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.

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 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.

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.

We report a case of an abdominal aortic rupture without aneurysm associated with giant cell arteritis. A 67-year-old woman presented with lower back pain. Contrast-enhanced computed tomography revealed a massive retroperitoneal hematoma with contrast leakage from the abdominal aorta, suggestive of abdominal aortic rupture. During emergency surgery, a rupture site was identified on the anterior wall of the abdominal aorta, while no aneurysmal changes or dilatation of the abdominal aorta were observed. Histopathological examination of the resected aortic wall revealed infiltration of giant cells positive for CD68, leading to the diagnosis of giant cell arteritis.

Herein, we describe the case of a 72-year-old man who presented with a residual inferior pancreaticoduodenal artery aneurysm following the rupture and treatment of a superior pancreaticoduodenal artery aneurysm. Open surgery for pancreaticoduodenal artery aneurysms requires carefully planned vascular reconstruction to prevent organ ischemia and minimize pressure changes caused by fluctuations in mechanical stress. Additionally, in cases of rupture, factors such as the patient’s condition, presence of hematoma and adhesions, and pressure changes resulting from prior transarterial embolization must be considered. This case report outlines the surgical strategy employed for managing the residual inferior pancreaticoduodenal artery aneurysm.

Subclavian artery aneurysms are rare and challenging to treat owing to their anatomical location and proximity to critical branches, including the vertebral artery. We report the case of a 78-year-old man with a left subclavian artery aneurysm. The aneurysm was located in the mediastinum and measured 31 mm in diameter. The proximal side of the aneurysm was sealed with a stent graft, while the distal side was accessed through a supraclavicular incision and directly ligated. Postoperative imaging confirmed complete exclusion. This hybrid approach avoided invasive open surgery and provided a favorable outcome.

We present a case of a common femoral artery aneurysm as an extremely rare manifestation of immunoglobulin G4-related disease (IgG4-RD). A 79-year-old male, who underwent emergency abdominal aortic aneurysm repair at age 60 due to rupture, developed enlarging aneurysms of the right internal iliac artery, the right common femoral artery, and the left common femoral artery. Consequently, the right iliac artery was replaced with a graft extending to the right deep femoral artery, also reconstructing the right internal iliac artery. Histopathological examination of the resected common femoral artery wall confirmed the diagnosis of IgG4-RD.

A 76-year-old male patient, who had undergone right axillary artery bypass and arch replacement surgery for retrograde type A aortic dissection after thoracic endovascular aortic repair 2 years ago, was referred to our department with complaints of swelling and pain in the right subclavian region. A computed tomography scan suspected an abscess around the bypass graft; however, the culture was negative. Pathological examination indicated a diffuse large B-cell lymphoma (DLBCL) diagnosis. Chemotherapy was not indicated due to the patient’s condition, and he passed away after 3 months. DLBCL originating around a graft is extremely rare but crucial for differential diagnosis.

We experienced a case in which a myxoma in the inferior vena cava (IVC) was surgically removed along with the IVC using deep hypothermic circulatory arrest. A 42-year-old female with no subjective symptoms was incidentally found to have a mass in the IVC at the junction of the hepatic veins on contrast-enhanced computed tomography. Ultrasonography revealed a mobile tumor attached to the junction of the hepatic veins. Surgery was performed via median sternotomy and laparotomy. Cardiopulmonary bypass and deep hypothermic circulatory arrest were utilized to safely operate.

Persistent sciatic artery (PSA) is an exceptionally rare vascular condition that occurs in approximately 0.025%–0.04% of the general population. We describe the case of a 51-year-old man who presented with acute left lower limb pain and high fever. He was diagnosed with COVID-19 and isolated, and conservative treatment was performed for toe pain, resulting in left toe necrosis. Computed tomography revealed PSA occlusion in the left lower extremity. We diagnosed the patient with acute occlusion of the PSA due to COVID-19. The complicated disease was successfully treated using distal artery bypass.

We report a case of a 68-year-old female patient with an 8-mm right gastric artery aneurysm. The attempt at endovascular treatment was unsuccessful and therefore the patient underwent laparoscopic surgery for the resection of the unruptured right gastric artery aneurysm. The postoperative course was uneventful, and the patient is currently under observation as an outpatient. Although endovascular treatment is the first choice for treatment of unruptured right gastric aneurysms, laparoscopic surgery offers advantages such as less invasiveness, anatomical accessibility, and the ability to perform histopathological examination, making it an effective treatment option when endovascular treatment is difficult.

Intravenous leiomyomatosis (IVL) remains scarcely reported, and complete tumor resection is the recommended treatment. Herein, we present a comprehensive review of the case of a 52-year-old woman who suffered from recurrent syncope episodes due to IVL with intracardiac extension to the right atrium. Partial tumor resection and postoperative hormone therapy were conducted first. However, the 6-month postoperative follow-up computed tomography scan revealed a tendency for the IVL to increase in size, and complete resection was conducted. In this article, we would like to emphasize that partial resection followed by hormone therapy is insufficient for IVL, and complete resection should be chosen.

Cold agglutinin disease (CAD) is a rare and autoimmune hemolytic disorder caused by the presence of cold-reacting autoantibodies against red blood cells. An abdominal aortic aneurysm (AAA) is a potentially life-threatening condition. This report describes an 83-year-old man with AAA who was diagnosed with primary CAD 9 years before undergoing AAA surgery. The patient underwent successful endovascular aortic repair. Temporary hemolytic anemia and exacerbation of jaundice were observed postoperatively despite strict temperature control. Red blood cell and haptoglobin transfusions may prevent fatal hemolytic anemia, renal disorders, embolism, and systemic complications.

During thoracic endovascular aneurysm repair for aortic arch aneurysms, deployment of the stent graft parallel to the aortic neck is crucial to preventing a type Ia endoleak from the proximal end. We report the early tip capture release and push-up technique that comprises early release of the proximal bare stent, which is typically deployed last during stent graft deployment, followed by a push-up maneuver after landing the proximal edge, thus allowing conformation to the aortic morphology. This technique is effective even for complex aortic arch anatomy.

Intraoperative venous bleeding, particularly from deep pelvic veins, can be difficult to control with suturing or standard compression. We introduce the “French toast method,” a hemostatic technique that combines Hydrofit (Terumo, Tokyo, Japan) with a gelatin sponge (Spongel; LTL Pharma, Tokyo, Japan). A small amount of Hydrofit is spread onto the sponge, which is then applied to the bleeding site. Immediately afterward, saline is poured over the area to activate Hydrofit, followed by fingertip compression. This method enables rapid and secure hemostasis without the need to remove a silicone sheet, thereby reducing the risk of rebleeding and simplifying management of difficult venous hemorrhage.

In the treatment of saphenous varicose veins with endovenous laser ablation, simultaneous treatment of varicose tributaries using stab avulsion or sclerotherapy is commonly performed. To address the limitations of these conventional treatments, laser ablation for varicose tributaries has recently gained widespread acceptance. This guideline, developed by the Japanese Society of Phlebology, outlines appropriate treatment protocols for laser ablation of varicose tributaries. Indications include primary varicose veins requiring concurrent treatment of the saphenous trunk and varicose tributaries. The procedure utilizes slim radial fibers, with puncture and ablation performed using either short- or long-axis approaches. Although rare, adverse events such as skin burns, nerve injury, and fiber breakage have been reported. A learning curve is necessary to ensure the safe execution of the procedure. Further clinical studies are essential to enhance the safety and efficacy of laser ablation for varicose tributaries. (This is a secondary publication from Jpn J Phlebol 2025; 36: 51–58.)