Acute limb ischemia (ALI) is a sudden decrease in lower limb arterial perfusion that poses a threat not only to limb viability but alsoto life and requires urgent evaluation and management. The etiology of ALI is broadly divided into embolism and thrombosis, along with various comorbidities. Severity and treatment strategy should be determined based on physical and image findings. Revascularization can be performed surgically (thromboembolectomy or bypass), endovascularly, or through a hybrid procedure. In all cases, it is important to conduct intraoperative angiography and perform the necessary additional procedures. A prompt response to myonephropathic metabolic syndrome or compartment syndrome during or after revascularization is also essential. ALI is a serious condition that requires emergency treatment, and it is important to be familiar with all treatment options, including surgical and endovascular treatments, fasciotomy, and primary limb amputation, and to promptly provide the best available initial treatment at each facility. (This is a translation of Jpn J Vasc Surg 2024; 33: 199–204.)

Endovascular treatment (EVT) is now performed worldwide for patients with lower extremity artery disease due to its safety and advances in devices. However, a common femoral artery (CFA) lesion often has severe calcification, and balloon angioplasty alone for such a lesion is ineffective in terms of patency. EVT with stent implantation for a CFA lesion may result in stent fracture and difficulty with puncture for subsequent interventions during the follow-up period. Given these issues, endarterectomy for a CFA lesion remains as the gold standard treatment in the endovascular era. However, the method of endarterectomy (i.e., arterial incision, patch use or not, patch material, intimal layer fixation or not) differs among centers. Thus, further investigation is needed for each method to promote the performance of high-quality CFA endarterectomy by vascular surgeons in the current endovascular era. (This is a translation of Jpn J Vasc Surg 2024; 33: 91–95.)

Endovascular treatment for patients with lower extremity artery disease (LEAD) has expanded its indications owing to the evolution of devices, improvements in techniques, and the establishment of clinical evidence. In particular, improvements in balloon and stent performance have significantly contributed to improved treatment outcomes. Herein, we describe the current status of basic balloon- and stent-related topics for the treatment of LEAD. (This is a translation of Jpn J Vasc Surg 2024; 33: 281–288.)

Diagnosis and treatment of cardiovascular diseases often require the administration of iodinated contrast media. However, it is sometimes difficult to use such contrast media in patients with renal dysfunction because direct mechanisms of tubular cell injury and indirect mechanisms of medullary ischemia, together with the contrast medium, may cause contrast-induced nephropathy (CIN). Although the frequency of developing CIN is said to be lower than previously estimated, once it develops, there is no effective treatment, and it may affect mortality. Therefore, before using a contrast medium, it is necessary to identify the risk factors of CIN in patients—including chronic kidney disease, advanced age, and diabetes mellitus—and understand the risk differences between intravenous and intra-arterial contrast medium administration. If there is any risk, intravenous saline or sodium bicarbonate treatments may be used to prevent CIN onset, and the use of minimum amounts of contrast media, within the corresponding range, may be recommended. (This is a translation of Jpn J Vasc Surg 2024; 33: 143–147.)

Thoracic endovascular aortic repair has revolutionized the treatment of thoracic aortic diseases. It is now indicated not only for descending aortic aneurysms but also for acute and chronic type B dissections and blunt thoracic aortic injuries. In addition, the scope of treatment is expanding. The thoracic aortic stent graft has been on the market in Japan for 15 years with good results, and the number of operations continues to increase. However, although stent grafts are highly recommended in Japanese and international guidelines for many aortic diseases, re-intervention increases over time in all disease groups. Careful follow-up is important because of morphologic changes and new complications after treatment. (This is a translation of Jpn J Vasc Surg 2024; 33: 73–77.)

Serious complications due to remote control often may occur during endovascular surgery. Therefore, it is necessary to know what complications are likely to occur or how to bail out those complications. Herein, we explain complications related to endovascular surgery and their bail-out procedures. (This is a translation of Jpn J Vasc Surg 2024; 33: 131–136.)

Femoropopliteal (FP) arterial lesions represent the most prevalent and challenging targets for endovascular therapy (EVT) in patients with lower extremity artery disease (LEAD). Despite significant advances in device technology, FP interventions continue to be limited by high rates of restenosis and occlusion. To date, no conclusive evidence has demonstrated the superiority of any specific endovascular device strategy for FP artery disease. Importantly, stent restenosis is characterized by longer lesion lengths and a higher incidence of occlusive failure, which may substantially compromise the feasibility of subsequent reintervention.

Simple renal cysts (SRCs) have traditionally been regarded as benign, age-related incidental findings with limited clinical significance. However, accumulating evidence suggests that SRCs are associated with abdominal aortic aneurysm (AAA), thoracic aortic aneurysm (TAA), and aortic dissection (AD), indicating that they may reflect systemic extracellular matrix (ECM) degeneration rather than isolated renal aging. This narrative review summarizes the current evidence linking SRCs to aortic disease, explores the underlying biological mechanisms, and discusses their potential prognostic significance following endovascular aortic repair. Observational studies have consistently reported a 2- to 3-fold higher prevalence of SRCs in patients with aortic disease compared with controls. Shared mechanisms, including ECM remodeling, matrix metalloproteinase activation, genetic susceptibility, and arterial stiffening, provide biological plausibility for this association. Emerging evidence further suggests that SRCs are independently associated with reduced sac shrinkage after endovascular aneurysm repair (EVAR) and thoracic endovascular aortic repair (TEVAR), as well as with an increased risk of aortic-related adverse events following TEVAR for type B AD. Although the current evidence is derived predominantly from retrospective studies, SRCs represent a readily identifiable imaging marker that may enhance risk stratification and postoperative surveillance. Prospective multicenter studies are warranted to validate these findings and clarify their clinical implications.

Isolated iliac artery aneurysm—defined as aneurysmal dilatation of the common, internal, or external iliac artery without a concurrent abdominal aortic aneurysm requiring simultaneous repair—accounts for approximately 2%–7% of intra-abdominal aneurysms. This narrative review examines its natural history and the relative merits of open and endovascular treatment, with particular attention to internal iliac artery management, drawing on literature published since 2007. Two features deserve greater attention. First, much of what is cited as evidence on isolated disease derives from mixed aorto-iliac cohorts: across 7 such series, isolated aneurysms accounted for 120 of 897 patients (13.4%). Second, the frequently repeated claim that Japanese patients experience rupture at smaller diameters rests on comparisons between treated referral cohorts and Western imaging-surveillance cohorts, whose denominators are not equivalent. Reported growth rates range from 0.2 to 1.6 mm/year and accelerate with increasing diameter. Endovascular repair offers consistent perioperative advantages, whereas open repair may prove more durable when internal iliac artery sacrifice would otherwise be required. Although iliac branch devices are widely used in clinical practice, only 97 patients with truly isolated disease have been reported in dedicated series. The positions on treatment thresholds and techniques presented in this review are therefore identified as the author’s opinions.

Machine learning (ML) has been primarily used for predictive modeling in medical research, but this reflects only part of its potential. This review proposes a conceptual distinction between predictive ML and exploratory ML. Predictive ML aims to maximize accuracy on unseen data. Exploratory ML focuses on identifying underlying structures in data to generate hypotheses. Exploratory ML plays an important role under conditions where conventional hypothesis-driven statistics have limitations, including high-dimensional data, small sample sizes, and biopsy-inaccessible organs such as the vascular system. Because ML-derived results are based on associations rather than causality, they should be interpreted as hypothesis-generating rather than confirmatory. Methods including unsupervised learning, interpretable supervised learning, and network analysis are discussed as exploratory ML approaches. The differences in objectives and evaluation criteria between exploratory ML and conventional hypothesis-driven statistics are also discussed, together with the structural gap in peer review. The key argument is that studies using exploratory ML should be evaluated not by predictive performance but by the stability, reproducibility, and interpretability of the identified structures. Without this shift, exploratory analyses may be systematically misjudged within current evaluation standards. This perspective may bridge exploratory analysis and confirmatory research and support new study designs in medicine.

There are no guidelines to suggest repair versus ligation for traumatic deep venous injuries. We aimed to compare the outcomes after reconstruction versus ligation of isolated traumatic venous injuries. This systematic review and meta-analysis (PROSPERO Registration Number: CRD42019143136) included all literature reported on the management of isolated venous injuries in adult trauma patients, excluding case reports from 1950 to 2020. Primary outcomes were mortality and amputation, while compartment syndrome, chronic venous hypertension, deep venous thrombosis, and pulmonary embolism were the secondary outcomes. PubMed, Google Scholar, Cochrane database, and Web of Science were searched. Study selection and synthesis were done following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A total of 25 studies were included. All the studies were observational, with the majority being retrospective in nature. Results of our meta-analysis show that ligation is significantly associated with higher rates of amputation (odds ratio [OR] = 1.73, 95% confidence interval [CI] = 1.20–2.48, p = 0.003) and mortality (OR = 1.50, 95% CI = 1.09–2.06, p = 0.01), whereas there is no significant difference in the rates of chronic venous insufficiency, deep venous thrombosis, and pulmonary embolism. There is insufficient data to analyze various types of venous repair, as well as to account for clinical severity at the time of presentation. Our results favor repair over ligation.

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.

We previously analyzed a saccular abdominal aortic aneurysm model and elucidated that saccular abdominal aortic aneurysms manifest abnormal hemodynamic factors from an early stage and that stenting improves these factors. In this study, we analyzed a model of a saccular abdominal aortic aneurysm implanted with stents of different diameters and lengths to determine the optimal stent size for improving hemodynamic factors. The stent diameter was set in 3 patterns as follows: 24 mm, the same as the aortic diameter; 26.4 mm, a 10% increase; and 28.8 mm, a +20% increase. The stent length was extended 10 mm vertically from the 28-mm length of the aneurysmal portion to 50 and 70 mm in 2 patterns, for a total of 6 types. The analysis revealed that all hemodynamic factors improved for all sizes compared with those prior to stenting. Streamlines entering the aneurysm were reduced with larger stent diameters; however, no difference in length was observed. Moreover, no clear differences in the mean flow velocity within the aneurysm, maximum shear stress, or pressure loss coefficient between the models were observed. An implanted stent was sufficient in terms of efficacy if it adhered to the aortic wall and covered the saccular aneurysm area. (This is a secondary publication from J Jpn Coll Angiol 2024; 64: 69–78.)

Objectives: This exploratory, cross-sectional study aimed to examine the association between coagulation factor activity and coagulation/fibrinolysis markers and the presence of cancer-associated thrombosis (CAT).

Methods: Patients diagnosed with cancer complicated by thrombosis and those without thrombosis between November 1, 2020, and December 31, 2022 were included. The clinical characteristics and values of each coagulation factor and coagulation/fibrinolysis marker in the CAT and non-CAT groups were compared.

Results: Of the 117 patients analyzed, 22 (18.8%) had CAT and 95 (81.2%) did not have CAT. Fibrinogen/fibrin degradation product (FDP), D-dimer, alpha2-plasmin inhibitor–plasmin complex (PIC), fibrin monomer complex (FMC), thrombin–antithrombin complex (TAT), and soluble fibrin (SF) levels were significantly higher in the CAT group than that in the non-CAT group. Receiver operating characteristic curve analysis was performed, and the proportions of patients with CAT were 7.9% when the number of factors with a value higher than the cutoff was 0 among the 6 factors of FDP, D-dimer, PIC, FMC, TAT, and SF levels; 17.1% for factors 1–3 and 31.6% for factors 4–6.

Conclusions: When hypercoagulability and hyperfibrinolysis coexist in patients with cancer, CAT is likely to be present, and it is necessary to confirm the presence of CAT at an early stage.

Objectives: The treatment of ruptured abdominal aortic aneurysms (rAAAs) remains associated with high morbidity and mortality. While endovascular aortic repair (EVAR) has shown promising results in elective settings, the evidence supporting its use as the primary treatment for patients with rAAA remains controversial. We aimed to evaluate both the clinical outcomes and the inherent advantages and disadvantages of our “EVAR-first” protocol for patients with rAAA over a 10-year period.

Methods: A retrospective review of data extracted from medical records identified 93 consecutive patients with rAAA who underwent EVAR from January 2014 to January 2024. All patients were treated using the “EVAR-first” protocol. Initially, percutaneous puncture of the bilateral common femoral arteries and the left brachial artery was performed. General anesthesia was then induced with the endovascular balloon control and EVAR was performed.

Results: EVAR was successfully performed in all patients with rAAA. The mean follow-up period was 1386.5 ± 1171.1 days. After the 30-day period, no new complications were observed. Endovascular re-interventions were performed in 9 patients (9.7%). The overall survival rates at 30 days, 1 year, and 3 years for the entire cohort were 87.1%, 70.9%, and 60.5%, respectively.

Conclusions: This single-center experience suggests favorable outcomes for adopting the “EVAR-first” policy for all rAAA patients.

Objectives: Although prophylactic branch embolization is known to reduce Type II endoleak after endovascular aneurysm repair (EVAR), its reproducibility and clinical value in low-volume regional centers remain under-discussed. This study evaluated the efficacy of an anatomy-guided embolization strategy for improving long-term sac behavior.

Methods: This retrospective, single-center cohort study included 132 patients who underwent elective EVAR. Prophylactic embolization (Coil+ group, n = 30) was performed based on standardized anatomical criteria, while 102 patients underwent standard EVAR (Coil− group). Preoperative anatomical risks and mid-term clinical outcomes, including sac expansion and re-intervention rates, were compared.

Results: Preoperatively, the Coil+ group showed significantly higher anatomical risk than the Coil− group, including a higher prevalence of a patent inferior mesenteric artery (IMA) (90.0% vs. 69.6%; p = 0.031) and a greater mean IMA diameter (3.18 ± 0.73 mm vs. 2.76 ± 0.77 mm; p = 0.011). The Coil+ group achieved a 0% sac expansion rate at 24 months. Notably, the 5-year re-intervention rate was 0% (0/30) in the Coil+ group compared to 10.8% (11/102) in the Coil− group, representing a trend toward superior mid-term durability (p = 0.069).

Conclusions: Standardized prophylactic branch embolization was associated with durable sac stability. This proactive approach may offer a rational pathway for optimizing long-term outcomes, even in low-volume centers.

Objectives: Although magnetic resonance imaging (MRI) is widely used to evaluate extracranial vascular anomalies (VAs), its diagnostic accuracy remains uncertain.

Methods: We retrospectively assessed MRI accuracy for VAs and identified nonvascular lesions mimicking them. Patients who underwent surgical resection for suspected VAs at a tertiary referral center in Japan between April 2019 and June 2025 were analyzed.

Results: A total of 172 patients met the inclusion criteria (mean age 34.9 ± 18.8 years; 62.8% female). Lesions were most commonly located in the extremities (54.1%), followed by the head and neck (32.6%) and the trunk (13.4%). Histopathology identified venous malformations (VMs) as the most frequent subtype (73.8%), followed by arteriovenous malformations (AVMs; 11.0%) and lymphatic malformations (LMs; 6.4%). MRI showed moderate sensitivity and high specificity: AVM sensitivity 0.68 and specificity 0.99; VM sensitivity 0.70 and specificity 0.98; LM sensitivity 0.80 and specificity 0.98. Seven cases (4.1%) were ultimately diagnosed as non-VA lesions despite MRI findings suggestive of VAs. Common mimickers included angioleiomyoma and myopericytoma.

Conclusions: MRI demonstrates moderate sensitivity and strong specificity for VAs, although false-positive interpretations remain an important consideration.

Objectives: Surgical site infection (SSI) remains a serious complication following bypass surgery for chronic limb-threatening ischemia (CLTI). This study aimed to characterize wound complications (WCs) preceding SSI and to identify predictors of SSI in a Japanese CLTI cohort with a high prevalence of dialysis.

Methods: A single-center retrospective study was conducted in patients undergoing infra-inguinal bypass with saphenous vein grafts (2012–2021). WCs and subsequent SSI within 3 months were evaluated. Predictors of SSI were examined using the Mann–Whitney U test for continuous variables and the χ² tests for categorical variables.

Results: Among 148 patients, the incidence of SSI was 8.7% (n = 13). Preceding WCs included lymphorrhea/lymphocele (n = 7), hematoma (n = 4), and edema (n = 2). Hematoma had the highest conversion rate to SSI (25.0%). Staphylococcus aureus was the predominant pathogen. Univariate analysis identified female sex as a potential predictor of SSI (p = 0.03), while dialysis dependence (43.9% of the cohort) was not associated with SSI risk.

Conclusions: SSI following bypass surgery in CLTI predominantly arises from preceding WCs, characterized by edema or inadequate drainage of blood or lymph. Targeted management to prevent these preceding WCs may be a crucial strategy to reduce SSI.

Objectives: This study aimed to clarify the relationship between selection of compression stockings and grip strength in older outpatients with secondary lower limb lymphedema following gynecologic cancer surgery.

Methods: This retrospective observational study involved 71 outpatients aged ≥65 years with late-stage II (International Society of Lymphology) secondary lower limb lymphedema requiring compression therapy after gynecologic cancer surgery. We investigated the patient’s profile, grip strength, and the status of compression therapy. Patients were divided into early-older (65–74 years; n = 41) and late-older (75–86 years; n = 30) groups, and outcomes were compared. Additionally, patients were divided by compression stocking types: a flat-knit stocking group (n = 51) and a circular-knit stocking group (n = 20).

Results: All patients continued compression therapy during the observation period between September 2022 and April 2025. Grip strength was comparable between the early-older and late-older patient groups. However, the flat-knit stocking group had significantly greater grip strength (21.1 kg) than the circular-knit stocking group (19.1 kg) (p = 0.004).

Conclusions: Even late-older patients could continue to use flat-knit stockings as long as their grip strength was maintained.

Objectives: We aimed to determine echocardiographic changes following arteriovenous fistula (AVF) creation and identify predictors of major adverse cardiac events (MACE) in end-stage renal disease (ESRD) patients.

Methods: A retrospective study of ESRD patients who underwent AVF creation between 2014 and 2022 was conducted at a tertiary care center. Cardiac echocardiograms performed within 3 months before and at least 6 months after surgery were compared using paired t-tests. Predictors of MACE were assessed using Cox regression, with results reported as hazard ratios (HR).

Results: A total of 119 patient records were included. Mean age was 58.2 ± 13.6 years, and 66 (55.5%) patients were male. Following the procedure, left atrial volume index (LAVI) increased (34.339 ± 10.361 vs. 37.964 ± 9.739, p = 0.001), whereas E′ velocity (0.052 ± 0.018 vs. 0.047 ± 0.016, p = 0.011) and left-ventricular ejection fraction (50.798 ± 11.442 vs. 47.374 ± 12.277, p <0.001) decreased significantly. Ejection fraction was maintained in 81 patients (68.07%), improved in 12 (10.08%), and declined in 26 (21.85%). Cox regression showed a significant association between preoperative atrial fibrillation (p = 0.019) and severe left ventricular dysfunction (p = 0.026) with MACE.

Conclusion: AVF creation was associated with increased LAVI and decreased E′ velocity. Preoperative atrial fibrillation and severe left ventricular dysfunction were associated with increased risk of postoperative MACE.

Objectives: This study aimed to evaluate the short- and long-term outcomes of endovascular aneurysm repair (EVAR) for abdominal aortic aneurysms (AAAs), with a particular focus on the impact of immunosuppressive therapy.

Methods: The authors retrospectively reviewed the institutional data of patients with AAAs who underwent EVAR between 2008 and 2023.

Results: A total of 307 consecutive patients underwent elective EVAR for AAA. Of these, 26 patients (8.5%) were receiving immunosuppressive therapy (IT group). Patients in the IT group had a significantly higher incidence of early postoperative complications than those in the non-IT group (42.3% vs. 17.4%). The mean follow-up period was 40.7 ± 33.6 months. The cumulative incidence of sac shrinkage was similar between the groups, whereas the cumulative incidence of sac expansion was significantly higher in the IT group. The rates of reintervention and open aneurysmorrhaphy were also significantly higher in the IT group. The use of immunosuppressive therapy was one of the significant risk factors for late sac expansion (hazard ratio, 4.66, 95% confidence interval, 2.12–10.23). Overall survival was similar regardless of immunosuppressive therapy status.

Conclusions: Immunosuppressive therapy may be associated with an increased risk of early postoperative complications and late sac expansion in patients undergoing EVAR.

Objectives: This study evaluated the outcomes of acute type A aortic dissection (ATAAD) complicated by mesenteric malperfusion managed with femoral arterial perfusion and intraoperative transesophageal echocardiography (TEE).

Methods: We retrospectively reviewed 246 patients who underwent surgery for ATAAD between April 2011 and May 2022. Mesenteric malperfusion was identified in 8 of 49 patients (20%) with malperfusion syndrome. Femoral arterial perfusion was initiated to restore true lumen flow, and intraoperative TEE was used to assess abdominal aortic true lumen expansion and superior mesenteric artery (SMA) perfusion. Central aortic repair was performed after confirmation of mesenteric reperfusion.

Results: Dynamic and static mesenteric obstructions were present in 5 and 3 patients, respectively. Femoral perfusion improved SMA flow in all dynamic cases and in 2 static cases. Seven patients (87.5%) survived to discharge; 1 patient with preoperative coma, shock, and static SMA obstruction died. In 1 patient with combined SMA and celiac artery obstruction, residual celiac malperfusion was not detected intraoperatively.

Conclusions: Femoral arterial perfusion guided by intraoperative TEE is a feasible and effective strategy for mesenteric malperfusion in ATAAD. However, static branch obstruction and limitations of TEE warrant consideration of hybrid approaches.

Objectives: Atherosclerotic plaque progression involves dynamic interactions between angiogenesis and lymphangiogenesis. This pilot, hypothesis-generating study aimed to explore the spatial balance between blood microvessels and lymphatic vessels in human carotid plaques.

Methods: Carotid plaques from 4 patients who underwent carotid endarterectomy were examined histologically. Blood microvessels (CD31+) and lymphatic vessels (Podoplanin+) were quantified in severely and mildly thickened lesions. The blood microvessel-to-lymphatic vessel (BMV/LV) ratio was compared between regions, along with macrophage polarization (CD80+: M1 and CD163+: M2).

Results: Severely thickened lesions exhibited a 15.5-fold higher density of blood microvessels than mildly thickened lesions (median 31 vs. 2 vessels; p = 0.012), whereas lymphatic vessel counts were comparable (median 31 vs. 32 vessels; p = 0.978). Consequently, the BMV/LV ratio was 16-fold higher in severely thickened lesions (1.203 vs. 0.121, p = 0.060). CD80-positive areas were larger in severely thickened lesions (0.395% vs. 0.078% area, p = 0.006), whereas CD163-positive areas were comparable between regions (1.036% vs. 0.215%, p = 0.154).

Conclusions: Mildly thickened carotid atherosclerotic plaques demonstrated relative lymphatic predominance, whereas severely thickened lesions showed angiogenic predominance accompanied by increased M1 macrophage infiltration. These exploratory findings suggest that regional imbalance between lymphatic vessels and blood microvessels within individual plaques may contribute to localized plaque vulnerability.

Objectives: This study aimed to identify anatomical predictors of aneurysm enlargement in patients with lumbar artery (LA)–related type 2 endoleak (T2EL) after endovascular aortic repair (EVAR).

Methods: This retrospective observational cohort study included 59 patients with infrarenal abdominal aortic aneurysms who developed T2EL caused exclusively by LAs after EVAR between January 2019 and July 2024. Computed tomography–based anatomical parameters, including mural thrombus volume ratio, calcified volume ratio, aneurysm diameter, and LA anatomy, were analyzed.

Results: During a median follow-up of 33 months, aneurysm enlargement occurred in 9 patients (15.3%). Patients with aneurysm enlargement had a significantly lower mural thrombus volume ratio (p <0.001). Female sex (hazard ratio [HR], 0.23; 95% confidence interval [CI], 0.06–0.84; p = 0.026) and mural thrombus volume ratio (HR, 0.88 per 1% increase; 95% CI, 0.80–0.96; p = 0.003) were significantly associated with aneurysm enlargement, whereas LA anatomy was not. Receiver operating characteristic analysis identified an optimal cutoff value of 29.2% (area under the curve, 0.82).

Conclusions: A low preoperative mural thrombus volume ratio was associated with aneurysm enlargement in patients with LA–related T2EL after EVAR. This parameter may serve as a practical imaging biomarker to support selective consideration of preemptive embolization.

Objectives: Type II endoleaks (T2ELs) after endovascular aneurysm repair (EVAR) are associated with delayed adverse events. This study evaluated the association between changes in stent graft volume (SgV) and T2EL after EVAR.

Methods: This study included 127 patients who underwent EVAR for abdominal aortic aneurysms between 2010 and 2022. SgVs were calculated using computed tomography, and SgV ratios were calculated by dividing SgV 2 years after EVAR by SgV immediately after EVAR. The association between the SgV ratio and T2EL 2 years after EVAR was evaluated.

Results: T2ELs were detected in 62 patients (49%) 2 years after EVAR. Univariate analysis revealed that age, number of patent lumbar arteries, expanded polytetrafluoroethylene (ePTFE) stent grafts, and the SgV ratio were significantly correlated with T2EL. Multivariate analysis showed that age ≥80 years, patent lumbar arteries ≥4, ePTFE stent graft, and SgV ratio ≤1.23 were independently associated with T2EL. In both the ePTFE (80 patients) and polyester (47 patients) stent graft groups, the SgV ratio was independently associated with T2EL.

Conclusions: The SgV ratio was significantly correlated with T2EL and may improve T2EL surveillance after EVAR.

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 aortic complications are common in patients with Marfan syndrome (MFS), spontaneous peripheral arterial rupture is rare. Herein, we report a 40-year-old woman with MFS who presented with left-sided chest pain and hoarseness due to a massive intrathoracic hematoma. She had undergone multiple thoracic surgeries for aortic dissection. Rupture of fragile neovessels associated with surgery-related inflammation was suspected. Hemostasis was achieved by transcatheter embolization of the left lateral thoracic and supreme intercostal arteries. Intrathoracic bleeding should be considered in patients with MFS presenting with chest pain or hoarseness, particularly those receiving anticoagulation therapy or those who have undergone prior thoracic surgery.

An 85-year-old man, with a history of coronary artery bypass grafting (CABG) using bilateral internal thoracic artery (ITA) grafts, underwent zone 0 thoracic endovascular aortic repair (TEVAR) for an aortic arch aneurysm. The procedure involved axillary debranching and the combined use of conventional and fenestrated stent grafts. During deployment of the fenestrated graft, ventricular fibrillation occurred, temporally associated with a transient reduction in brachiocephalic artery blood flow that compromised ITA graft flow. He was discharged without neurological deficits. This case highlights the potentially critical risk of myocardial ischemia during zone 0 TEVAR in post-CABG patients, emphasizing the need for meticulous multidisciplinary planning.

An 85-year-old man underwent endovascular repair using the Excluder iliac branch endoprosthesis (IBE) for an abdominal aortic aneurysm with a left internal iliac artery aneurysm. He was discharged uneventfully but returned on postoperative day 16 with acute left limb occlusion. Imaging revealed complete occlusion of both the internal and external iliac limbs of the IBE, requiring emergent thrombectomy. Intraoperative assessment demonstrated mechanical compression of the external iliac limb by the internal iliac limb, causing stenosis and thrombosis. This rare complication highlights the importance of meticulous preoperative planning to prevent limb-related events, particularly in patients treated outside the device’s indications.

A patient in his 40s, who had experienced acute deep vein thrombosis (DVT) of his left leg 13 years ago, developed acute DVT of his right leg due to an inferior vena cava filter (IVCF) thrombotic occlusion. A thrombus extended from just below the IVCF to the bilateral femoral veins. Given the limited availability of urokinase and the strict guidelines for the proper use of the Indigo CAT8 in Japan, we first performed catheter-directed thrombolysis with alteplase for 2 days, followed by aspiration with the CAT8 catheter after confirming the absence of an IVC thrombus. Finally, we successfully retrieved this IVCF, implanted 13 years earlier, using the bidirectional technique.

A 50-year-old man with type 2 diabetes mellitus was admitted for chronic limb-threatening ischemia (CLTI). Ulcers involved several toes on both feet. Angiography of the left lower extremity demonstrated severe below-the-ankle arterial disease with markedly compromised pedal runoff. After unsuccessful endovascular therapy of the left lower extremity, low-density lipoprotein (LDL) apheresis was initiated for limited-option CLTI. An increase in microcirculatory flow in the left foot was observed after LDL apheresis, as assessed by angiography and GOKO Bscan-ZD. Complete wound healing was achieved after a transmetatarsal amputation. GOKO Bscan-ZD may represent a novel noninvasive method with which to evaluate microcirculation.

Antiphospholipid syndrome (APS) is an autoimmune prothrombotic disorder characterized by recurrent arterial and venous thrombosis, as well as pregnancy complications. Laboratory findings often show prolongation of activated partial thromboplastin time, which complicates monitoring during heparin therapy. We present the case of a 69-year-old woman with APS who developed chronic limb-threatening ischemia. She underwent successful bilateral lower-extremity open surgical revascularizations guided by a preoperatively obtained heparin–activated clotting time (ACT) titration curve to define individualized intraoperative anticoagulation targets. This method offered a straightforward and dependable strategy for personalized anticoagulation management and may enhance the safety of peripheral arterial revascularization in patients with APS.

Celiac artery aneurysms are rare and carry a substantial risk of rupture. A 64-year-old woman was incidentally found to have a 38-mm celiac artery aneurysm on computed tomography. The left gastric and common hepatic arteries arising from the aneurysm were coil-embolized, and a 6 × 59-mm balloon-expandable covered stent was deployed from the celiac artery to the splenic artery. Postoperative imaging confirmed aneurysm exclusion and preserved splenic perfusion. At 13-year follow-up, computed tomography showed sustained stent patency and aneurysm shrinkage from 38 to 31 mm without complications, supporting the long-term durability of endovascular treatment in anatomically suitable patients.

Idiopathic iliac vein rupture (IIVR) is a rare, life-threatening condition. We report a successful case of a 66-year-old woman with hemorrhagic shock and disseminated intravascular coagulation managed with a strategic surgical approach. To prevent intraoperative pulmonary embolism from extensive deep vein thrombosis, a temporary inferior vena cava filter was placed. Distal venous control was achieved via a femoral vein clamp through a separate inguinal incision prior to pelvic exploration. Primary suture repair combined with thrombectomy successfully preserved venous outflow. This multistep strategy is effective for managing IIVR, ensuring hemodynamic stability and preventing fatal embolic complications.

A 76-year-old female Jehovah’s Witness presented with an acute Stanford type A intramural hematoma. To avoid transfusion, she underwent ascending aortic replacement with a frozen elephant trunk and total fenestration. During chest closure, she developed sudden bilateral lower-limb ischemia, with regional oxygen saturation declining from 70% to 40%. Transesophageal echocardiography confirmed patency of the frozen elephant trunk and revealed rapid collapse of the distal true lumen beyond the stented segment. Emergent angiography demonstrated severe true-lumen compression. Thoracic endovascular aortic repair with distal bare-metal stent support was performed urgently, restoring flow. Stent deployment began 50 min after ischemia onset, and complete reperfusion was achieved 82 min after onset. The patient was discharged on postoperative day 17 without neurologic or ischemic sequelae.

An 82-year-old man underwent surgical repair of an infectious abdominal aortic aneurysm using a cryopreserved homograft. Twelve years later, a pseudoaneurysm at the right iliac anastomosis was treated with a stent-graft limb. Sixteen years after the initial surgery, a saccular aneurysm developed in the mid-portion of the homograft without signs of infection. Endovascular aortic repair using an AFX2 stent graft (Endologix, Irvine, CA, USA) was performed to cover the entire graft. Postoperative CT showed no endoleaks or aneurysm enlargement. Although homografts are considered infection-resistant, late degenerative complications may occur, requiring lifelong follow-up.

Venous aneurysms of the upper extremity have rarely been reported. A 78-year-old woman presented with swelling, discomfort, and mild tenderness on the medial side of the right elbow. Ultrasonography showed a 2.1 × 1.8 cm dilated structure connected to the basilic vein. Because a venous pseudoaneurysm was suspected and the patient had discomfort and mild tenderness, aneurysm excision and venous reconstruction were performed under local anesthesia. Histopathological examination confirmed a true venous aneurysm. The postoperative course was uneventful, with complete symptom resolution and no recurrence at 6 months.

Deep femoral artery aneurysm (DFAA) is rare, and metachronous bilateral occurrence is extremely rare. An 83-year-old man presented with right thigh pain and swelling. He had undergone left DFAA repair at another hospital 13 years earlier, with no contralateral lesion at that time. CT revealed a ruptured right DFAA with hematoma and contrast extravasation. Emergency surgery was performed, and the proximal DFA was ligated without reconstruction due to distal occlusion. The postoperative course was uneventful. Ligation alone may be feasible in selected cases, and long-term follow-up is essential.

A patient who underwent endovascular abdominal aortic repair for a non-inflammatory abdominal aortic aneurysm developed asymptomatic periaortitis 2.5 years postoperatively. Conservative management resulted in aneurysm shrinkage and reduced inflammation. However, at 6 years postoperatively, tumor-like soft tissue shadows appeared around the aorta and the aneurysm diameter re-expanded. This was diagnosed as a recurrence and worsening. Prednisolone was initiated, leading to reductions in both aneurysm size and the mass-like shadow size. When the dosage was decreased, inflammation flared up again. The medication dose was then increased. Gradual dose reduction was subsequently attempted and treatment was successfully discontinued without recurrence.

Postsurgical thrombotic microangiopathy (TMA) is a highly lethal complication. We report a 71-year-old woman who developed TMA following open thoracoabdominal aortic aneurysm repair. From postoperative day 2, she presented with progressive thrombocytopenia, acute kidney injury, and hemolytic anemia. Therapeutic plasma exchange (PE) and hemodialysis were promptly initiated upon clinical suspicion, without waiting for ADAMTS13 results. In conclusion, we experienced a case of postsurgical TMA triggered by profound surgical stress, in which prompt initiation of PE was effective. The patient successfully recovered from the acute phase and has remained in remission for over 3 years.

We report a rare case of a ruptured deep femoral artery aneurysm caused by direct infiltration of diffuse large B-cell lymphoma (DLBCL). An 82-year-old man presented with acute left thigh pain and a rapidly formed aneurysm revealed by imaging. Open aneurysmectomy and bypass grafting were performed. Histopathology demonstrated destruction of the elastic laminae and media with diffuse infiltration of atypical lymphoid cells, thus confirming DLBCL. The patient received the best supportive care. Further arterial ruptures developed, and the patient died 8 months after surgery. Malignancy should be considered in the differential diagnosis of rapidly progressive, peripheral aneurysms.

A 71-year-old man was referred to our department for open surgery for complex aortoiliac aneurysms. Computed tomography angiography demonstrated aneurysms of the abdominal aorta, bilateral common iliac arteries, and the left internal iliac artery. After stent graft placement in bilateral internal iliac arteries, we planned open surgery. Before cross-clamping the aorta, regional saturation of oxygenation in the left lower limb suddenly decreased from approximately 60% to 30%, despite being stable in the right lower limb. Intraoperative angiography revealed occlusion at the popliteal artery level, for which thromboembolectomy was successfully performed. After that, the aortoiliac aneurysms were replaced. The postoperative course was uneventful.

An 87-year-old man with a distal aortic arch aneurysm underwent 2-debranching thoracic endovascular aortic repair (TEVAR). Five days postoperatively, he developed sudden chest pain and syncope, with severe upper-limb hypoperfusion. Contrast-enhanced computed tomography (CECT) revealed brachiocephalic artery (BCA) dissection compressing the true lumen. Although conservative management was initially selected, percutaneous transluminal angioplasty with kissing bare-metal stents from the BCA to the right subclavian and right common carotid arteries was performed for recurrent hypotension. Postprocedural CECT confirmed satisfactory stent expansion and graft patency. This case demonstrates that careful monitoring enables timely intervention for BCA dissection after TEVAR.