A higher prevalence of diabetes mellitus (DM) and renal failure on hemodialysis (HD) is observed in patients with critical limb ischemia (CLI) in Japan compared with Europe and North America. DM and HD are associated with the involvement of infrapopliteal arterial lesions and the presence of arterial calcification. These comorbidities are known to be major risk factors for poor clinical outcomes after either endovascular therapy or bypass surgery. Furthermore, many CLI patients with DM and HD lack a prior history of intermittent claudication. Therefore, their CLI likely stems from severe limb ischemia without ischemic symptoms, namely “subclinical CLI” (or “chronic subclinical limb ischemia”), instead of from intermittent claudication. DM, HD, and subclinical CLI are key features of CLI in Japan, and their impact should be fully considered when discussing practical strategies for its management.

Objectives: To analyze early-term outcome of debranching TEVAR for high-surgical-risk patients. Methods: 133 patients underwent debranching TEVAR. Results: The 30-day mortality was 3.0%. Postoperative endoleaks were observed in 26% of patients. Conclusion: Total debranching technique by full sternotomy was more invasive than others. Therefore, recently we started surgeon-modified fenestration technique.

A 65-year-old woman was referred to our hospital because of sudden chest pain. Electrocardiogram (ECG) showed ST segment elevation in leads aV_R, V₂–V₆, and emergency coronary angiography (CAG) was performed. CAG revealed malperfusion of the left main coronary artery (LMT) due to type A aortic dissection. Percutaneous transluminal coronary angioplasty (PTCA) of the LMT was performed preceding the aortic repair surgery, because the patient was already in state of shock. After PTCA, ascending aorta replacement with coronary artery bypass grafting (CABG) was performed. The patient was discharged from our hospital without any major complication.

A 58-year-old man with diabetes mellitus was diagnosed acute arterial thrombosis of right leg and had been treated with anticoagulants. Gradually skin ulcer of the right leg had been developed, thus, we were consulted and performed distal bypass with endoscopic vein harvesting system. His postoperative course was uneventful and now skin ulcer was completely healed. After bypass surgery for the patients of critical limb ischemia, shortening incision may benefits by reduction of wound complication and infection. We report a successful surgical case of distal bypass with endoscopic harvesting for critical limb ischemia.