With the accelerated aging of society, the use of endovascular therapy for femoropopliteal arterial lesions continues to increase. In recent years, several therapeutic devices have been introduced in Japan, improving clinical outcomes after endovascular treatment in this region. Of them, drug-coated devices, including drug-coated balloons (DCBs) and drug-eluting stents (DESs), have become the mainstream treatment devices. This article provides an overview of the details, indications, and clinical outcomes of drug-coated devices in femoropopliteal arterial lesions.

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The JETSTREAM atherectomy system is expected to successfully treat heavy calcified lesions in the femoropopliteal artery that have poor outcomes in angioplasty with a drug-coated balloon (DCB). However, severe complications such as distal embolism may occur. This article reviews clinical trials of the JETSTREAM atherectomy system and describes the standard procedure and complications.

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Intravascular ultrasound (IVUS)-guided wiring is one of the techniques for crossing chronic total occlusive lesions developed in Japan. IVUS-guided antegrade intraplaque wire crossing may reduce complications mostly related to distal puncture and improve long-term patency. Unlike from conventional IVUS-guided parallel wiring, IVUS-guided parallel single wire technique, the Detach and Go technique, provides a higher success rate with fewer wires. In this article, the recent IVUS-guided antegrade wiring technique is described with representative case presentations.

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In recent years, the approach to endovascular therapy (EVT) in lower extremity artery disease (LEAD) has shifted from the “leave nothing behind” philosophy to focusing on intraplaque crossing, which has led to improved outcomes with drug-coated balloons (DCBs) and stent treatments. However, achieving intraplaque crossing in EVT is not straightforward and requires the use of various techniques.
In the treatment of complex femoropopliteal lesions with chronic total occlusion (CTO) and calcification, it is often challenging to re-enter the true lumen or intraplaque after the guidewire becomes trapped in the subintimal space of the occluded segment. In these cases, an antegrade approach often presents significant technical difficulties. The retrograde approach can be effective when the antegrade approach fails, but it requires multiple devices and extended procedure times.
For successful antegrade crossing of guidewires through femoropopliteal (FP)-CTO, advanced techniques and specialized devices are essential. Three-dimensional (3D) wiring is one such method that facilitates the manipulation of stiff guidewires, which are typical in CTO cases, and can enhance the success of endovascular procedures.
This chapter provides an overview of the procedural steps for 3D wiring, based on clinical experience, and discusses how it can be effectively implemented in endovascular treatment.

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Central venous ports (CVPs) are primarily implanted via the subclavian, internal jugular, brachial, or femoral veins. In patients with superior vena cava syndrome (SVCS), implanting the catheter in the superior vena cava is not ideal. Implantation via the femoral vein is feasible, but not always recommended because of the increased risk of infection and thrombosis. Moreover, patients with SVCS may have dilated superficial epigastric veins, which act as collateral vessels. The cases of two patients with SVCS who underwent CVP implantation via the superficial epigastric vein are reported.
The patients were a woman in her 60s and a man in his 50s who were each diagnosed with small cell lung carcinoma and SVCS. Both patients underwent CVP implantation for therapeutic purposes. Because of SVCS, catheter implantation into the superior vena cava was considered difficult. Therefore, the superficial epigastric vein, which had developed as a collateral vein, was chosen. In each case, the dilated superficial epigastric vein was punctured directly, and a CVP was placed on the chest wall on the cranial side of the right costal arch. The CVPs were then used without complications for several months until their deaths.

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Apseudoaneurysm in the pancreatic region is a serious complication that can occur after pancreatitis or pancreatic surgery. In particular, pseudoaneurysm rupture related to pancreatic surgery is associated with a high mortality rate of 20-50%. The first-line treatment is transcatheter arterial embolization (TAE), with metallic coils or n-butyl cyanoacrylate (NBCA) used as embolic agents. Due to the complex branching and numerous anastomoses of the vessels in the pancreatic region, especially when modified by pancreatitis, guiding the catheter can be challenging. In such cases, NBCA is a useful embolic material. Though it has been reported frequently, there are risks of complications such as post-embolization pancreatitis or pancreatic infarction. A case of a ruptured pancreatic pseudoaneurysm following endoscopic retrograde cholangiopancreatography (ERCP) that was successfully treated with embolization using both NBCA and metallic coils, resulting in a good outcome, is presented.

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