The underlying mechanisms of abdominal aortic aneurysms (AAAs) are not fully understood. Given the multifactorial nature of AAA development and progression, a comprehensive approach is essential. Throughout my academic career, I conducted various studies on AAA. To better understand this mechanism, I initially developed an elastase-infused rat AAA model and applied it to nanoparticle drug delivery systems. While open surgery has traditionally been the standard treatment for AAA, endovascular aneurysm repair (EVAR) has seen significant advancements over the past 25 years. However, insufficient evidence exists regarding this novel treatment, particularly in Japan. To address this issue, we analyzed extensive datasets on EVAR using various registries, including the Japanese Committee for Stent Graft Management. Furthermore, through medical–engineering collaboration, simulation methods were utilized to generate evidence addressing clinical questions encountered in practice.

Chronic limb-threatening ischemia (CLTI) occurs in the advanced stage of peripheral artery disease and is associated with high risks of mortality and amputation. Universal management strategies are not always applicable, owing to population diversity, and the Western trials may not be applicable to Japanese patients, owing to differences in demographics and clinical profiles. This paper examines the outcomes of revascularization in Japanese CLTI patients and emphasizes the benefits of tailored management. Post-hoc analysis of the bypass versus angioplasty in severe ischemia of the leg (BASIL)-1 trial validated the use of the Global Limb Anatomic Staging System for predicting the outcomes of endovascular therapy (EVT) but not bypass surgery (BS). The SPINACH (surgical reconstruction versus peripheral intervention in patients with critical limb ischemia) registry revealed comparable 3-year amputation-free survival rates between patients who underwent EVT and those who underwent BS, with patient-specific factors such as limb status and general health influencing its success. Revascularization improved the quality of life, but benefits declined over time, especially in non-ambulatory and older patients on dialysis. Surgical reconstruction is better for preserving ambulation. Retrospective studies revealed pedal branch artery bypass as a viable option, functional independence as a predictor of survival, and zinc supplementation as promising for wound healing. Future research should focus on refining these strategies and exploring innovative approaches to overcome persistent challenges in CLTI care.

Objectives: Hypertension is a metabolic disorder affecting a significant proportion of the global population. Growing evidence suggests the contribution of gut microbiota to blood pressure homeostasis and the effectiveness of antihypertensive interventions. This systematic review evaluates the role of gut microbiota in hypertension and identifies microbial taxa contributing to or alleviating the condition.

Methods: A systematic search was conducted in PubMed and Cochrane databases for non-randomized studies, randomized controlled trials, and registry studies published in English. Studies were classified according to microbial taxa involved in the improvement or worsening of hypertension.

Results: According to the inclusion criteria, 19 studies were included. Some bacterial genera, such as Lactobacillus paracasei, Akkermansia, and Veillonella, had potential protective effects against hypertension by regulating blood pressure through dietary interactions and microbial metabolites. On the other hand, Klebsiella sp., Streptococcus sp., and Parabacteroides merdae were more abundant in hypertensive patients and were involved in dysbiosis and inflammation. The fungal taxa Malassezia and Mortierella were also involved in the pathogenesis of hypertension.

Conclusions: Gut microbiota composition may play crucial roles in hypertension, with certain taxa potentially contributing to or alleviating the condition. Modulating gut microbes through probiotics and diet may offer new therapeutic approaches.

One of the factors that contribute to the development of aortic aneurysms is hemodynamic factors. In this study, we analyzed the hemodynamic changes in a stented saccular abdominal aortic aneurysm model to improve hemodynamic factors. We discovered that stenting reduced wall shear stress, mean flow velocity in the aneurysm, energy loss, and pressure loss coefficient, and improved hemodynamics around the saccular abdominal aortic aneurysm. Stenting is expected to become a new treatment modality for abdominal aortic aneurysms. (This is a translation of J Jpn Coll Angiol 2022; 62: 111–119.)

Objectives: Endovascular aortic repair (EVAR) should be performed using a less invasive procedure based on the patient’s clinical condition, as many patients who undergo this procedure are elderly and have poor surgical tolerance. We report our experience and results of percutaneous EVAR under local anesthesia in order to practice minimally invasive EVAR at our hospital.

Methods: In August 2019, we started percutaneous EVAR using Perclose ProGlide under local anesthesia. We compared the backgrounds and surgical outcomes of patients who underwent EVAR at our hospital before and after the introduction of percutaneous EVAR under local anesthesia.

Results: We included 148 patients in this study. The age at surgery and prevalence of severe renal dysfunction were significantly higher in percutaneous EVAR under local anesthesia group. The operative time and postoperative hospital stay were significantly shorter in the percutaneous EVAR group under local anesthesia.

Conclusions: The introduction of percutaneous EVAR under local anesthesia enabled minimally invasive EVAR to be performed safely even in high-risk patients. (This is a translation of J Jpn Coll Angiol 2022; 62: 1–5.).

Endovenous surgery in the treatment of varicose veins generally consists of laser or radiofrequency ablation (RFA) as endovenous thermal ablation (ETA) with a phlebectomy or foam sclerotherapy of tributary varicose veins to improve symptomatic or cosmetic problems. Nevertheless, the efficacy of their concomitant treatments is still controversial for a decade. In the guidelines of the Japanese Society of Phlebology, concomitant phlebectomy of tributary varicose veins with ETA is described that it is not recommended officially. In our hospital, RFA without concomitant phlebectomy of tributary varicose veins accounts for 74% of the RFA cases and it shows a relatively higher percentage than other institutions in Japan. The data of RFA without concomitant phlebectomy of tributary varicose veins are evenly matched in RFA with concomitant treatments in our data concerning recurrence, remnants, endovenous heat-induced thrombosis (EHIT), and complications. This article provides the conclusion that it would be acceptable to perform isolated RFA compared to RFA with concomitant phlebectomy or foam sclerotherapy of tributary varicose veins in short- and mid-term periods. In addition, concomitant treatments might contribute to rapid improvement of the short-term and better long-term outcomes, not to mention cosmetic problems that are not identified demonstrably. (This is a translation of J Jpn Coll Angiol 2022; 62: 49–54.)

Objectives: In Japan, radiofrequency ablation (RFA) was covered by insurance in 2014. Regarding the early results, there are many reports that it is excellent, but the long-term results are rarely shown. Therefore, the purpose of this study was to examine the results up to 5 years after RFA, which was the only means of endovascular treatment at my facility, and to evaluate recurrent varices after surgery (REVAS), reoperation, and complications.

Methods: In 2017, 275 consecutive cases (male 83, female 192, 67.5 ± 10.0 years old), involving 350 limbs (C2, 3, 4a, 4b, 5, 6 = 217, 18, 89, 18, 1, 7) and 354 veins (great saphenous vein [GSV]: 290, small saphenous vein [SSV]: 64), underwent RFA. Postoperative follow-up was usually performed at 3 days (100%), 1 week (100%), 1 month (99.4%), and 6 months (93.5%) after RFA. Of the 334 patients contacted 5 years later, 327 (92.4%), excluding deaths from other diseases, were interviewed about reoperation, recurrence, and neuropathy. Of these, 223 patients (63%, GSV: 180, SSV: 43) underwent an ultrasound examination.

Results: Endovenous heat-induced thrombosis (EHIT) of more than grade 2 occurred in 5.9% of cases (GSV: 6.6%, SSV: 3.1%) and regressed within 1 month in all cases using anticoagulant therapy. Neuropathy occurred in 6.3%, mainly in GSV full-length ablation cases, and 41% of these disappeared completely between 6 months and 5 years after RFA. The reoperation rate up to 5 years after RFA was 10.7% (GSV: 9.7, SSV: 15.6%). In the reoperation cases after the RFA of GSV, the sites of reflux were 14 incompetent perforating veins (IPVs), 7 deep venous junction-related, and 6 distal GSVs. In the reoperation cases after the RFA of SSV, there were 5 IPVs and 3 isolated branch varices. The time of diagnosis of recurrence by ultrasonography was within 6 months of regular follow-up in 61% of GSVs and 79% of SSVs. The occlusion rate after 5 years was 98.9% for GSV and 95.3% for SSV. Only 1 recanalized vein was symptomatic and underwent retreatment. After RFA of GSV, 80% of accessory saphenous veins were retained at 5 years.

Conclusions: 1) The 5-year results after RFA were generally good. 2) IPV played the most important role in reoperation cases by REVAS after RFA of the saphenous veins. 3) The majority of postoperative recurrences could be identified by follow-up up to 6 months. 4) Neuropathy after RFA disappeared completely in half of the cases within 5 years. 5) After GSV-RFA, accessory saphenous vein blood flow persisted in most cases. (This is a translation of Jpn J Phlebol 2024; 35: 403–408.)

Objectives: The superficialized brachial artery (SBA) is an important alternative vascular access for hemodialysis patients when autogenous vein fistula creation is not feasible. However, repeated puncture of the SBA can lead to severe complications such as aneurysm formation, pseudoaneurysm, and infection. This study aimed to review surgical strategies for revascularization and infection control in SBA aneurysms.

Methods: We retrospectively analyzed 8 cases of SBA aneurysms treated at our institution between November 2020 and June 2025. Patient demographics, comorbidities, surgical procedures, and outcomes were evaluated based on medical records and follow-up data.

Results: Patients ranged in age from 43 to 81 years and had been on dialysis for an average of 19 years. Six aneurysms were ruptured, and 5 were associated with infection. Brachial artery bypass was the most common procedure, performed in 6 patients using autologous veins or prosthetic grafts. One patient underwent fistula closure with a bovine pericardial patch, and another received direct arterial anastomosis. In infected cases, autologous vein bypass or aneurysm resection with direct anastomosis was performed after thorough debridement. All patients maintained adequate dialysis access postoperatively.

Conclusions: Revascularization of the SBA using autologous vein bypass is effective for managing aneurysms, especially in infected cases. Careful infection control and individualized surgical planning are essential for maintaining safe dialysis access and preserving limb function.

Objectives: Thoracic endovascular aortic repair (TEVAR) has recently emerged as a less invasive alternative to open thoracotomy for the treatment of Kommerell’s diverticulum (KD). However, anatomical challenges, including an acute aortic arch and an aberrant subclavian artery, often limit its feasibility. This study aimed to evaluate the outcomes of TEVAR for KD.

Methods: Between February 2012 and July 2023, 6 patients with KD underwent TEVAR at 3 institutions. Subclavian artery embolization or reconstruction was performed when necessary. Morphological parameters, including the Kommerell’s diverticulum diameter (KDd) and the distance to the opposite aortic wall (DAW), were assessed.

Results: Four patients underwent subclavian artery embolization, including 1 requiring bilateral embolization. Subclavian artery reconstruction was performed in 2 cases. Intraoperative type 1a endoleaks were observed in 3 cases and were successfully managed with additional stent grafts. During a follow-up period ranging from 13 to 83 months, 1 patient required open surgical conversion due to graft infection. No other severe complications or aneurysmal progression were noted.

Conclusions: Despite the limited follow-up period and lack of long-term data, TEVAR for KD demonstrated favorable short- to mid-term outcomes and may represent an effective treatment option in selected patients.

Objectives: The introduction of direct oral anticoagulants (DOACs) has significantly changed the management of deep vein thrombosis (DVT) in Japan. This study aimed to elucidate recent trend0s in the diagnosis and management of DVT following this shift.

Methods: This retrospective observational study involved 154 patients with acute and subacute DVT, and 96 patients with chronic or unknown-onset DVT, diagnosed between October 1 and 31, 2020, across 29 institutions affiliated with the Japanese Society of Phlebology. Data included patient demographics, diagnostic modalities, thrombus location, treatments, and clinical outcomes.

Results: The mean age was 70.0 years, and 57.8% of patients were female. Duplex ultrasonography was the predominant diagnostic modality (96.1%). DOACs were prescribed in 64.9% of patients, replacing warfarin and heparin. Compression therapy was used in 41.6% of patients. Soleal vein thrombosis was significantly more common in isolated distal DVT (right: 50.6% vs. 30.0%, p = 0.0082; left: 66.3% vs. 35.2%, p = 0.0001). Major bleeding occurred in 3.2% of patients. Post-thrombotic syndrome was observed in 0.6% of patients with acute/subacute DVT and 12.0% of those with chronic DVT patients.

Conclusions: Since the introduction of DOACs, DVT management in Japan has evolved considerably. Periodic multicenter surveys would be beneficial for evaluating long-term outcomes, treatment safety, and evolving clinical practices.

Objectives: Dementia and chronic limb-threatening ischemia (CLTI) are independent risk factors for a poor life prognosis. We investigated the long-term results of surgical revascularization for CLTI complicated by dementia.

Methods: The clinical records of 174 consecutive patients with CLTI and 205 revascularized limbs were prospectively collected from a database. According to the criteria for dementia, the patients were divided into a low-grade dementia group (L group, n = 152) and a high-grade dementia group (H group, n = 22), and the long-term results after surgery were retrospectively analyzed.

Results: The 2-year amputation-free survival (AFS) after surgery was significantly lower in the H group than in the L group (L group, 82.3%; H group, 39.3%; p <0.001). However, no marked differences were observed between the dementia groups regarding the freedom from major adverse limb event (MALE) (L group, 86.6%; H group, 83.1%; p = 0.103), freedom from major adverse cardiovascular event (MACE) (L group, 75.6%; H group, 71.3%; p = 0.685), and limb salvage (L group, 75.6%; H, group 71.3%; p = 0.685) after surgery.

Conclusions: Dementia may be a predictor of a poor prognosis after surgery for CLTI. However, surgical revascularization may lead to limb salvage without serious postoperative complications. Therefore, surgical revascularization may be a useful treatment option if the patient or family requires such treatment.

Objectives: A narrow aortic bifurcation poses technical challenges during endovascular aneurysm repair (EVAR). We aim to compare the unibody AFX2 (Endologix, Irvine, CA, USA) vs the bifurcated ALTO (Endologix) system in EVAR patients with a narrow bifurcation.

Methods: Retrospective single-center study, including patients undergoing standard EVAR over 3 years. Patients with a bifurcation diameter <20 mm were identified, and outcomes were compared between the AFX2 and ALTO groups. Primary endpoints were primary and overall technical success, primary and overall clinical success, rate of adverse limb events, rate of limb occlusion, and need for secondary interventions. The analysis was repeated using a diameter threshold of <18 mm.

Results: Among 151 cases, 26 presented with bifurcations <20 mm and 12 with <18 mm. In the primary analysis, 15 patients were treated with the AFX2 and 11 with the ALTO endograft. Both groups achieved 100% technical and clinical success. No limb occlusions occurred, and no reinterventions were recorded. Preoperative anatomy was suitable for ALTO in all cases, while eligibility for AFX2 was 15 out of 26 cases. Secondary analysis displayed similar results.

Conclusions: In patients with narrow aortic bifurcation, the AFX2 endograft can be safely used when appropriate anatomic conditions are met. If the AFX2 system is unsuitable due to other anatomic restrictions, the ALTO endograft is a viable alternative.

Objectives: Advancements in imaging technology have led to an increase in the incidental detection of visceral artery aneurysms (VAAs), which are associated with high mortality when ruptured. In 2020, the Society for Vascular Surgery (SVS) released updated guidelines, replacing the previous 2005 ACC/AHA recommendations. This study aimed to evaluate the impact of the new guidelines through a retrospective analysis of VAA cases treated at our department.

Methods: We retrospectively reviewed 43 cases of VAA treated between 2002 and 2024 at our department. Each case was re-evaluated to determine whether it met the treatment criteria defined in the 2020 SVS guidelines.

Results: Of the 43 cases, 23 (53.5%) met the new guideline criteria. Notably, treatment eligibility for renal and splenic artery aneurysms decreased significantly due to the revised aneurysm size threshold, raised from 2 to 3 cm. The remaining 20 cases were considered ineligible based solely on size, with the exception of cases involving young female patients, ruptured aneurysms, symptomatic lesions, or pseudoaneurysms.

Conclusions: The 2020 SVS guidelines impose stricter treatment indications for VAAs. However, clinical decisions should also consider aneurysm location, patient age, gender, symptoms, and rupture risk on an individual basis.

Objectives: Gait disturbances increase mortality rates in lower extremity artery disease. Changes in gait biomechanics after endovascular therapy for intermittent claudication associated with lower extremity artery disease remain unknown. This prospective study investigated the effect of endovascular therapy on gait biomechanics in intermittent claudication.

Methods: We recruited 10 patients (14 affected limbs) with intermittent claudication caused by isolated aortoiliac artery lesions who underwent endovascular therapy, and 10 healthy controls. Using 3-dimensional motion analysis, we measured biomechanical gait parameters preoperatively and over 6 months postoperatively, comparing them with those of healthy controls.

Results: One month after endovascular therapy, parameters improved significantly compared with preoperative values: step length (preoperative median 52.47 [interquartile range 47.11, 60.33]–postoperative 58.53 [54.63, 64.54] cm; P < 0.0037), walking speed (90.17 [73.98, 108.9]–103.49 [97.66, 117.94] cm/s; P = 0.0022), hip flexor moment (−0.75 [−1.04, −0.51] to −0.94 [−1.07, −0.74] Nm/kg; P = 0.04), and pull-off power generated by hip flexor muscles (H3, 0.68 [0.38, 1]–0.86 [0.72, 1.1] W/kg; P = 0.018). Preoperative joint power declined significantly compared to control parameters. However, 6 months postoperatively, no significant differences were observed.

Conclusions: Endovascular therapy for isolated aortoiliac artery lesions improved biomechanical gait parameters in patients with intermittent claudication.

Objectives: The venous cuff technique has been used primarily for arterial bypass using artificial grafts to the lower extremities. The boat-form vein cuff was designed to allow adjustment of the size and angle of the anastomosis at any anatomic site. We report our experience and outcomes of the original vein cuff technique in various peripheral artery bypass grafting procedures.

Methods: A total of 10 patients underwent arterial bypass grafting using a polytetrafluoroethylene (PTFE) graft with a boat-form venous cuff. The indications for the surgery consisted of peripheral artery disease (n = 4), acute limb ischemia (n = 4), chronic mesenteric ischemia (n = 1), and traumatic upper limb ischemia (n = 1). Five patients required emergency surgery. Surgical outcomes, such as mortality and morbidity, limb salvage rate, and graft patency, were examined using perioperative and postoperative follow-up data.

Results: There were no operative deaths or serious complications, including amputation of the lower extremity. During the follow-up period (44 ± 36.9 months), the PTFE graft remained patent in 9 patients (90%). In 1 patient, occlusion of the femoropopliteal bypass graft was observed 3 months after surgery.

Conclusions: The simple design and creation of the boat-form vein cuff are useful at any anatomical site in peripheral artery bypass grafting with a PTFE graft.

Objectives: Thoracic endovascular aneurysm repair (TEVAR) has revolutionized the treatment of thoracic aortic aneurysms (TAA) by providing a less invasive alternative to open surgery. This study aims to identify risk factors for early mortality following TEVAR for degenerative TAA using a machine learning-based decision tree analysis (DTA).

Methods: This retrospective observational study analyzed 79 patients who underwent elective TEVAR to identify predictors of early mortality (within 2 years) using decision tree analysis. The dataset included 36 variables, covering age, sex, nutritional status, comorbidities, inflammation, immune status, and surgical details. The decision tree classifier was developed and validated using Python 3.7 with the scikit-learn toolkit.

Results: DTA identified octogenarian status as the strongest predictor of early mortality, followed by poor nutritional status, debranching procedures, and compromised immunity. The model identified 7 terminal nodes, with early mortality risk ranging from 0% to 77.7%. It demonstrated moderate accuracy (65.8%) and high sensitivity (81.0%) but had relatively low specificity (60.3%), effectively identifying high-risk patients.

Conclusions: Machine learning-based DTA identified key predictors of early mortality following TEVAR, including octogenarian status, poor nutritional status, compromised immunity, and debranching procedures. The model provides an interpretable risk stratification tool, but its clinical applicability requires further validation.

Objectives: Peri-aortitis following endovascular aneurysm repair (EVAR) is a rare phenomenon with unclear pathogenesis. In this study, we investigated its clinical features and sac prognosis.

Methods: A retrospective analysis was conducted on 1369 EVAR. Peri-aortitis was defined using post-EVAR computed tomography. Clinical and imaging data were assessed.

Results: Peri-aortitis following EVAR was identified in 12 patients (0.89%) with a mean age of 74 ± 8.9 years; 83.3% were male, and 41.7% had allergic or autoimmune histories. There were eight symptomatic cases (66.7%), including seven with fever, three with back or abdominal pain, and one with hydronephrosis. Precautionary antibiotic treatment was administered in five febrile cases. Although persistent and recurrent inflammation was observed in two cases (16.7%) each, inflammation resolved spontaneously in seven patients (58.3%). One (8.3%) needed steroid therapy for severe back pain. Aneurysm shrinkage was observed in seven cases (58.3%), while enlargement was noted in one case (8.3%) with type II endoleak. No correlation was found between aneurysm growth and peri-aortitis development.

Conclusions: Peri-aortitis following EVAR may present significant challenges, including differentiation from infection, management of symptomatic cases requiring medical therapy, and addressing recurrences. Accurate diagnosis, individualized treatment, and meticulous follow-up are essential for favorable outcomes.

Objectives: We primarily aimed to compare the acute effects of hand-squeezing exercises, with and without tourniquet-like compression, on vessel size 5 minutes post-exercise in patients after arteriovenous fistula (AVF) creation. The secondary aim was to assess differences in AVF blood flow rates between the 2 interventions.

Methods: A randomized study was conducted at a university hospital in Bangkok, Thailand, from October 2018 to September 2023. Seventy-eight participants, 2 weeks post-first-time autogenous AVF creation, were randomized into 2 groups: a non-compression group (n = 39) performing 5 minutes of hand-squeezing exercises and a compression group (n = 39) performing the same exercises with tourniquet-like compression. Ultrasound measured venous diameter and blood flow rates pre- and post-exercise.

Results: Both groups showed increased venous diameter, but the difference between the groups was not statistically significant (mean difference: 0.18 mm with compression vs. 0.12 mm without; P = 0.489). Blood flow rates increased significantly in the compression group compared to the non-compression group (mean difference: 171.49 vs. 24.44 mL/min; P = 0.002).

Conclusion: Hand-squeezing exercises with tourniquet-like compression significantly improved AVF blood flow rates acutely, supporting its potential to enhance AVF maturation. Further research is needed to assess long-term benefits.

Objectives: Acute hemorrhagic rectal ulcer (AHRU) occurs with a sudden onset of painless bloody stools and is caused by impaired blood flow in the rectal mucosa due to arteriosclerosis or prolonged bedridden status. Little information is available about AHRU in patients with chronic limb-threatening ischemia (CLTI). This study aimed to identify factors related to AHRU among CLTI patients after bypass surgery.

Methods: Between 2019 and 2023, we enrolled 80 CLTI patients at our institution who underwent bypass surgery using autogenous veins. Data were collected prospectively and supplemented with retrospective medical record reviews. Information regarding demographic and clinical characteristics was collected. The outcomes of patients without AHRU (non-AHRU group) and those with AHRU (AHRU group) were compared. Logistic regression analysis was used to assess factors associated with AHRU after bypass surgery.

Results: During the study period, 6 of the 80 patients (7.5%) experienced AHRU after bypass surgery. There was no significant difference in the global limb anatomic staging system (GLASS) or wound ischemia and foot infection (WIfI) stage between the 2 groups. The percentage of patients taking oral steroids was significantly greater in the AHRU group. In addition, the AHRU group had a significantly greater percentage of postoperative ambulatory failure and a longer hospital stay. In the univariate analysis of factors associated with the incidence of AHRU after bypass surgery, steroid use (odds ratio [OR], 13.8; 95% confidence interval [CI], 2.19–86.9; P = 0.005) and nonambulatory status after surgery (OR, 7.22; 95% CI, 1.26–41.4; P = 0.026) were significant factors.

Conclusions: Steroid use and postoperative nonambulatory status were associated with AHRU after bypass surgery for CLTI.

Objectives: This study aimed to investigate the actual detection process and diagnostic methods for asymptomatic abdominal aortic aneurysm (AAA) in a multicenter setting, and to plan an effective screening strategy for asymptomatic AAA.

Methods: The subjects of this multicenter study were collected in a retrospective manner at 7 facilities. A total of 1894 patients with AAA, including iliac artery aneurysms, who were considered asymptomatic with a confirmed initial diagnosis from January 2018 to December 2022, were collected and reviewed.

Results: A total of 1666 patients who were diagnosed with asymptomatic AAA were included [83.9% males, median age of 75 (69–81) years]. Asymptomatic AAAs were frequently diagnosed during examinations for other diseases in 1339 patients (80.4%), whereas health screenings accounted for only 313 (18.8%). Computed tomography (CT) was the most commonly used diagnostic method (n = 1352, 81.2%) compared to abdominal ultrasonography (n = 252, 15.2%).

Conclusions: Asymptomatic AAAs are detected incidentally during examinations for other diseases, and there is an urgent need to promote health screening. Most AAAs are diagnosed by CT; nevertheless, we consider that abdominal ultrasonography would be the most appropriate modality for AAA screening because of its reasonable accuracy, noninvasiveness, and low cost.

Objectives: The Gore iliac branch endoprosthesis (IBE) enables internal iliac artery (IIA) reconstruction, extending the indications of endovascular aneurysmal repair (EVAR); however, the up-and-over technique is challenging. This study aimed to clarify the advantages and procedural limitations of the up-and-over technique.

Methods: From January 2019 to October 2022, 22 patients who underwent IIA reconstruction with Gore IBE were enrolled. The patients were divided into the S and Up groups that underwent IIA reconstruction using the standard and up-and-over techniques, respectively. Aortic anatomic measurements, surgical factors, and postoperative outcomes were examined.

Results: No significant differences in operative time, fluoroscopy time, contrast medium use, blood loss volume, and length of postoperative hospital stay were observed between the S (12 patients) and Up (10 patients) groups. However, the distance from the lower renal artery to the reconstructed IIA origin was considerably shorter in the Up group than in the S group. During the 19-month follow-up, no adverse events were observed in the Up group.

Conclusions: The up-and-over technique can be a valuable option for cases where IIA reconstruction is difficult with standard procedures with Gore IBE. Therefore, understanding the procedural precautions and ensuring safety are crucial to its success.

Objectives: The objective of this research was to examine the occurrence, clinical features, treatment approaches, and results associated with a rare complication of thrombosis of the popliteal artery after total knee arthroplasty (TKA), leading to acute limb ischemia (ALI).

Methods: A retrospective study on 1020 TKA procedures spanning 5 years. Cases of ALI were identified through clinical evaluation and arterial Doppler studies. Peripheral angioplasty was done to recanalize the popliteal artery. Manifestations, complications, and management strategies were evaluated.

Results: Among the 1020 TKA cases, 5 cases of ALI were identified which accounts for 0.49% of all TKA cases. Female predominance and left-sided presentations are notable observations. Most patients presented within 8 hours of symptom onset with diverse complications ranging from foot drop to compartment syndrome. Except for 1 case, all patients recovered with thrombosuction and balloon dilatation.

Conclusions: A rare but potentially fatal complication of TKA is popliteal artery thrombosis leading to ALI so it becomes important for early recognition and intervention to mitigate the adverse outcomes. In our study, endovascular treatment has emerged as the preferred modality in terms of effective management and reducing complications and morbidity from surgical procedures.

Objectives: Surgical thrombectomy has been established as an effective treatment for acute limb ischemia (ALI). Nevertheless, manipulation via the common femoral artery (CFA) to retrieve thrombus in the infra-popliteal artery sometimes proves less effective.

Methods: We retrospectively reviewed patients undergoing surgical thrombectomy for infra-inguinal ALI from January 2010 to December 2022. The primary endpoint was the rate of amputation. Secondary endpoints were technical and clinical success rates, incidence of distal embolism, and freedom from reintervention.

Results: A total of 35 patients underwent surgical thrombectomy where the popliteal artery or below is occluded. The CFA approach was utilized in 13, and the below-knee popliteal artery (BKPA) approach in 22. There were no differences in background between groups. The reintervention rate was lower in the BKPA group (BKPA group: 0% vs. CFA group: 30.8%; P = 0.01). The BKPA group showed a significantly lower incidence of distal embolism (BKPA group: 4.5% vs. CFA group: 38.5%; P = 0.02) and freedom from reintervention (BKPA group 100% at 12 months vs. CFA group: 68.7% at 12 months; log-rank P = 0.01).

Conclusions: The BKPA approach-first strategy for surgical thrombectomy in the management of ALI is feasible with better outcomes compared with the CFA approach.

Objectives: The pathophysiological mechanism of abdominal aortic aneurysm (AAA) remains unclear. We previously reported that Bifidobacterium adolescentis levels were reduced in the feces of patients with AAA by 16S ribosomal ribonucleic acid (RNA) gene sequencing. In this study, we increased the number of cases and conducted metagenomic analyses to examine bacterial genes associated with the pathophysiology of AAA.

Methods: For gut microbiota data, feces from 55 patients with AAA and 52 patients with no history of AAA, lower extremity artery disease, or coronary artery disease (control group) were collected. Metagenomic analysis was performed by collecting raw stool samples from patients. For intestinal microbiota analysis, metagenomic analysis of the fecal samples was performed.

Results: Oral bacteria, including Actinomyces oris (p <0.0001), Streptococcus salivarius (p <0.001), Lactobacillus salivarius (p <0.001), and Streptococcus sp. (p <0.001), were increased in the feces of patients with AAA. In addition, bacterial genes related to alpha lipoic acid (ALA) biosynthesis (M00882, M00883, and M00884, p <0.0001) were decreased in patients with AAA.

Conclusions: In the feces of patients with AAA, there was an increase in oral bacteria, and the expression of bacterial genes related to ALA biosynthesis was reduced. The results suggest the possibility of developing gut microbial drug treatments for AAA.

Objectives: We sought to clarify the interface pressure (IP) and its variation by applying Biflex16, a calibrated bandage, to the lower leg.

Methods: In Study I, 50 participants applied a bandage to the lower leg of a single subject in two ways: first, with 50% overlap, while the calibration rectangle became a square (Application 1), and then with 50% overlap without intentional stretch (Application 2) which served as a control. In Study II, another 51 participants applied the bandage to their lower leg via Application 1. The IP was measured at the level of the transposition of the medial gastrocnemius muscle into the Achilles tendon (B1).

Results: In Study I, the median IP (37 mmHg) and interquartile range (IQR; 9 mmHg) in the standing position were the same for Applications 1 and 2. In Study II, the obtained IP and IQR values were 38 and 12 mmHg, respectively, in the sitting position. This IP was similar to that obtained in Study I, and no correlation was found between IP and leg circumference.

Conclusions: The variation in the IP obtained by the calibrated bandage was reasonably small when applied via Application 1. The obtained IPs did not correlate with the leg circumference.

Objectives: We investigated the association between brachial-ankle pulse wave velocity (PWV) and arterial stiffness and distensibility in the aneurysmal sac of abdominal aortic aneurysm (AAA).

Methods: Data from 49 patients with AAA from June 2020 to November 2022 at Tokyo Medical University Hospital were retrospectively analyzed. Brachial-ankle PWV (cm/s) was obtained via an automated oscillometric method. Regional arterial stiffness and distensibility parameters, such as stiffness parameter (β), pressure-strain elasticity modulus (Ep, kPa), one-point PWV (PWV β, m/s), and arterial compliance (AC, mm²/kPa⁻¹), were assessed using 2-dimensional automated tissue tracking (2DTT) ultrasonography. Patients were divided into two groups: high PWV (≥1800) and low PWV (<1800).

Results: Patients with high PWV showed significantly higher β and PWV β (30.6 ± 10.1 vs. 25.2 ± 6.3, p = 0.047; 11.6 ± 2.3 vs. 10.5 ± 1.5, p = 0.048) and significantly lower AC in the aneurysmal sac (10.6 ± 5.3 vs. 14.7 ± 8.1, p = 0.045) than those with low PWV. AC was negatively correlated with PWV (r = −0.361, p = 0.011).

Conclusions: Brachial-ankle PWV can reflect arterial stiffness and distensibility, as measured by 2DTT ultrasonography, in the aneurysmal sac of AAA, suggesting its potential as an elasticity index for assessing regional arterial stiffness and distensibility in AAA.

A 74-year-old man with hypertension and hyperuricemia was incidentally diagnosed with a 39-mm brachiocephalic artery aneurysm. Because of a sufficient proximal sealing zone, a hybrid repair was performed, consisting of a right common carotid–axillary bypass with a prosthetic graft, followed by endovascular exclusion using covered stents, a vascular plug, and coils. Completion angiography confirmed complete aneurysm exclusion without endoleak and satisfactory bypass flow. The postoperative course was uneventful. Computed tomography (CT) angiography demonstrated persistent aneurysm exclusion without endoleak and a patent bypass. At 12 months, plain CT confirmed no aneurysm enlargement.

An 82-year-old woman underwent zone 4 thoracic endovascular aortic repair (TEVAR) for a descending aortic aneurysm. Four years later, an additional TEVAR was performed for a type Ib endoleak. Preoperative computed tomography angiography (CTA) initially identified the intercostal artery branching of the Adamkiewicz artery (ICA-AKA) at the left 10th thoracic level, which was covered by a stent graft. Prior to the second TEVAR, CTA showed the ICA-AKA via the left first lumbar artery. Reevaluation of the ICA-AKA is important, particularly after coverage. Surgeons should interpret CTA findings carefully, as other arteries or veins may resemble the AKA.

The Thoraflex Hybrid prosthesis (Terumo Aortic, Inchinnan, UK) is widely used for total arch replacement, but postoperative stenosis or pseudo-coarctation is rare and potentially fatal. We report an 83-year-old man who underwent a Bentall procedure and total arch replacement with a 36-mm Thoraflex Hybrid graft (Terumo Aortic). Postoperative imaging showed mild stenosis, but distal perfusion was maintained. Eighteen hours later, his cardiac index dropped to 1.4 L/min/m² and lactate rose to 11.2 mmol/L. Computed tomography (CT) revealed severe graft stenosis. Although rescue thoracic endovascular aortic repair (TEVAR) transiently improved hemodynamics, the patient succumbed to multiorgan failure despite veno-arterial extracorporeal membrane oxygenation (VA ECMO). This case underscores the need for early recognition and prompt intervention.

True aneurysms of the digital artery are extremely rare, and only several dozen cases have been reported worldwide. A 29-year-old man presented with a pulsatile, tender nodule in his left index finger. Angiography revealed a 7-mm saccular aneurysm of the proper palmar digital artery with well-developed distal collaterals. Under local anesthesia, the aneurysm was excised following proximal and distal ligation. It was histopathologically confirmed as a true aneurysm. Postoperatively, symptoms resolved without ischemic or neurological complications and without recurrence after 1 year. Thus, simple ligation and excision are effective when collateral circulation is sufficient.

Spontaneous rupture of the iliac vein (SRIV) requires surgical hemostasis and venous return restoration. We herein report a case treated with initial thrombus removal and direct venous repair. Because of early occlusion, a 2nd surgery was performed for iliac vein reconstruction using a 14-mm ringed Gore-Tex graft (W. L. Gore & Associates, Newark, DE, USA), and a 4-mm Gore-Tex arteriovenous shunt was created between the femoral artery and the femoral vein to prevent reocclusion. The patient had an uneventful recovery without recurrence. A single-stage procedure including hemostasis, vein replacement, and arteriovenous bypass may be ideal for radical SRIV treatment.

A patient with complicated Stanford type B aortic dissection and a large ulcer-like projection just distal to the left subclavian artery (LSA) underwent thoracic endovascular aortic repair (TEVAR) using a physician-made 1-cm fenestration and L-shaped marker. This technique allowed accurate alignment with the LSA under fluoroscopic guidance without additional devices. Postoperative and 6-month follow-up computed tomography confirmed good outcomes. This simplified, economical Zone 2.5 TEVAR approach may be a viable treatment option for high-risk patients with anatomically challenging aortic dissections.

Pancreaticoduodenal aneurysms are commonly associated with narrowing of the celiac artery, although involvement of the superior mesenteric artery (SMA) is rare. A 77-year-old man presented with a 5-day history of abdominal and back pain. Contrast-enhanced computed tomography revealed hemorrhagic ascites, a pancreatic arcade aneurysm, and dissection of the SMA. Endovascular embolization was performed using metallic coils. Follow-up imaging demonstrated isolation of the aneurysm and improvement in the shrunken true lumen of the dissected SMA. This case suggests that narrowing of the SMA may alter blood flow in the pancreatic arcade and contribute to aneurysm formation.

A 76-year-old woman with rheumatoid arthritis receiving long-term corticosteroid therapy, who underwent bilateral femoro-inframalleolar bypasses, suffered from interval skin necrosis in both lower legs after vein harvest in the contralateral leg and hematoma formation in the ipsilateral leg. Bilateral interval skin necrosis was improved eventually after revascularization for femoropopliteal lesions. In patients receiving long-term corticosteroid therapy who undergo distal bypass surgery, it is essential to address not only foot ischemia but also ischemia in the infrapopliteal region along the graft route and at the vein harvest site when formulating the surgical strategy.

Idiopathic inferior mesenteric arteriovenous fistula is an extremely rare pathology, and symptoms vary greatly depending on the shunt flow volume through the fistula. We report a case of idiopathic inferior mesenteric arteriovenous fistula in a 63-year-old man who presented with a pulsating sensation in the upper abdomen. Computed tomography revealed an inferior mesenteric arteriovenous fistula with aneurysmal dilatation and a drainage vein into the dilated marginal vein of the descending colon. Surgical resection and ligation of the fistula were successfully performed, and the postoperative course was uneventful. The patient’s symptoms resolved, and no recurrence was observed during the 5-year follow-up.

A single-stage extensive aortic replacement is necessary for infected stent graft explantation after thoracic endovascular aortic repair (TEVAR). However, establishing selective cerebral perfusion and antegrade myocardial protection while ensuring a clear view of the distal aorta is challenging. We adopted a semi-clamshell approach with rib cross for a case of infection following hybrid TEVAR. This approach provides visualization of the ascending aorta, aortic arch, and the descending aorta down to the diaphragm. It is a viable option for cases requiring total arch and distal descending aorta replacement, offering reliable cerebral and myocardial protection, particularly in open conversion of hybrid TEVAR.

Successful thoracic endovascular aortic repair for chronic type B aortic dissection with an enlarged false lumen depends on complete exclusion of the false lumen. Stent-assisted balloon-induced intimal disruption and relamination in aortic dissection repair (STABILISE) creates a single lumen in the dissected thoracic and abdominal aorta by disrupting the intima. We report our experience in the treatment of 3 cases of chronic dissection using the STABILISE procedure at our hospital from December 2019 to May 2022. The STABILISE technique appears to be an effective procedure; however, further evaluation of risk factors for complications such as intraoperative aortic rupture is necessary.

A 79-year-old man was admitted for transurethral resection of a bladder cancer. He had a history of thoracic endovascular aortic repair for Stanford type B acute aortic dissection and thoracic aortic aneurysm performed 2 years prior. During hospitalization, computed tomography scan findings raised suspicion of a stent-graft infection. Blood cultures confirmed the presence of Streptococcus gallolyticus ssp. pasteurianus. Gallium scintigraphy supported the diagnosis of a stent-graft infection. A subsequent lower gastrointestinal endoscopy revealed a colorectal cancer in the lower rectum. We then performed surgery for the stent-graft infection.

A 41-year-old woman with a 1-year history of right chest pain, with normal cardiology and pulmonology assessments. The chest pain was reproducible upon upper limb elevation. Computed tomography (CT) angiography in the arm-elevated position revealed subclavian artery and vein stenosis at the costoclavicular space, and the diagnosis was neurogenic thoracic outlet syndrome (TOS). Surgery involving endoscopic-assisted infraclavicular resection of the first rib and scalene muscles resulted in immediate postoperative symptom improvement. When chest pain persists after ruling out other conditions, neurogenic TOS should be considered in the differential diagnosis.

Intravenous leiomyomatosis with intracardiac extension is a rare benign tumor originating from uterine smooth muscle. A 50-year-old woman presented with a cardiac mass 3 years after hysterectomy. Imaging revealed a tumor extending from the right internal iliac vein to the right atrium. Complete resection was achieved via a 2-stage surgery. In the 1st stage, median sternotomy and a retroperitoneal approach were performed, and the intracardiac tumor was excised under deep hypothermic circulatory arrest with cardiopulmonary bypass. Postoperatively, gonadotropin-releasing hormone (GnRH) agonist therapy was administered, followed by a 2nd-stage resection of the residual pelvic tumor and right ovary. The patient remained recurrence-free for 15 months.

A 59-year-old patient was undergoing careful monitoring of an isolated superior mesenteric artery dissection discovered 6 years prior. He was admitted after outpatient imaging revealed multiple visceral aneurysms including common hepatic and splenic artery aneurysms that had enlarged. Based on anatomical reasons and the past history, the splenic artery aneurysm was treated with endovascular therapy, while the common hepatic artery aneurysm was resected, and blood flow reconstruction was performed. The patient was discharged without any complications. Visceral artery aneurysms have diverse locations and morphologies, illustrating the importance of treatment strategies that consider the blood flow to the organs.

A 52-year-old man with scoliosis and psoriasis vulgaris, treated with infliximab, presented with a large right gastroepiploic artery aneurysm (GEAA). Following surgical resection, additional aneurysms of the anterior communicating artery and abdominal aorta were identified. Histopathological examination revealed a pseudoaneurysm with organizing thrombus and marked acute inflammation, including neutrophilic infiltration of the medial wall. Despite negative cultures, an infection-related vascular insult could not be excluded. This case highlights a rare immune-mediated vascular pathology in the context of chronic inflammatory disease, emphasizing the potential role of acute inflammation and psoriasis-associated immune dysregulation in visceral artery aneurysm formation.

An 84-year-old woman with an acute type B aortic dissection (ATBAD), an entry tear in a distal arch aneurysm, and lower-body malperfusion underwent a hybrid approach combining total arch replacement with an elephant trunk (TAR+ET), thoracic endovascular aortic repair (TEVAR), and left renal artery stenting. This strategy avoided direct resection of the aneurysm or primary entry, yet stabilized hemodynamics and restored organ perfusion. Postoperative CT was favorable, and the patient was discharged without complications. In this elderly case of complicated ATBAD involving a distal aortic arch aneurysm, we performed TAR+ET, TEVAR, and renal artery stenting, and achieved a favorable outcome.

Diffusion-weighted whole-body imaging with background body signal suppression has been used to diagnose fever of unknown origin. An 86-year-old man who underwent bile duct jejunostomy for bile duct cancer presented with fever (body temperature, 40°C). Escherichia coli was detected in blood cultures. Diffusion-weighted whole-body imaging with background body signal suppression revealed accumulation in the aortic arch. Therefore, infectious aortitis secondary to retrograde cholangitis was diagnosed. The patient was treated with antibiotics, and the aortic arch accumulation disappeared. Diffusion-weighted whole-body imaging with background body signal suppression is a useful modality for diagnosing vasculitis and assessing treatment effectiveness.

Iatrogenic type A aortic dissection (TAAD) is a rare but potentially fatal complication of coronary angiography. We report a case of iatrogenic retrograde TAAD originating from the right subclavian artery. Endovascular entry closure using a stent graft led to resolution of the false lumen and favorable aortic remodeling. The patient remained free from cardiovascular events over a 4-year follow-up. This case highlights the potential efficacy of endovascular treatment, even in retrograde TAAD with its entry located in the subclavian artery.

A 50-year-old male with diabetes mellitus, who experienced recurrent sternal dehiscence secondary to a deep sternal wound infection, failed to respond to treatment with both pectoralis major muscle and greater omental flaps. Consequently, we performed a vertical rectus abdominis muscle flap in a double-pedicle fashion, utilizing the internal mammary artery and the 12th intercostal artery perforator. This intervention successfully addressed the condition. This novel technique offers an excellent therapeutic option for managing this life-threatening complication.

We report a rare case of phlebosclerosis in the left antecubital region after peripheral intravenous chemotherapy, which caused elbow contracture. A 54-year-old woman with breast cancer underwent partial mastectomy of the right breast and 8 courses of neoadjuvant chemotherapy, 6 of which were administered via venipuncture in the left forearm. She developed progressive flexion contracture of the left elbow despite rehabilitation. Two cord-like fibrotic veins were identified in the antecubital region and surgically excised. Postoperative rehabilitation led to full elbow extension within 5 months. In cases with elbow extension limitation, proactive surgical intervention should be considered.

A 56-year-old woman with recurrent acute pulmonary embolism was diagnosed with a left popliteal venous aneurysm (PVA) by venous echocardiography. During anticoagulation therapy with heparin for acute pulmonary embolism, she was found to be positive for heparin-induced thrombocytopenia (HIT) antibodies. Surgery was performed with argatroban for anticoagulation, removal of the thrombus in the PVA, and suturing of the vein. Postoperatively, the popliteal vein showed shrinkage, and no recurrence of thromboembolism was observed. We report a case in which a patient with a PVA positive for HIT antibodies was successfully treated with PVA resection and anticoagulation therapy with argatroban.

A 78-year-old male presented with progressive enlargement of a pararenal abdominal aortic aneurysm following chimney endovascular aneurysm repair. The aneurysmal expansion was attributed to an endoleak secondary to migration of the left renal artery chimney stent graft, resulting in a 5-mm increase in aneurysm diameter over 6 months. Endovascular reintervention successfully induced aneurysm regression, with no recurrence of endoleak on annual imaging follow-up. While chimney endovascular aneurysm repair presents a minimally invasive alternative for managing complex aortic pathologies, including pararenal abdominal aortic aneurysms, vigilance regarding potential stent graft migration is essential.

Late postoperative type 3 endoleaks associated with the AFX (Endologix, Irvine, CA, USA) stent-graft are commonly reported. The AFX’s endoskeletal design raises concerns about wire entrapment between its frame and fabric, as well as a risk of type 1a endoleak. An 84-year-old man with prior EVAR using the AFX presented with a type 3b endoleak 4 years postoperatively. He underwent relining with the TREO stent-graft (Terumo Aortic, Sunrise, FL, USA), which enabled easy contralateral gate cannulation and secured a long proximal landing zone. The TREO appears to be a viable option for relining the AFX in type 3b endoleak cases.