It is a clear fact that many complications in surgical treatment, not just in cardiovascular surgery, are caused by things related to surgical techniques. In other words, postoperative problems are already determined by preoperative surgical management and intraoperative surgical operations. This describes strategies to avoid the surgical complications of distal bypass using the autogenous veins for each item. (This is a translation of Jpn J Vasc Surg 2024; 33: 67–72)

Objective: To comparatively examine in-hospital mortality between open aneurysm repair (OAR) and endovascular aneurysm repair (EVAR) for ruptured abdominal aortic aneurysm (rAAA) in Japan.

Methods: Using administrative data, this retrospective cohort study analyzed rAAA patients treated at 482 Japanese acute care hospitals between April 1, 2018 and March 31, 2021. Patients were assigned to an OAR group or EVAR group. The propensity score for EVAR was calculated, and logistic regression analysis using inverse probability of treatment weighting was performed with in-hospital mortality as the dependent variable and surgical procedure (EVAR vs OAR) as the main independent variable of interest.

Results: The OAR group and EVAR group comprised 2650 patients from 372 hospitals and 2656 patients from 356 hospitals, respectively. In-hospital mortality was significantly higher (P <0.01) in the OAR group (11.7%) than in the EVAR group (9.4%). The logistic regression analysis calculated the odds ratio for in-hospital mortality to be 0.74 (95% confidence interval: 0.60–0.92; P <0.01) in the EVAR group (reference: OAR group).

Conclusion: EVAR was significantly associated with reduced in-hospital mortality and shorter hospitalizations in patients treated for rAAA in Japan.

Objectives: With improved surgical outcomes for non-ruptured abdominal aortic aneurysm (AAA), the primary objective has shifted toward the detection of asymptomatic AAA. Since ultrasonographic visualization from the anterior abdominal wall is often obstructed by intestinal gas, utilizing additional bilateral posterior approaches via the retroperitoneal tissue may be beneficial. This study investigates the feasibility of assessment using three approaches through computed tomography (CT) data analyses.

Methods: The study included 27 surgical patients with AAA (AAA group) and 37 patients with other atherosclerotic diseases (non-AAA group). CT data were analyzed to locate the infrarenal aorta relative to the navel, availability of acoustic window, depth of the aorta, and assessment of aneurysmal aorta using three approaches.

Results: The “AAA area” for ultrasonographic screening may be set at 0–4 cm above the navel. An acoustic window was unavailable in 8.1% of AAA cases and 7.4% of non-AAA cases in the anterior approach; however, it was available in the posterior approach. Although the depth of the aorta was greater in obese patients, it remained within 20 cm.

Conclusion: Ultrasonographic screening is feasible by incorporating posterior approaches in cases where anterior visualization is difficult, enhancing the detection of asymptomatic AAA.

Objectives: We evaluate the preliminary and intermediate-term results of Viet Duc modification of the frozen elephant trunk (FET) technique.

Methods: During December 2019 and May 2023, 47 patients underwent surgery using our modification of the FET at Viet Duc University Hospital. The mean age of the patients was 56.8 years (±9.4, range 31–72). In all, 34 (72.3%) of the patients were men.

Results: There were 5 (10.6%) perioperative deaths. The duration of cardiopulmonary bypass, cross-clamping, circulatory arrest, and total operation were 165 (±49.1 range 94–330), 100 (±37, range 46–205), 32.6 (±8, range 20–58), and 366 (±60.6, range 270–540) minutes, respectively. In complications, tracheotomy, temporal hemodialysis, cerebral shock, and type 1A endoleak were noted in 3 (6.4%), 4 (8.5%), 4 (8.5%), and 3 (6.4%) patients, respectively. The mean follow-up time was 25.8 months (±11.7, range 3–42). One case was dead in the follow-up period. Three patients (6.3%) had successful reoperation for type 1A endoleak, and 4 patients (8.5%) underwent a second intervention. One (2.1%) patient had a second intervention and an infrarenal abdominal aortic replacement.

Conclusions: Our modification of the FET technique was feasible, effective, and safe, with good early and intermediate-term outcomes.

Objectives: Although direct oral anticoagulants (DOAC) have become widely used, little is known about the efficacy of DOAC for isolated distal deep vein thrombosis (DVT).

Methods: In-hospitalized orthopedic patients with isolated distal DVT who were diagnosed from 2016 to 2018 were enrolled and were followed for 1 year. Embolic events included symptomatic pulmonary embolism (PE) and DVT extension above the knee. Bleeding events were determined in the presence of bleeding academic research consortium (BARC) 2, 3 or 5 bleeding.

Results: Of 196 orthopedic patients, 84% of patients (n = 164) received DOAC (DOAC+ group), whereas 16% of patients (n = 32) did not (DOAC– group). Cumulative incidence of embolic events was observed in 1.5% of the DOAC+ group and none of the DOAC– group (p = 0.443). Cumulative incidence of bleeding events was observed in 5.1% of the DOAC+ group and none of the DOAC– group (p = 0.157). The majority of bleeding events (80%) occurred in patients with HAS-BLED scores of 3 or greater.

Conclusions: There were no significant differences in embolic events and bleeding events in retrospective data. Balancing thrombotic risk and bleeding risk remains to be key for isolated distal DVT.

Objectives: We report our hospital-based experience in management strategies and outcomes for pediatric extremity vascular trauma at a major trauma center.

Methods: A retrospective chart review was conducted on patients under 18 with extremity vascular injuries who had surgery between May 2021 and February 2023.

Results: Among 46 children, 16 (34.8%) had upper extremity injuries, while 30 (65.2%) had lower extremity injuries. Blunt trauma mechanism (82.6%) was dominant, followed by penetrating (17.4%). In all, 34 patients (73.9%) had at least 1 extremity injury, including 14 open fractures. 58.9% of patients did not present with acute ischemic syndrome. Regarding vascular repair, 16 patients (34.8%) underwent direct revascularization, 13 (28.3%) cases involved arterial dilatation using a Fogarty catheter, 9 patients (19.5%) had vascular repair using the great saphenous vein, and 1 case had cephalic and basilic venous repair using an allograft vein. Six patients had a temporary external fixation for complex lower limb fractures. One patient had a secondary amputation after a popliteal injury. One death was documented (2.7%).

Conclusions: Blunt trauma poses challenges in pediatric cases. Vascular surgeons must consider children’s future growth. Early diagnosis and treatment by experienced vascular surgeons at major surgical centers can lower mortality and amputation rates.

Objectives: This study aimed to quantitatively evaluate peripheral nerve injury (PNI) after varicose vein (VV) surgery using endovenous laser ablation (EVLA).

Methods: Overall, 25 cases were analyzed. All patients underwent EVLA of the great saphenous vein (GSV) with or without resection of the varix of the GSV tributaries in stab and avulsion fashion (microphlebectomy). For evaluation of PNI, the current perception threshold (CPT) was measured preoperatively at 1 week, 1 month, 3 months, and 6 months postoperatively. In each leg, CPT was measured at 6 points. PNI was defined as >40% elevation from preoperative data.

Results: A significant elevation in CPT was observed at 2 points (knee joint level [P = 0.01] and upper portion of the lower leg [P = 0.008]) 1 week postoperatively. CPT decreased after 1 month and recovered to the same level after 6 months. PNI occurred in 52% and 36% of patients at the knee joint level and upper portion of the lower leg, respectively. Microphlebectomy was indicated as a factor associated with PNI (P <0.01).

Conclusions: Although VV surgery using EVLA is less invasive, the occurrence of transient PNI in the early postoperative period should be noted when concomitant microphlebectomy is performed.

Objectives: The purpose of this study is to evaluate the feasibility and clinical outcomes of vasa vasorum embolization for preventing continuous aneurysmal expansion after endovascular aneurysm repair (EVAR).

Methods: We retrospectively reviewed the medical records of patients who underwent vasa vasorum embolization between August 2018 and May 2022. Vasa vasorum embolization was attempted in cases of continuous aneurysmal expansion after EVAR, where the vasa vasorum was identified through catheter angiography. The vasa vasorum was accessed and embolized with a microcatheter. The outcomes of vasa vasorum embolization were evaluated based on technical success, defined as the successful completion of the embolization procedure, and clinical success, defined as the prevention of continuous aneurysmal expansion after the embolization.

Results: Seven cases of endoleak with developed vasa vasorum were confirmed by catheter angiography. The mean age was 83.7 years, and the mean aneurysmal diameter was 60.6 mm. Technical success was achieved in 6 cases, while clinical success was not achieved in any of the cases. The mean observation period was 16.5 months, and the mean increase in aneurysmal diameter was 9.7 mm.

Conclusions: Although the vasa vasorum embolization is a technically feasible procedure, it is not effective in preventing continuous aneurysmal expansion.

Objectives: Evidence for antithrombotic therapy after endovascular therapy (EVT) is limited.

Methods: This retrospective, multicenter, observational study enrolled 732 consecutive patients with lower extremity artery disease who underwent EVT between January 2018 and December 2019. Overall, 570 patients who received single antiplatelet therapy (SAPT) and dual antiplatelet therapy (DAPT) were selected and divided into the SAPT (n = 189) and DAPT (n = 381) groups. The primary outcome was bleeding events at 24 months. The secondary outcomes were bleeding events at 30 days and 24 months after 30 days, ischemic events, and all-cause death at 24 months. Bleeding and ischemic events at 24 months were investigated in subgroups.

Results: A propensity score matching yielded 164 patients in both groups. There were no significant differences in bleeding events between the SAPT and DAPT groups (14.2% and 11.3% at 24 months, p = 0.775; 2.5% and 6.1% at 30 days, p = 0.106; 11.7% and 6.7% at 24 months after 30 days, p = 0.162). Additionally, there was no significant difference in ischemic events at 24 months between the two groups (32.7% and 30.6%, p = 0.625). Bleeding and ischemic events at 24 months were similar between subgroups.

Conclusions: No significant differences in bleeding or ischemic events between SAPT and DAPT were observed.

We present a case of arterial bypass for extensive stenosis of the ulnar artery and superficial palmar arch. The ulnar artery and the superficial palmar arch were bypassed using the great saphenous vein. Postoperatively, blood flow to the affected fingers gradually improved and the pain disappeared. Contrast-enhanced CT showed good visualization of the superficial palmar arch and more distal digital arteries. Considering the slow improvement in blood flow and the dilation of the stenotic finger artery postoperatively, it appeared that there was a significant effect of spasm in addition to organic stenosis preoperatively and that revascularization was an effective treatment.

Antiphospholipid syndrome (APS) and systemic lupus erythematosus (SLE) are similar to be characterized by thromboembolic events and various clinical manifestations. We experienced a 21-year-old man with acute iliocaval deep vein thrombosis (DVT). Primary APS was initially diagnosed on the criteria, and after multidisciplinary treatment, iliocaval DVT was gradually regressed. Six months later, the patient complained of acute enteritis, followed by peripheral neuropathy and butterfly lupus. SLE was diagnosed, which suggested that the onset of SLE was preceded by APS. This case raises the question of a present consensus that these two diseases are clearly different clinical entities, although these are closely related.

Ruptured iliac artery aneurysms are serious conditions with high mortality, occasionally perforating into the venous system. A 73-year-old male presented with left leg edema and a pulsatile left lower abdominal mass. Computed tomography revealed a ruptured left common iliac artery aneurysm with perforation into the left common iliac vein. Additionally, bilateral internal iliac veins were noted to form an anomalous common trunk draining into the left common iliac vein. Treatment involved internal iliac vein balloon occlusion under fluoroscopy followed by open surgery for artificial graft replacement and fistula repair. The patient was discharged on the 8th postoperative day.

A 19-year-old female presented with intermittent claudication without anatomical abnormality in the popliteal fossa on magnetic resonance imaging and computed tomography. However, duplex ultrasound (DUS) showed compression of the popliteal artery (PA) and vein during plantarflexion and dorsiflexion. She was diagnosed with functional PA entrapment syndrome (PAES) and underwent resection of the plantaris and gastrocnemius muscles using DUS with stress maneuvers, which relieved the symptoms. In physically active adults, functional PAES can develop without anatomical abnormality. Thus, in the field of vascular medicine, it is important to consider this underrecognized pathophysiology among young people with lower leg pain.

A superior mesenteric arteriovenous fistula (SMAVF) following gastrointestinal surgery represents a rare vascular complication. Enhanced computed tomography with 3-dimensional reconstruction proves to be the most efficacious modality for detecting this uncommon entity. Superior mesenteric angiography becomes imperative to accurately delineate the location and extent of mesenteric vessel involvement, which is essential for devising an optimal treatment strategy. Recently, endovascular therapy has garnered significant favor due to its less invasiveness compared to surgical interventions. Herein, we present a case of SMAVF after pancreaticoduodenectomy, manifesting with symptoms indicative of portal hypertension. Successful endovascular fistula closure using a balloon-expandable stent graft was achieved.

Superior mesenteric artery (SMA) aneurysm and their surgical interventions are rare, leading to infrequent reports of postoperative complications. This report describes 2 cases of refractory diarrhea following vascular reconstruction for infectious SMA aneurysms. Both patients underwent aneurysm resection and SMA reconstruction but experienced persistent diarrhea despite treatment with anti-diarrheal medications.

Postoperative diarrhea, a complication observed after resection of the nerve plexus around the SMA in gastrointestinal surgery, may be attributed to intraoperative injury to the nerve plexus in our cases. Though palliative therapy is partially effective, more efficacious management strategies are desirable to address this persistent complication.

Myasthenia gravis (MG) is an autoimmune neuromuscular junction disorder that rarely coexists with infectious thoracoabdominal aortic aneurysms (TAAA) requiring open repair. A 57-year-old patient with MG underwent elective thoracoabdominal aortic replacement. He was diagnosed with MG (Osserman classification II A). Extent IV thoracoabdominal aortic repair was performed under general anesthesia and maintained by total intravenous anesthesia. The patient was withdrawn from the ventilator on postoperative day 5 without spinal cord ischemia and myasthenic crisis. The management of infectious TAAA with myasthenia gravis warrants not only the prevention of complications associated with the crisis but also multidisciplinary treatments for infection control.

Disseminated venous thromboembolism (VTE) occurs commonly in cancer patients, who tend to have contraindications to systemic thrombolysis and require cancer surgery. Such clinical scenarios are often challenging to manage. In this case report, we illustrate an innovative, single procedural approach in such a patient to remove extensive VTE, improve symptoms, prevent hemodynamic decompensation, and allow for a minimal level of anticoagulation such that necessary cancer surgery can proceed safely.

Thoracic descending aortic perforation with overlap syndrome (systemic sclerosis and dermatomyositis) is a rare, unreported vascular pathology. We describe the case of a 75-year-old woman who presented with chest tightness, back pain, and dyspnea. Computed tomography revealed a pinhole rupture in the descending aorta. The patient underwent a thoracic endovascular aortic repair and left chest drainage. Her postoperative course was uneventful.

Loeys–Dietz syndrome (LDS) is a genetic connective tissue disorder associated with vascular involvement and craniofacial, skeletal, and cutaneous abnormalities. Herein, we describe the case of a 28-year-old female who presented with a pulsatile mass in her abdomen. Imaging studies revealed multiple aneurysms, including a 53-mm abdominal aortic aneurysm (AAA) and tortuosity of the intracranial arterial vasculature. Genetic testing revealed a mutation in transforming growth factor beta receptor 1, leading to a diagnosis of LDS. The patient underwent open surgical repair of AAA. Other arterial lesions were carefully followed. This case demonstrates that AAA can be a primary manifestation of LDS.

Fibromuscular dysplasia (FMD) is an arterial disease characterized by fibrous arterial wall thickening and irregular proliferation and degeneration of smooth muscle cells in muscular arteries. Abdominal aortic aneurysms (AAA) are rare, with only a few reported cases. A characteristic feature of AAA is an aneurysm protruding forward near the terminal aorta with stenosis. Here, we report a rare case of a 66-year-old woman who underwent abdominal aortic replacement for a fusiform AAA, diagnosed with aortic FMD (without stenotic lesions) on pathological examination.

Objectives: This is an annual report indicating the number and early clinical results of annual vascular treatment performed by vascular surgeons in Japan in 2017, as analyzed by Database Management Committee (DBC) members of the Japanese Society for Vascular Surgery (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, including the number of treatments and early results such as operative and hospital mortality.

Results: In total, 137,909 vascular treatments were registered by 1,076 institutions in 2017. This database comprised seven 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 21,680, 18,123, 4,765 2,418, 669, 48,625, and 41,629, respectively. In the aneurysm treatment, 19,982 cases of abdominal aortic aneurysm (AAA), including common iliac aneurysm, were registered, and 64.1% were treated by endovascular aneurysm repair (EVAR). Among AAA cases, 1,824 (9.1%) cases were registered as ruptured AAA. The operative mortality rates of ruptured and unruptured AAA were 15.0%, and 0.7%, respectively. 37.9% of ruptured AAA were treated by EVAR, and the EVAR ratio was gradually increasing, but the operative mortality rates of open repair and EVAR for ruptured AAA were 14.5%, and 12.3%, respectively. There was no statistical significance. Regarding chronic arterial occlusive disease, open repair was performed in 7,277 cases, including 1,348 distal bypasses to the crural or pedal artery, whereas endovascular treatment (EVT) was performed in 9,248 cases. The EVT ratio was gradually increased at 56.0%. The number of varicose vein treatments decreased to 46,754 (11.2% less than in 2016), and 73.7% of the cases were treated by endovenous laser or radiofrequency ablations. Regarding other vascular operations, 38,769 cases of vascular access operations and 1,548 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 fields of vascular diseases, especially EVAR for AAA and EVT for chronic arterial occlusive disease. (This is a translation of Jpn J Vasc Surg 2021; 30: 359–379.)

Objectives: This is an annual report indicating the number and early clinical results of annual vascular treatment performed by vascular surgeons in Japan in 2018, as analyzed by database management committee (DBC) members of the Japanese Society for Vascular Surgery (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, 143,745 vascular treatments were registered by 1,090 institutions in 2018. This database comprises seven 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 24,495, 18,700, 4,813, 2,363, 694, 45,088, and 47,592, respectively. In the field of aneurysm treatment, 20,160 cases of abdominal aortic aneurysm (AAA), including common iliac aneurysm, were registered, and 61.6% were treated by endovascular aneurysm repair (EVAR). Among AAA cases, 1,794 (8.9%) cases were registered as ruptured AAA. The operative mortality rates of ruptured and unruptured AAA were 15.7% and 0.6%, respectively. Approximately 43.3% of ruptured AAA were treated by EVAR, and the EVAR ratio was gradually increasing, but the operative mortality rates of open repair and EVAR for ruptured AAA were 14.0% and 14.6%, respectively. Regarding chronic arterial occlusive disease, open repair was performed in 8,336 cases, including 1,348 distal bypasses to the crural or pedal artery, whereas endovascular treatment (EVT) was performed in 9,710 cases. The EVT ratio was gradually increased at 51.9%. Varicose vein treatment was decreased in 43,133 cases (7.7% less than that in 2017), and 77.3% of the cases were treated by endovenous thermal ablation (ETA), including endovenous laser ablation (EVLA) and radiofrequency ablation (RFA). Regarding other vascular operations, 44,003 cases of vascular access operations and 1,631 lower limb amputation surgeries were included.

Conclusions: The number of vascular treatments increased since 2017, and the proportion of endovascular procedures increased in almost all fields of vascular diseases, especially EVAR for AAA, EVT for chronic arterial occlusive disease, and ETA for varicose veins. (This is a translation of Jpn J Vasc Surg 2022; 31: 217–237.)

Since 2013, the Japanese Society for Vascular Surgery has started the project of nationwide registration and tracking database for patients with critical limb ischemia (CLI) who are treated by vascular surgeons. The purpose of this project is to clarify the current status of the medical practice for patients with CLI to contribute to the improvement of the quality of medical care. This database is created on the National Clinical Database (NCD) and collects data on patients’ backgrounds, therapeutic measures, early results, and long-term prognoses as long as 5 years after the initial treatment. The name of this database was changed from the JAPAN Critical Limb Ischemia Database to the JAPAN Chronic Limb Threatening Ischemia Database in 2021 because of the alteration of the definition of registered patients. The abbreviation remains JCLIMB. The limbs managed conservatively are also registered in JCLIMB, together with those treated by surgery and/or endovascular treatment (EVT). In 2021, 1338 CLTI limbs (male 916 limbs: 68%) were registered by 78 facilities. Arteriosclerosis obliterans (ASO) has accounted for 99% of the pathogenesis of these limbs. In this manuscript, the background data and the early prognosis of the registered limbs of the ASO cohort are reported. (This is a translation of Jpn J Vasc Surg 2024; 33: 229–250.)