In Japan, the absence of commercially available fenestrated and/or branched endografts has necessitated widespread adoption of physician-modified endografts (PMEGs) for complex aortic aneurysms. This paper compares PMEG use in Western countries and Japan, summarizes multicenter outcome data, and highlights the gap between real-world practice and current Japanese aortic disease guidelines. Recent Japanese series report high technical success and acceptable mid-term outcomes, comparable to Western reports. While long-term durability remains uncertain, structured training, national registries, and standardized protocols are essential. Guideline acknowledgment of PMEGs could improve safety, consistency, and international alignment in complex endovascular therapy. Establishing structured training, national registries, and evidence-based policy recognition of PMEGs is essential to ensure safe and standardized practice in Japan.

Artificial intelligence (AI) and machine learning (ML) are transforming vascular surgery by enabling precise risk stratification, individualized treatment planning, and improved prognostic prediction. In abdominal aortic aneurysm (AAA) management, ML algorithms integrate complex clinical and imaging data to estimate survival, guide procedural decisions, and identify key factors influencing aneurysm remodeling. These models outperform traditional statistical approaches by capturing nonlinear interactions among variables such as nutritional status, immune function, and anatomical features. Despite these advances, challenges remain. Many studies rely on single-center datasets, raising concerns about overfitting and limited generalizability. The use of black-box models can hinder clinical trust due to limited interpretability. However, recent developments in multicenter data collection and explainable AI techniques are improving model robustness and transparency. As these tools continue to evolve, ML is poised to contribute meaningfully to precision vascular care. By supporting more individualized and data-informed decision-making, ML has the potential to enhance long-term outcomes and guide the future of AAA management after endovascular aneurysm repair.

Objectives: We aimed to elucidate the long-term outcomes of acute symptomatic spontaneous isolated dissection of the superior mesenteric artery (SIDSMA) to inform optimal decision-making during the acute phase.

Methods: We retrospectively collected and analyzed data from 14 consecutive patients diagnosed with SIDSMA by using computed tomography angiography (CTA) between January 2010 and August 2024.

Results: The cohort comprised 13 males and 1 female, with a mean age of 59.36 ± 14.90 years. All patients presented with acute abdominal pain, and some experienced vomiting. Thirteen patients received conservative treatment, while only 1 patient underwent open surgery with extra-anatomical bypass; this patient required no further intervention 10 years postoperatively. One of the patients, whose abdominal pain worsened with food intake, showed SMA stenosis and decreased intestinal blood flow. His symptoms improved after heparin anticoagulation therapy followed by direct oral anticoagulant therapy. Over a follow-up period of 7.20 ± 3.21 years, none of the patients experienced recurrent SIDSMA-related abdominal pain, and all survived without the need for additional invasive treatment.

Conclusions: Conservative treatment effectively manages SIDSMA over the long term without reintervention. Early diagnosis and management of intestinal ischemia are essential for optimal treatment outcomes.

Objectives: We conducted a detailed comparison of inpatient medical costs between endovascular aneurysm repair (EVAR) and open aneurysm repair (OAR) for abdominal aortic aneurysms.

Methods: We evaluated 312 EVAR and 205 OAR cases performed at our institution between January 2007 and December 2017. Patient background characteristics were adjusted between the EVAR and OAR groups using propensity score matching (PSM). Surgical outcomes and inpatient medical costs were compared.

Results: After PSM, 161 cases were included in each group for comparison. Operative time, blood loss, intensive care unit (ICU) stay, and hospital stay were significantly lower in the EVAR group than in the OAR group. Total inpatient medical costs were significantly higher in the EVAR group (3111× 10³ vs. 2156 × 10³ JPY [Japanese yen], p <0.01). The surgical material costs in the EVAR group were significantly higher than those in the OAR group, accounting for 58% of total medical expenses. Other costs (diagnosis procedure combination, ICU management, surgical procedure, transfusion, intraoperative injection, and room) were all lower in the EVAR group than in the OAR group.

Conclusions: The cost-saving effects of EVAR, such as reduced transfusion costs and ICU stay fees, were offset by the significantly higher cost of surgical materials.

Objectives: Coronavirus disease 2019 (COVID-19) causes endothelial injury through inflammatory and hypoxic stress, leading to vascular dysfunction and immunothrombosis. The plasma level of von Willebrand factor (VWF) could serve as a biomarker of vascular injury. While elevated VWF predicts mortality in severe COVID-19, its relationship with post-discharge functional outcomes remains unclear. This study aimed to determine whether plasma VWF antigen (VWF:Ag) levels at admission predict functional status at discharge in patients hospitalized for COVID-19.

Methods: This was a single-center prospective cohort study conducted at Tokai University Hospital from July to September 2021. We evaluated the relationship between plasma VWF:Ag levels at admission and a Clinical Frailty Scale (CFS) score ≥4 at discharge using univariable and multivariable logistic regression analyses.

Results: A total of 97 patients were enrolled in the study. The median VWF:Ag level at admission was 330.0% (95% confidence interval [CI]: 273.0–391.8). Univariable analysis showed a significant association between elevated VWF:Ag levels and CFS score ≥4 at discharge. This association remained significant after adjusting for age and sex (odds ratio 1.010, 95% CI: 1.000–1.010, p = 0.005).

Conclusion: Elevated VWF:Ag levels at admission predict poor functional outcomes at discharge in COVID-19 patients, independent of age and sex.

Objectives: Familial hypercholesterolemia (FH) accelerates systemic atherosclerosis and worsens prognosis from youth. While present in 5%–10% of premature coronary artery disease (pCAD) cases, its prevalence and impact in lower extremity artery disease (LEAD) remain unclear. This study investigated FH prevalence and prognostic impact in premature LEAD (pLEAD).

Methods: We retrospectively analyzed LEAD patients aged ≤70 years undergoing first revascularization. FH was diagnosed according to the 2022 Japan Atherosclerosis Society Guidelines, based on dyslipidemia and Achilles tendon thickness. Primary outcomes were survival, amputation-free rate, and secondary intervention-free rate.

Results: Among 66 pLEAD patients (median age 66 years, 76% male), 10 (15%) met the FH criteria. Compared with non-FH patients, FH patients more frequently presented with chronic limb-threatening ischemia (CLTI) (90% vs. 36%, p = 0.001), bilateral lesions (100% vs. 36%, p <0.001), and dialysis dependence (90% vs. 25%, p <0.001). Three-year survival (28% vs. 90%, p <0.001), amputation-free rate (64% vs. 89%, p = 0.028), and secondary intervention-free rate (38% vs. 63%, p = 0.031) were significantly lower in FH patients. In the CLTI subgroup, survival was markedly reduced in FH (17% vs. 71%, p = 0.011).

Conclusions: FH was present in 15% of pLEAD patients and associated with poor outcomes. Routine FH screening, including pCAD history and Achilles tendon evaluation, may improve prognosis.

Objectives: Femoral endarterectomy often requires patch angioplasty, and saphenous vein patch (SVP) was the standard. However, bovine pericardial patch (BPP) provides potential advantages, including no requirement for vein harvest, use of the access site for concomitant endovascular procedures, and favorable handling characteristics. We compared the short- and mid-term outcomes of BPP and SVP in femoral endarterectomy.

Methods: This retrospective, single-center study included 42 patients (49 limbs) who underwent elective femoral endarterectomy with patch closure between September 2016 and January 2025. The patients were grouped by patch type as follows: 28 limbs with BPP and 21 limbs with SVP. Primary endpoints included patency and freedom from target lesion revascularization at the endarterectomy site. Secondary endpoints included perioperative complications, limb salvage, and intraoperative arterial clamp time.

Results: No patch-site restenosis or re-intervention occurred in either group. There were no patch infections, and the perioperative complications were similar. Limb salvage at 40 months was 87.5% with BPP vs. 95.0% with SVP (p = 0.42). Intraoperative arterial clamp time was significantly shorter in the BPP group (55.0 vs. 69.5 min, p = 0.01).

Conclusions: BPP represents a safe and valuable alternative option for femoral endarterectomy.

Objectives: The purpose of this study was to evaluate the results of endovascular therapy (EVT) with common femoral artery (CFA) endarterectomy site access for lower extremity artery disease (LEAD).

Methods: Records were reviewed retrospectively for patients who underwent EVT with CFA endarterectomy site access from 2014 to 2023 at 7 hospitals.

Results: A total of 74 EVT procedures with CFA endarterectomy site access were performed in 65 patients with LEAD. The median [interquartile range] interval between CFA endarterectomy and the first EVT access was 435 [237–1153] days. Technical success of EVT was achieved in 72 procedures (97%). Technical success of the puncture was achieved in all 74 procedures (100%). The median [interquartile range] puncture time and hemostasis time were 4 [2–6] and 13 [10–20] min, respectively. Two cases (3%) had access site hematoma, which was cured with conservative treatment.

Conclusions: The CFA after endarterectomy may be a safe and suitable access site for EVT.

Objectives: The objective of this study was to compare the adhesive strength and flexibility of 3 surgical sealants—synthetic (Hydrofit; Sanyo Chemical Industries, Kyoto, Japan), albumin-based (BioGlue; Artivion, Kennesaw, GA, USA), and fibrin-based (Beriplast; CSL Behring, Tokyo, Japan)—which are commonly used in cardiovascular surgery but unexplored under identical experimental conditions.

Methods: Adhesive strength was evaluated using a tensile adhesion test on collagen, polyester, and polytetrafluoroethylene substrates. Flexibility was assessed by measuring the maximum stress and elongation at failure in Hydrofit and BioGlue film samples. Beriplast was excluded as it failed to form films.

Results: Hydrofit and BioGlue showed similar collagen–collagen adhesion strengths (p = 0.11), while Beriplast was significantly weaker (p <0.01). Hydrofit outperformed both BioGlue and Beriplast (p <0.01) in collagen–polyester and collagen–expanded polytetrafluoroethylene (ePTFE) adhesions. Hydrofit also demonstrated a significantly higher elongation rate, strength, and maximum stress before rupture than BioGlue.

Conclusions: These surgical sealants possess distinct adhesive and mechanical characteristics. Hydrofit showed stable adhesion across various substrates, with notable flexibility. BioGlue displayed adequate adhesion on collagen surfaces but had restricted flexibility. Beriplast demonstrated reduced adhesion. Although only adhesive strength and flexibility were evaluated, such properties may offer valuable insights into sealant traits contextually. These potentially aid in the selection of appropriate sealants for cardiovascular procedures that require both durable adhesion and tissue compliance. Further in vivo validation is warranted.

Although both open and endovascular repair are available for hepatic artery aneurysms (HAAs), the optimal treatment strategy remains controversial, particularly in anatomically complex cases. In the present case, a large common HAA measuring 100 × 49 mm with a short proximal neck posed significant challenges for both modalities. To ensure intraoperative hemostasis, a hybrid approach was adopted: open surgical ligation combined with prophylactic balloon occlusion at the aneurysmal neck. This strategy enabled safe exclusion of the aneurysm without hepatic ischemia. The case underscores the importance of selecting open, endovascular, or hybrid techniques based on individual anatomical complexity to optimize outcomes in HAA management.

An 80-year-old female presented with a thoracoabdominal aortic aneurysm (TAAA) that had progressively enlarged to a diameter of 58 mm. She was scheduled for TAAA repair; however, she had a severe obstructive ventilatory disorder, which posed significant risks. Both open repair and general anesthesia were deemed to carry a high risk of respiratory complications. Consequently, an endovascular TAAA repair was performed using a physician-modified inner-branched endograft under locoregional anesthesia. This approach successfully treated the TAAA without any major complications. This strategy opens up the possibility of treating TAAA in patients with severe comorbidities that were previously challenging to treat.

A female in her early 40s with no skeletal abnormalities was incidentally found to have a 45-mm saccular aneurysm at the aortic isthmus during evaluation for pharyngitis. She had sustained blunt trauma 20 years earlier, resulting in multiple fractures and pneumothorax. Her family history included premature vascular or sudden death and scoliosis. Imaging showed no arterial tortuosity. She underwent successful open surgical repair. Histologic examination revealed disorganized elastic fibers with irregular thickening and partial loss of lamellar architecture. Postoperative genetic testing identified a heterozygous missense variant in SLC2A10, suggesting a possible association between monoallelic variants and vascular fragility.

An 81-year-old female with bilateral small saphenous vein varicosities (CEAP, C2s, Ep, As, Pr) underwent cyanoacrylate closure (CAC) and stab avulsion under general anesthesia. Fourteen days later, she developed severe dyspnea and was diagnosed with pulmonary embolism (PE) and deep vein thrombosis. Despite anticoagulation, cardiopulmonary support, and catheter-directed thrombectomy, she died 24 days after admission. Adequate heparin dosing with activated partial thromboplastin time monitoring is important. Prolonged procedures under general anesthesia may increase PE risk. Early ambulation, compression therapy, and follow-up ultrasonography beyond 24 hours may help detect delayed thrombus formation and reduce life-threatening complications after CAC.

We report a rare case of a radial artery aneurysm associated with ulnar artery occlusion in an 80-year-old female. Preoperative imaging showed poor visualization of the palmar arch and absent ulnar flow, prompting aneurysmectomy and radial artery reconstruction using a vein graft. Intraoperative findings revealed good retrograde flow, suggesting preserved distal perfusion. This case highlights the importance of accurate preoperative assessment of hand arterial anatomy, particularly the palmar arch, in determining the need for revascularization in radial artery aneurysms with compromised collateral circulation.

Tracheo-innominate artery fistula (TIF) is rare but potentially fatal, especially in pediatric patients. We present a case treated by emergency endovascular stenting followed by elective open surgery. Stent grafting achieved immediate hemostasis and served as a lifesaving bridge, but its limitations—including risks of infection, rebleeding, and graft mismatch due to somatic growth—made definitive surgery necessary. Laryngoscopic findings revealed intratracheal graft exposure, prompting timely graft removal and tracheal repair. This staged strategy highlights both the value of stenting as bridging therapy and the importance of early multidisciplinary planning in pediatric TIF.

A 62-year-old male with empyema underwent an attempted pleural drainage, which resulted in iatrogenic pseudoaneurysm formation of the right pulmonary artery in the interlobar segment. Endovascular treatment was favored over surgical intervention due to the presence of empyema. The pulmonary artery in the interlobar segment was embolized with metallic coils, with inevitable occlusion of blood perfusion in the middle and lower lobes. Despite the perfusion loss in a large lung territory, the patient eventually required no supplemental oxygenation. Coil embolization can be a favorable alternative to stent-grafting for pseudoaneurysm even in the interlobar segment, despite the potential risk of post-procedure hypoxemia.

We present a rare case of type II endoleak (T2EL) from an atypical mediastinal artery following total arch replacement with a frozen elephant trunk (FET) for chronic aortic dissection. A 63-year-old male with a history of multiple thoracic aortic surgeries, including FET, developed enlargement of an aortic arch aneurysm on follow-up. Computed tomography and diagnostic angiography revealed a T2EL due to a newly developed mediastinal collateral artery arising from the left subclavian artery feeding the sac. Selective transcatheter embolization with N-butyl-2-cyanoacrylate successfully eliminated the endoleak. Recognizing such atypical T2EL sources is crucial for managing post-FET aneurysm expansion.

Ascending aortic pseudoaneurysm is a rare but life-threatening complication after cardiac surgery, typically requiring redo open repair with substantial risk. We report a 58-year-old male with an incidental 85-mm ascending pseudoaneurysm discovered during evaluation for recurrent hepatocellular carcinoma. Due to prior sternotomy, cirrhosis, and urgent oncologic need, open surgery was deemed prohibitive. He successfully underwent thoracic endovascular repair with reverse extra-anatomical aortic arch debranching technique. He recovered uneventfully and proceeded to cancer treatment without delay. This case highlights the feasibility of hybrid endovascular strategies for ascending aortic pathology in high-risk patients.

This case report presents a case of lower extremity peripheral arterial disease (PAD) with severe calcified lesions extending from the external iliac artery to the bifurcation of the superficial femoral artery, involving the groin region. Owing to the complexity and risk of complications, such as infections and delayed wound healing, revascularization was performed with extensive endarterectomy. The inguinal-lifting technique (ILT) was used to provide safe surgical access and minimize complications. The procedure resulted in successful revascularization with no major wound-related issues. The ILT proved to be an effective approach for safe, extensive endarterectomy in complex PAD cases.

Tracheoinnominate artery fistula is a rare but potentially fatal complication of tracheostomy. We report the case of a 22-year-old male at high risk for tracheoinnominate artery fistula due to severe thoracic deformity. To mitigate the risk, a prophylactic transection of the innominate artery was successfully performed using a combined suprasternal and intercostal approach, thereby avoiding limb perfusion. The patient was discharged without complications. This case highlights the effectiveness of the combined approach for safe innominate artery transection in anatomically challenging cases.