As medical treatment for lymphedema, combined physical therapy with guidance regarding daily living is recommended. Recently, training has been conducted on a nationwide scale, and this therapy has gradually and commonly been employed. This therapy consists of daily living guidance to prevent edema deterioration, skin care, manual lymph drainage, compression therapy, and exercise therapy. The number of hospitals in which all procedures can be adequately performed is limited. There is no treatment to completely cure lymphedema. Patients’ self-care based on the contents of treatment is essential for relieving symptoms. (*English Translation of J Jpn Col Angiol 2008; 48: 167-172.)

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This paper reviews the morphology of lymphatics and lymphangiogenesis in vivo, microenvironments that promote lymphangiogenesis, and the structure and function of lymph nodes. Lymphatic capillaries consist of a single layer of lymphatic endothelial cells (LECs) and have valves, while collecting lymphatics are endowed with smooth muscle cells (SMCs) and valves besides a single layer of LECs. In the embryonic rat diaphragm, LECs first migrate presumably according to interstitial fluid flow and later join to form lymphatic vessels. SMCs of the collecting lymphatics are apparently differentiated from mesenchymal cells. LECs cultured on Cell Culture Inserts under a low oxygen condition proliferate very well and form a lymphatic network. LECs cultured on a collagen fiber network with a natural three-dimensional (3D) architecture under low oxygen rapidly form a 3D lymphatic network. The lymph node initiates an immune response as a critical crossroads for the encounter between antigen-presenting cells, antigens from lymph, and lymphocytes recruited into nodes from the blood. The node consists of spaces lined with LECs and parenchyma. High endothelial venules in the node strongly express Aquaporin-1, suggesting their involvement in the net absorption of water from lymph coming through afferent lymphatics. SMCs in node capsules seem to be involved in squeezing out lymphocytes and lymph. (*English Translation of J Jpn Col Angiol 2008; 48: 107-112.)

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Background: Data on diabetes-related lower extremities amputations in the Kingdom of Saudi Arabia (KSA) and perhaps in all of Middle East and North African (MENA) countries are limited, in view of the absence of national registries.
Methods: This review aims to challenge media figures by review of data in the local database of the author, available published data, as well as by analysis of recent annual reports of the Saudi Ministry of Health to estimate the magnitude of the problem. Different methods of analysis are used based on the number of beds, operations and admissions in KSA to generate approximate figures of the annual expected numbers of amputations in KSA and MENA countries. The 2010 International Diabetes Federation IDF comparative prevalence rate of 16.8% was used to standardize the analysis methods.
Results: Findings of 2 previous studies and 3 analytical methods led me to the prediction that about 325 amputations are likely to occur annually in Jeddah compared to 741 in Riyadh and 3970 in KSA. When we applied the results of KSA to those of MENA countries, 44208 amputations were predicted annually.
Conclusion: Half a million diabetes-related amputations of the lower extremities are likely to occur in KSA and MENA countries over the coming decade. National registries are urgently needed.

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Objective: The aim of this study was to assess the strategy and surgical procedures for treating a renal artery aneurysm (RAA).
Patients and Methods: We retrospectively reviewed the surgical strategy for 21 cases with RAA between 2001 and 2010 at this institution. Treatment was indicated for patients with an RAA larger than 2 cm and/or symptoms. Surgical treatment was the initial strategy, and coil embolization was indicated in the case of narrow-necked, saccular, extraparenchymal aneurysms.
Results: Fifteen patients in 21 cases received an aneurysmectomy and renal artery reconstruction with an in-situ repair. One patient underwent an unplanned nephrectomy, and coil embolization was performed in 5 patients.
Conclusion: In-situ repair was safe and minimally invasive. RAA, even in the second bifurcation, could be exposed by a subcostal incision, and the transperitoneal approach permitted the safe treatment of an RAA with acceptable results, in our simple preservation of renal function.

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Purpose: The aim of this study was to examine the usefulness of the subtraction technique of non-contrast renal magnetic resonance angiography (MRA) between tagged and non-tagged data collection.
Material and Methods: We performed renal MRA on eleven healthy volunteers using a 3T MRI unit. For renal MRA, a three dimensional balanced type steady-state free precession (SSFP) sequence (True FISP, Siemens) was used with diaphragmatic navigator gating. We tried to acquire selective arterial images by subtracting black-blood images (tagged images, on which arterial longitudinal magnetization was nearly zero by selective inversion of upper-stream aortic flow) from bright-blood images (non-tagged images, on which arterial flow is bright due to inflow effect). For analysis, two radiologists independently evaluated the visual quality of the axial and coronal targeted maximum intensity projection images (MIP) of original bright-blood MRA and subtraction MRA.
Results: Visualization of the main stem of the renal arteries and their 1st branches were satisfactory on both techniques, and there was no statistically significant difference. The score of 2nd branch appeared superior with the subtraction method, but only the right side showed a statistically significant difference (P <0.01). Visualization of small intraparenchymal arteries was significantly superior with subtraction method on both sides.
Conclusion: We tried to improve selective demonstration of renal arterial branches using subtraction technique. Although full sequence optimization was not performed, this pilot study showed this technique to be slightly time-consuming but superior in visualization of peripheral branches and possibly more sensitive in detecting small vessel abnormalities.

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Objective: Chronic renal insufficiency may be a relative contraindication to endovascular aneurysm repair (EVAR) for the use of contrast enhanced mediums. It is thought that more contrast enhanced media are needed in patients who are not anatomically suitable for EVAR, because of procedural difficulties. We reviewed a 2 year EVAR experience at our institution to determine whether the procedure and use of contrast enhanced mediums has any deleterious effect on renal function in patients with pre-existing chronic renal insufficiency.
Materials and Methods: EVAR was performed in 46 patients with pre-existing chronic renal insufficiency without hemodialysis. Patients were retrospectively assigned to two groups on the basis of their preoperative creatinine clearance levels. Furthermore, patients were assigned to two other groups on the basis of anatomical suitability for EVAR. The absolute change in the serum creatinine (Cr) level was reviewed in the each renal insufficiency group between the preoperative and post-operative time periods.
Results: No increase in the serum Cr level was noted, and no patient required temporary or permanent hemodialysis, in any of the groups.
Conclusions: EVAR with contrast agents can be accomplished in patients with chronic renal insufficiency without hemodialysis; therefore,elevated Cr levels maynot be a contraindication in EVAR.

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Objective: Early outcomes of open abdominal repair (OS) versus endovascular repair (EVAR) for abdominal aortic aneurysm were retrospectively analyzed, after commercialized devices for EVAR had become available in Japan.
Patients and Methods: A total of 781 consecutive patients (OS, n = 522; EVAR, n = 259) were treated at ten medical centers between January 2008 and September 2010. The OS group comprised patients with preoperative shock (SOS, n = 34) and without shock (NOS, n = 488).
Results: Patients in the EVAR group were 3 years older than those in the NOS group. There was greater prevalence of hostile abdomen, on dialysis, chronic obstructive pulmonary disease on inhaled drug, and cerebrovascular disease in the EVAR group than in the NOS group. Surgical mortality was 16 cases (2.0% in all patients, EVAR: 0.8%, NOS: 1.4%, SOS: 21%). Hospital stay >30 days was documented in 52 (11%) with NOS, 11 (33%) with SOS, and 8 (3%) with EVAR. Thirty late deaths included 6 aneurysm related death and 14 cardiovascular causes at a mean follow up of 1.0 year. The survival rates freedom from all cause death at one year, were 95 ± 1% in NOS and 94 ± 2% in EVAR respectively.
Conclusion: Though significant differences in patient characteristics among three groups were noted, early results were satisfactory.

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Purpose: To examine the relationship between incidence of later, local vascular events (restenosis and occlusion) and clinical factors including lipid levels after surgical or endovascular treatment of peripheral artery disease (PAD).
Methods: Consecutive 418 PAD lesions (in 308 patients under the age of 70) treated with surgical(n = 188) or endovascular (n = 230) repair for iliac (n = 228) and infrainguinal (n = 190) lesions were retrospectively analyzed. Clinical features and lipid levels were compared between patients who developed vascular events (n = 51; VE group) and those who did not (n = 257; NoVE group).
Results: Among assessed factors, post-therapeutic low-density lipoprotein cholesterol (LDL-C) levels (mg/dL) were significantly higher in the VE group (120.4 ± 31.2) than in the NoVE group (108.2 ± 25.1) (P = 0.01). Infrainguinal lesions were more common in the VE than in the NoVE group (P <0.001). Cox hazard analysis indicated that infrainguinal lesions relative to iliac lesions significantly increased the risk of vascular events (hazard ratio (HR) 3.35; 95% CI 1.63-6.90; P = 0.001) and post-therapeutic LDL-C levels <130 (mg/dL) decreased the risk (HR 0.34; 95%CI 0.17-0.67; P = 0.002).
Conclusion: Lowered post-therapeutic LDL-C levels can decrease the risk of later, local vascular events after PAD treatment. These results may support the rationale for aggressive lipid-modifying therapy for PAD.

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We describe a patient with adventitial cystic disease of the popliteal artery with intermittent claudication involving the right calf during exercise. Magnetic resonance imaging (MRI) and computed tomography (CT) revealed a cystic lesion that encircled and compressed the popliteal artery. Resection of the cyst involving a segment of the affected popliteal artery and interposing an autologous vein graft resolved the symptoms, and the postoperative course was uneventful. The cyst was histologically similar to a ganglion.

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Subclavian artery aneurysms are comparatively rare in peripheral aneurysms. We experienced a case of intrathoracic aneurysm originating from the proximal part of the right subclavian artery. A 78 year-old man was referred to our hospital with the diagnosis of a right subclavian artery aneurysm. Enhanced computed tomography demonstrated an intrathoracic aneurysm, originating from the right subclavian artery just proximal of its origin. Through a median sternotomy and supra-infraclavicular incision, we reconstructed the brachiocephalic and right common carotid arteries and bypassed to the distal part of the right subclavian artery by using a T-shaped vascular graft and the aneurysm was excluded.

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A 72 year-old man was admitted to the hospital to receive treatment for resting pain and an ulcer, which had developed on an amputation stump, 4 months after he had undergone a thrombectomy, below-the-knee popliteal-dorsal pedis artery bypass of his left leg, and digital amputation of his 2nd toe. Angiography demonstrated diffuse arterial and bypass occlusion in his left leg that did not include a sural artery, which was the main collateral. Therefore, the patient underwent reversed saphenous vein bypass from the common femoral artery to the medial sural artery. His leg pain disappeared, and the ulcer healed promptly.

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A 53 year-old man was admitted with acute onset of severe abdominal pain, and we performed emergent thrombectomy and intimectomy for acute, complete occlusion of superior mesenteric artery (SMA) due to its spontaneous dissection. However, 4 months later the operated part of the SMA enlarged due to aneurysm and the patient was treated by aneuysmectomy and iliac-mesenteric bypass using a saphenous vein. Aggressive treatment such as surgical or endovascular procedure is necessary for severe ischemia due to SMA dissection.

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Mycotic celiac artery aneurysm following infective endocarditis is extremely rare and, to our knowledge, only four cases have been reported in the literature to date. We describe the case of a 60 year-old man who developed a mycotic aneurysm of the celiac artery, which was detected by computed tomography (CT) following an episode of infective endocarditis. He successfully underwent endovascular isolation and packing of the aneurysm using N-butyl cyanoacrylate (NBCA) with embolization coils.

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Congenital systemic-pulmonary collateral vein (i.e. levoatriocardinal vein) is an uncommon cardiac anomaly. We report a rare case of congenital systemic-pulmonary collateral vein incidentally noticed after accidental migration of a central venous catheter. Cardiac CT showed the vertical vein connected to the left upper pulmonary vein (LUPV) and another thin abnormal vessel was shown running caudally from the LUPV, connecting to the coronary sinus. Furthermore, the normal connection between the LUPV and the left atrium remained. There were two levoatriocardinal veins from the LUPV without atrial egress failure. To our knowledge, this might be the first report of such a case.

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May-Thurner syndrome or iliac vein compression syndrome is associated with deep vein thrombosis (DVT) resulting from chronic compression of the left iliac vein against lumbar vertebrae by the overlying right common iliac artery. Historically, May-Thurner syndrome has been treated with anticoagulation therapy. However, this therapy can be problematic when given alone, because it prevents the propagation of the thrombus without eliminating the existing clot. Furthermore, it does not treat the underlying mechanical compression. Consequently, syndrome who was managed by anticoagulation therapy alone, there is a significant chance that the patient will develop recurrent deep vein thrombosis or post thrombotic syndrome or both. Recently, both retrospective and prospective studies have suggested that endovascular management should be front-line treatment; endovascular management actively treats both the mechanical compression with stent placement and the thrombus burden with chemical dissolution. We report our case of 53 years old male patient with May Thurner syndrome who managed by endovascular treatment.

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A 35 year-old man first noticed an elastic mass like breast tumor in his left chest 17 years ago. It enlarged to the size of a child’s head. Computed tomography showed a well-circumscribed mass in the left chest. Lumpectomy was performed. The mass was located under the thin major pectoralis muscle, covered with a white fibrous capsule. The specimen weighed 1360 g and measured 18 × 14 × 8 cm. Histological examination revealed a cavernous hemangioma. To the best of our knowledge, this is the first reported case of a chest hemangioma arising from connective tissue and located under the major pectoralis muscle.

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Endovascular repairs of thoracic and thoracoabdominal aortic aneurysm have recently been proposed as a less invasive alternative to conventional open surgical repair. In selective cases, adjunctive bypass surgery may be required to provide an adequate landing zone. We describe a case of staged hybrid debranching and thoracic endovascular aneurysm repair for distal aortic arch and thoracoabdominal aortic aneurysms after conventional open repair of the descending aorta.

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The present case was a 70 year-old dialysis patient who had experienced a prior cerebral infarction following atrial fibrillation. Her shunt suddenly occluded during dialysis, and she was transferred to our hospital. Transesophageal echocardiography revealed a floating, ball-like thrombus in the left atrial appendage (LAA). After thrombectomy in the shunt, acute thrombi were extracted. Despite anticoagulant therapy, the ball-like thrombus in the LAA did not dissipate and instead continued to enlarge. We planned surgical intervention involving a left atrial appendectomy without cardiopulmonary bypass through a left thoracotomy. However, her thrombus disappeared out of the LAA when she was intubated in the operating room. Her surgery was, therefore, stopped, and extubation was carried out. A computed tomography (CT) scan showed that the embolism had moved to the ostium of the celiac artery. Incidentally, this celiac artery had already been obstructed, and her inferior mesenteric artery had been the main supply of blood flow to the intestine, explaining why she had not developed intestinal ischemia. We continued anticoagulant therapy with warfarin. Follow-up CT studies were conducted at the outpatient clinic. However, the patient died due to a wide cerebral infarction before the 6-month checkup.

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The development of a ganglion in the hip joint is a rare cause of lower limb swelling. We herein describe a case of a ganglion of the hip with compression of the femoral vein that produced signs and symptoms that mimicked a deep vein thrombosis. Needle aspiration of the ganglion was easily performed, and swelling of the left lower limb promptly improved. Intensive follow-up of this case was important because the recurrence rate of ganglions after needle aspiration is high.

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