As per the World Health Organization, a disaster is defined as “an event that occurs in most cases suddenly and unexpectedly, causing severe disturbances to people or objects affected by it, resulting in the loss of life and harm to the health of the population.” A number of health issues are often reported following disasters, such as physical and psychological trauma, infections, malnutrition, and cardiovascular events. Among these, venous thromboembolism is deemed serious and thus should be taken into consideration. Indeed, its risk has been demonstrated to increase following earthquakes, floods, burns, and intoxications. The recent coronavirus pandemic summarizes some of the main triggering factors involved in acute and chronic venous disease development in a disaster setting: inflammation, infection, lockdown-induced reduced mobility, potential malnutrition, and overweight.

Proper venous risk assessment and guideline application have been determined to be essential in disaster management, particularly in the current time in which sheltering could lead to a potential exacerbation of the pandemic, which can only increase the risk for venous thrombotic diseases.

Global scientific teamwork is needed to make the recommendations as evidence-based and as homogeneous as possible among continents.

In this present review, we focus on how earthquakes impact venous thromboembolism, including an analysis of other disaster-related conditions, such as burns and intoxication. (This is a review article based on the informative seminar of the 40th Annual Meeting of Japanese Society of Phlebology.)

While endovenous thermal ablation (ETA) become first choice of treatment for varicose veins, overuse of ETA for the inappropriate indication is growing problem. ETA is performed not only on varicose cases without symptom but also non diseased cases with segmental reflux of saphenous veins or no reflux. Indications of ETA was demonstrated in “the Clinical Practice Guidelines for ETA for Varicose Veins 2019” by Japanese Society of Phlebology. Purpose of this supplement is description of basics of correct indication for ETA. We also demonstrate the typical case of overuse of ETA for wrong indication. (This is a translation of Jpn J Phlebol 2020; 31: 39–43.)

Objective: The perfusion index (PI) is a physiological marker for evaluating the peripheral circulation. We explored the possibility of using PI as a screening tool for development of critical limb ischemia in peripheral artery disease (PAD).

Method: We measured the PI in 79 limbs of 70 PAD patients. Data were analyzed to find a correlation between the PI and PAD severity.

Result: The PI tended to be lower as PAD became severer. Especially, there were significant differences between the Fontaine 1 and Fontaine 4 groups in average PI and minimum PI, and between Fontaine 1 and two other groups (Fontaine 2 and Fontaine 4 groups) in maximum PI. A mild correlation was found between PI and the ankle brachial index. These data were used to calculate an average PI of 0.27 as a cut-off value for critical limb ischemia (CLI). In 65 asymptomatic PAD patients and claudication, significantly more patients with a PI value greater than the cut-off value developed CLI than those with a PI lower than the cut-off.

Conclusion: The PI can be a useful tool for evaluating the development of CLI in mild PAD patients, and patients tended not to progress to CLI when their average PI was higher than 0.27. (This is a translation of Jpn J Vasc Surg 2020; 29: 103–108.)

Objective: We investigated the association between Controlling Nutritional Status (CONUT) scores and the outcomes of bypass surgery in patients with chronic limb-threatening ischemia (CLTI).

Methods: We retrospectively calculated preoperative CONUT scores in 118 patients (127 limbs) with CLTI who underwent infrainguinal bypass surgery. Survival, graft patency, and limb salvage were compared between the high and low CONUT score groups based on the respective cutoff points.

Results: The median and mean CONUT scores were 5 and 4.8, respectively. The postoperative survival rate was lower in the high CONUT score (3–12) group than in the low CONUT score (0–2) group (P=0.0043). The limb salvage rate after arterial reconstruction was also significantly lower in the high CONUT score (8–12) group than in the low CONUT score (0–7) group (P=0.0009).

Conclusions: The CONUT score can predict infrainguinal bypass surgery outcomes in patients with CLTI. (This is a translation of J Jpn Coll Angiol 2020; 60: 35–41.)

Objectives/Background: With decreased patient downtime and reduction in health expenditures, endovascular treatments have become popular for the treatment of venous insufficiency. In this study, we assessed the outcomes of using radiofrequency ablation (RFA) and sclerotherapy for refluxing veins and incompetent perforators in a developing country.

Materials and Methods: Subjects were selected from an ongoing registry from October 15, 2015 to April 5, 2018. Patients were followed up until 6 months. Pre- and post-procedural Clinical, Etiologic, Anatomic, and Pathophysiologic (CEAP) scores were compared, and complications were documented and treated accordingly.

Results: In total, 102 limbs (n=97) with 76 great saphenous veins (GSVs) and 26 small saphenous veins (SSVs) underwent RFA, with 79% undergoing concomitant sclerotherapy. Mean follow-up time was 188 days (±33.16). Moreover, 59% were males and 41% females. At the end of follow-up, 99% of the legs had complete occlusion. Pre- and post-procedural CEAP scores were 4.21±1.5 and 3.36±1.7, respectively (p-value <0.001). Endovenous heat-induced thrombosis (EHIT) types 1, 2, 3, and 4 were found in 8.8%, 3.9%, 1.9%, and 0% of the legs, respectively. Most common complications were pain and tenderness (51%), bruising (18%), and paresthesia (7%).

Conclusion: RFA and sclerotherapy have proved to be safe and efficacious. Computed tomography (CT) venous mapping aids in delineating complex venous anatomy and in ruling out deep vein thrombosis (DVT) in cases with discrepancy on Doppler ultrasound. Strict compliance of procedural and post-procedural protocol can assure promising results and futuristic value.

Objective: This is a prospective study concerning patients with symptomatic or asymptomatic significant carotid stenosis. Preoperative and intraoperative measurements of the peripheral extension of the carotid atherosclerotic plaque have been compared with postoperative measurements to identify a preoperative method that safely allows the performance of eversion carotid endarterectomy (ECEA).

Materials and Methods: The study included 37 patients with symptomatic internal carotid stenosis greater than 70% and 43 patients with asymptomatic stenosis greater than 80%. Four methods were used for establishing criteria: preoperative Doppler examination, intraoperative measurement of the carotid atheroma before artery division, measurement of the removed plaque, and histological measurement of the plaque.

Results: Preoperative Doppler examination is a method of estimating the actual distal extension of the internal carotid artery (ICA) atheroma, with correction as dictated by the following formula:

AL= 0.6704+0.7685·Doppler

In all cases, preoperative ultrasound measurements and intraoperative estimation confirmed the correct decision to proceed with the eversion technique.

Conclusion: The peripheral extension of the atherosclerotic plaque of the ICA can be assessed with accuracy by preoperative Doppler study, which can be used with safety as a predicting criterion of the existence of healthy peripheral carotid tissue that allows the performance of the eversion endarterectomy technique.

Objectives: Anterior accessory saphenous vein (AASV) insufficiency is one of the most common causes of recurrent varicose veins after endovenous thermal ablation (EVTA) for great saphenous vein (GSV) insufficiency. The purpose of this study was to evaluate the efficacy and safety of cranial tributary ablation (CTA) during laser crossectomy (LC) of the GSV.

Methods: We reviewed 182 limbs in 171 patients undergoing EVTA aiming for LC with a 1470-nm diode laser. In the CTA group, either the superficial circumflex iliac vein or the superficial epigastric vein was directly ablated during LC. The result was compared between the CTA (n=63) and control (n=119) groups using follow-up duplex ultrasound performed for 6 months after EVTA.

Results: Initial success rate of CTA was 69%. The AASV occlusion rate (90% vs. 63%, p<0.001) and the flush GSV occlusion rate (68% vs. 30%, p<0.001) at 6 months were better in the CTA group. No major adverse events were observed.

Conclusion: CTA during LC of the GSV is a safe and effective approach to achieve better flush or AASV occlusion rates after EVTA. It is occasionally technically demanding but can be a feasible option. Further investigation is needed to confirm our results.

Objectives: Distal stent graft-induced new entry (dSINE), defined as a new tear caused by a stent graft, has been increasingly observed following total arch replacement using frozen elephant trunk (FET) for aortic dissection. We aimed to investigate the incidence and treatment of dSINE after the use of FET.

Methods: This retrospective study evaluated 70 patients who underwent total arch replacement using FET for aortic dissection between August 2014 and March 2020. They were followed up for at least 6 months postoperatively. Between-group comparisons were performed between those who did and did not develop dSINE. The risk factors for the development of dSINE and the treatment of dSINE were analyzed.

Results: dSINE occurred postoperatively in nine patients (12.9%) with a median time frame of 17.7±11.7 months. The incidence of dSINE did not differ significantly according to classification, phase of dissection, or oversizing. All patients in the dSINE group developed enlargement of the false lumen. dSINE closure was successfully achieved without complications via thoracic endovascular aortic repair (TEVAR) in all patients.

Conclusion: No independent factors predicting the development of dSINE were noted in this study. Additional TEVAR for dSINE provides good results and achieves false lumen thrombosis in the thoracic aorta, with no complications.

Vascular closure devices (VCDs) are useful for reducing bed rest time after percutaneous catheterization procedure without manual compression at the femoral puncture site. Occlusion of the common femoral artery (CFA) related to VCDs has rarely been reported. Although catheter treatment for CFA occlusion may be the first choice, it may be insufficient. Surgical treatment should be performed immediately when catheter treatment for artery occlusion is deemed difficult. We report a case of surgical angioplasty performed for femoral artery occlusion by using a suture-mediated device.

A 68-year-old man with a history of esophageal resection and reconstruction by gastric tube in substernal fashion required aortic root replacement for annuloaortic ectasia and severe aortic regurgitation. The gastric tube attached closely at the manubrium of the sternum and around the xiphoid process, but it positioned leftward slightly at the body of the sternum. At the operation of the aortic root replacement, we decided the lower hemisternotomy approach to avoid injury of the gastric tube. The lower hemisternotomy to access the aortic root provides a useful alternative approach in some cases with substernal reconstruction after surgery of esophageal cancer.

In this study, we report a case of a patient on dialysis who presented necrotic lesions on the legs and penile ulceration 7 years after a mechanical aortic valve replacement. The diagnosis of calciphylaxis was not confirmed even after skin biopsy, and multidisciplinary management was not initiated until the patient was admitted with septic shock. Cardiovascular surgeons should be aware of warfarin-induced calciphylaxis, whose pathophysiology differs from that of atherosclerosis. Considering poor long-term survival of dialysis patients, mechanical valves should be reserved only for those patients whose estimated survival is longer than the time taken for a biological valve to deteriorate.

Immunoglobulin G4-related disease (IgG4-RD) can affect various organs, including the cardiovascular system. In this study, we described the case of a 72-year-old man with periaortitis both in the ascending and terminal aorta related to IgG4-RD. He presented with swelling in the left leg. Computed tomography (CT) showed increased wall thickness of the ascending aorta and retroperitoneal fibrosis, which, in turn, caused deep vein thrombosis. Using positron emission tomography-computed tomography, the patient was diagnosed with IgG4-RD in the aorta. Although it was difficult to distinguish intramural hematoma (IMH) from IgG4-related periaortitis, treatment with steroids has dramatically improved his periaortitis. IgG4-related periaortitis should be differentiated from IMH due to their similar morphologies.

A 73-year-old woman, who had previously undergone endovascular aortic repair (EVAR), developed severe back pain while shoveling snow. Preoperative computed tomography (CT) revealed marked retroperitoneal hematoma around the abdominal aortic aneurysm (AAA) with extravasation of contrast media. Intraoperative angiography demonstrated spontaneous lumbar artery injury (SLI). The bleeding lumbar artery was embolized using lipiodol, and deteriorated hemodynamics were stabilized. SLI is rare and can mimic the clinical symptoms and CT findings of AAA rupture. Vascular surgeons should focus on the status of the aneurysmal sac and the possibility of another retroperitoneal disease to determine appropriate treatment options, despite successful EVAR for AAA.

A 63-year-old man with a confirmed case of coronavirus disease 2019 and having complaints of severe pain and paralysis in his right lower limb was transported to our hospital in an ambulance. Because of thrombosis, a computed tomography angiogram revealed the occlusion of right common iliac artery and stenosis of abdominal aorta. Emergency angiography and thrombectomy were performed; after surgery, the patient was managed in the intensive care unit with mechanical ventilation and hemodialysis for renal failure. However, on postoperative day 7, thrombosis recurred, and he died because of multiple organ failure.

An 87-year-old man, who submitted to endovascular aneurysm sealing (EVAS) on 2017, presented a type Ia endoleak 2 years later, with enlargement of the aneurysmal sac. We planned an endovascular procedure of correction consisting of a proximal extension through two covered stent grafts deployed into the previous Nellix stent grafts, with associated triple chimney. However, 3 months later, he had a further 5 mm aneurysmal sac enlargement. He was submitted to angiography with coil embolization of gutters, obtaining a successfully result. At 1 and 3 months, he is free from endoleak, with a stable aneurysmal diameter.

We report a case of endovascular aneurysm repair (EVAR) in a patient with horseshoe kidney (HSK) in whom preoperative contrast-enhanced (CE) computed tomography (CT) showed watershed sign. This sign enabled prediction of postoperative renal function by accurate renal volumetry. A 75-year-old man with HSK and a 59-mm abdominal aortic aneurysm was referred for treatment. Preoperative CECT showed watershed lines at the margin of the isthmus, which was perfused by the accessory renal arteries. Using this sign, we calculated the accurate volume of the isthmus, which was 24.5% of the total parenchyma. EVAR was safely performed without renal dysfunction.

A 49-year-old man, who had undergone total arch replacement (TAR) with frozen elephant trunk (FET) technique for type A acute aortic dissection, was subsequently transferred to our hospital for uncontrollable infection. Since multiple blood cultures were positive for Candida parapsilosis and transesophageal echocardiography revealed vegetation attached to the FET, he was diagnosed with a graft infection. In addition, on the 18-fluorodeoxyglucose positron emission tomography scans, high uptake lesions were found around the quadrifurcated graft as well as the FET. Therefore, an extensive TAR through anterolateral thoracotomy with partial sternotomy was performed to remove all infected prothesis. Consequently, the patient completely recovered.

Re-expansion of thrombosed false lumen after aortic dissection due to collateral retrograde flow from the aortic branches has rarely been reported. Surgical or endovascular local management such as ligation or occlusion of culprit arteries may not be effective in case retrograde blood flow to the false lumen might occur again from another branch after the operation. Here, we report a 68-year-old woman with re-expansion of the thrombosed false lumen after acute type B aortic dissection due to collateral retrograde flow from the aortic branches successfully treated with tranexamic acid therapy and antihypertensive therapy.

Chronic mesenteric ischemia (CMI) involving occlusion and/or stenosis of multiple mesenteric arteries is rare. We report our experience with a 66-year-old man who presented with a more than 3 months history of abdominal pain and vomiting/diarrhea. A diagnosis of CMI due to occlusion of the superior mesenteric artery (SMA) and severe stenosis of the celiac artery by median arcuate ligament syndrome was made. Complete revascularization through iliac artery–SMA bypass grafting and arcuate ligament dissection assisted with staged-catheter intervention successfully alleviated the patient’s symptoms. The patient has maintained a normal daily diet for 6 months postoperatively.

A 75-year-old man with an abdominal aortic aneurysm underwent endovascular aortic repair (EVAR) using an AFX2 endograft with no endoleaks. Nevertheless, the aneurysmal sac increased by 8 mm at 24 months after EVAR despite no detectable endoleaks. Open surgical treatment was performed because of the risk of rupture. Intraoperative findings of much viscous cloudy fluid with no blood flow in the sac suggested that perigraft seroma resulted in sac enlargement. The endografts were replaced by a Dacron graft. Perigraft seroma should be considered as a cause of sac growth after EVAR with AFX2 when there are no detectable endoleaks.

Ductus arteriosus aneurysm (DAA) is rarely encountered in adults. There have been several hypotheses regarding its origin and potential indications for intervention in asymptomatic cases. If left untreated, rupture, compression of surrounding organs, and serious complications due to thromboembolism may occur, and aggressive surgical intervention appears desirable for patients who can tolerate surgery. We report a case involving a 30-mm, saccular, patent DAA that was incidentally discovered in a 49-year-old man on computed tomography. Open repair was performed by femorofemoral bypass assistance, which allowed decompression of the aorta and aneurysm and successful closure of the aortic and pulmonary artery ends.

Objectives: This is an annual report indicating the number and early clinical results of annual vascular treatment performed by vascular surgeon in Japan in 2016, 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 136,414 vascular treatments were registered by 1,070 institutions in 2016. 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 21,653, 17,560, 4,983, 2,557, 846, 54,462 and 34,353, respectively. In the field of aneurysm treatment, 19,144 cases of abdominal aortic aneurysm (AAA) including common iliac aneurysm were registered, and 60.3% were treated by endovascular aneurysm repair (EVAR). Among AAA cases, 1,714 (9.4%) cases were registered as ruptured AAA. The operative mortality of ruptured and unruptured AAA was 15.7%, and 0.6%, respectively. 35.9% 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 15.8%, and 15.3%, respectively. Regarding chronic arterial occlusive disease, open repair was performed in 9,303 cases, including 1,329 distal bypasses to the crural or pedal artery, whereas endovascular treatment (EVT) was performed in 8,257 cases. The EVT ratio was gradually increased at 47.0%. The number of varicose vein treatment tremendously increased to 52,639, and 68.5% of the cases were treated by endovenous laser ablations (EVLA). Regarding other vascular operations, 32,779 cases of vascular access operations and 1,411 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 EVLA for varicose veins. (This is a translation of Jpn J Vasc Surg 2021; 30: 23–41.)