Insufficient anticoagulant therapy has become a focus of attention because its clinical improvement is definitely required for current venous thromboembolism (VTE) treatment in Japan. Direct oral anticoagulants (DOACs) have been approved for VTE treatment since 2014 and highly expected to provide better outcomes. Endovascular therapy for deep vein thrombosis (DVT) are also performed in several hospitals in Japan and seemed to be effective in severe cases. These novel treatment options should be employed for appropriate cases based on patients’ background, such as risk for bleeding complications, and its cost efficiency.

A 64 year-old man undergone the original bypass surgery in his right lower limb due to Buerger’s disease 36 years ago. He had continued smoking after surgery and finally, the graft occluded at 33 years after operation. During an early period after occlusion, the symptom had been stable because he quitted smoking undoubtedly and he was prescribed various antithrombotic medications. However, he complicated diabetes and hyperlipidemia with aging and he suffered from a rest pain in his foot 3 years after the graft failure. Then, he successfully underwent redo bypass operation due to ASO using spliced vein grafts for limb salvage.