man was referred to our hospital for the suspicion of ruptured abdominal aortic aneurysm. Before admission, he was suspected of having a malignant lymphoma and underwent excisional biopsy in his right groin. A contrast enhanced computed tomography scan revealed a massive retroperitoneal hematoma with an extravasation arising from the infrarenal abdominal aorta coexisting with an extensive retroperitoneal mass surrounding the aorta. An emergency endovascular aneurysm repair was performed and the postoperative course was uneventful. After the treatment, histological examination of the previous biopsy confirmed the diagnosis of mantle cell lymphoma.

Extended inferior vena cava (IVC) filter implantation time increases the risk of complications in patients. Here we present the case of a 72-year-old woman with IVC filter-induced thrombosis who underwent catheter-directed thrombolysis with prophylactic IVC filter placement. Two IVC filters were successfully retrieved 70 and 1858 days post placement. The decision to insert an IVC filter should be carefully considered with appropriate indications and all filters should be removed after the risk of deep vein thrombosis has resolved.

This report describes a successful case of transcatheter arterial embolization for a critical vascular injury during lumbar disk surgery that resulted in a large retroperitoneal hematoma in a 72-year-old woman. A 4-Fr long sheath was inserted via the right popliteal artery in the prone position. Pelvic angiography revealed a pseudoaneurysm in the right internal iliac artery, which was managed with coil embolization. The patient underwent laparotomy because of abdominal compartment syndrome and was discharged in good condition after rehabilitation. The transpopliteal endovascular approach in the prone position may thus provide the best chance to treat this rare but critical condition.

We describe the case of a 66-year-old man with a thoracoabdominal aortic aneurysm, who presented with cardiac failure; he had complained of shortness of breath. A contrast-enhanced computed tomography scan and transthoracic echocardiography showed compression of the left atrium and ventricle by a giant thoracoabdominal aortic aneurysm. The cardiac failure resolved after early prosthetic graft replacement surgery.

We present a case of superior mesenteric venous thrombosis (SMVT) treated successfully with thrombectomy without bowel resection. A 73-year-old female was referred to our hospital with complaints of stomach ache. The patient was diagnosed with SMVT with impending bowel necrosis and underwent an emergency operation, after computed tomography (CT) revealed a thrombus in the superior mesenteric vein (SMV) extending to the splenic vein, ascites, and extremely edematous intestines. The intestines were not necrotic though highly congested. To avoid massive bowel resection, aggressive thrombectomy was performed. Postoperative CT confirmed resolved SMV and improved bowel edema. Prompt thrombectomy should be considered in such cases.

Superior mesenteric artery aneurysms (SMAAs) are rare and potentially life-threatening. Whether surgical or endovascular repair is performed, mesenteric ischemic complication is the greatest concern. A 56-year-old gentleman with SMAA underwent surgical resection with reconstruction of the superior mesenteric artery (SMA) and its branches using the great saphenous vein with several techniques, including island reconstruction of the branches, staged segmental cross-clamping, and an external shunt, to reduce the mesenteric ischemia time. The postoperative course was uneventful with no signs of mesenteric ischemia. A computed tomography scan showed that all grafts to the SMA and its branches were patent.

Anastomotic pseudoaneurysm and patch aneurysm are life-threatening complications following thoracoabdominal and descending thoracic aortic aneurysm (DTAA) repair. The aortic wall tissue is fragile in patients with Marfan syndrome, who are at high risk of anastomotic pseudoaneurysm and patch aneurysms. We experienced a rare case of ruptured pseudoaneurysm of the intercostal patch after DTAA repair in a patient with Marfan syndrome. A hematoma was separated from the pseudoaneurysm caused by adhesion of the left lung after DTAA repair, which made diagnosis difficult. To prevent type II endoleak and achieve thoracic endovascular aortic repair, we treated the patent intercostal arteries by embolization.

A 75-year-old man underwent emergent endovascular aortic repair for a ruptured abdominal aortic aneurysm. Two years later, computed tomography revealed aneurysm enlargement with endoleaks. Next, late open conversion was performed. Intraoperatively, we detected a spurting type II endoleak from an artery within the aneurysmal wall, which was unconnected to any branch vessels outside the aneurysm, and surgical ligation and sacotomy was performed uneventfully. To our knowledge, this is the first report to intraoperatively identify a type II endoleak from an artery within the aneurysm wall. Even for atypical type II endoleak, such as this case, open surgical repair should be effective.

Factor XII (FXII) deficiency is a rare coagulation disorder, and its potential relationship with venous thrombosis was reported. Here we present a case of a 67-year-old woman with FXII deficiency who successfully underwent endovenous thermal ablation (ETA) for primary varicose vein due to the incompetent great saphenous vein (GSV). The FXII deficiency was revealed through preoperative examinations, and the patient underwent ETA as a day surgery. For prophylaxis of thrombosis, she received compression therapy alone. Her postoperative course was uneventful, without any kind of thrombosis. In the presence of FXII deficiency, ETA could be safely performed.

A 76-year-old man was admitted to our hospital because of sudden pain in the left leg. Computed tomography and ultrasonography findings revealed occlusion of the plantar and sural arteries and atherothrombosis in the abdominal aorta, and thromboembolism was suspected. The foot was treated for ischemia and embolic sources in two stages. First, we performed embolectomy using a balloon catheter exposed to the common plantar artery through arteriotomy. This surgical revascularization is an effective treatment method for thromboembolism. Four weeks later, we performed graft replacement of the abdominal aorta to prevent thromboembolism.

Hepatic vein aneurysm is an extremely rare case. The etiology of hepatic vein aneurysms is uncertain, and endovascular treatment of this condition has not been reported. We report the case of a 71-year-old woman with right upper abdominal pain who was diagnosed with hepatic vein aneurysm and was successfully treated with an endovascular technique.

Objectives: This is an annual report indicating the number and early clinical results of annual vascular treatment performed by vascular surgeon in Japan in 2014, 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 National Clinical Database (NCD), including the number of treatments and early results such as operative and hospital mortality.

Results: In total 113,296 vascular treatments were registered by 1,002 institutions in 2014. 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 21,085, 14,344, 4,799, 2,088, 1,598, 42,864, and 26,518, respectively. In the field of aneurysm treatment, 17,973 cases of abdominal aortic aneurysm (AAA) including common iliac aneurysm were registered, and 55.7% were treated by endovascular aneurysm repair (EVAR). Among AAA cases, 1,824 (10.1%) cases were registered as ruptured AAA. The operative mortality of ruptured and un-ruptured AAA was 16.1%, and 0.6%, respectively. 32.1% of ruptured AAA were treated by EVAR, and the EVAR ratio was gradually increasing, but the operative mortality of open repair and EVAR for ruptured AAA was 15.7%, and 18.0%, respectively. Regarding chronic arterial occlusive disease, open repair was performed in 8,020 cases, including 1,210 distal bypasses to the crural or pedal artery, whereas endovascular treatment (EVT) were performed in 6,324 cases. The EVT ratio was gradually increased at 44.1%. Venous treatment including 41,246 cases with varicose vein treatments and 520 cases with lower limb deep vein thrombosis were registered. Regarding other vascular operations, 25,024 cases of vascular access operations and 1,322 lower limb amputation surgeries were included.

Conclusions: The number of vascular treatments increased since 2011, and the proportion of endovascular procedures increased in almost all field of vascular diseases, especially EVAR for AAA, EVT for chronic arterial occlusive disease, and endovenous laser ablation (EVLA) for varicose veins. (This is a translation of Jpn J Vasc Surg 2020; 29: 15–31.)