Vascular Behçet’s disease (BD) would keep risk of anastomotic pseudoaneurysm due to deterioration of the disease even after vascular surgery was successfully done. Therefore, it is one of the least-welcome diseases for vascular surgeons. There still exist several points on a concept and criteria of the vascular BD which not only general practitioners but also the vascular surgeons do not understand. Clinical findings strongly suspecting vascular BD are follows; saccular aneurysms without atherosclerosis developed in younger than 50 year-old patients, superior vena cava syndrome or deep vein thrombosis in bilateral legs without apparent causes, and multiple superficial thrombophlebitis, etc. It is very difficult to make a diagnosis of BD in the patients whose onset of the disease is a vascular lesion, because vascular BD combines few ocular lesions. In such case, it is very important to find out not only oral and genital ulceration, but also past history of arthritis. To establish the vascular BD, we vascular surgeons have to collect cases of the vascular BD and to revise criteria of the disease.

According to expansion of dialysis-dependent population, more than half of patients with critical ischemic limbs are dialysis-dependent in Japan. Although patients with end-staged renal disease are well-known as poor life prognosis, well-managed dialysis patients in Japan can survive much longer compared to dialysis patients in United States and Europe. Therefore, some dialysis patients can enjoy the long-term benefits of bypass surgery. To decide the indication of bypass surgery, patient’s general condition, nutrition status, and vein availability are more important rather than arterial disease anatomy. Ultrasound guided nerve block anesthesia blocking both sciatic and femoral nerve is contributing greatly to quick postoperative recovery of high risk patients. Preoperative ultrasound examination also contribute to not only vein mapping but also find out the graftable segment of artery. The selection of distal target should be decided based on the degree of arterial disease (luminal surface as well as wall calcification), and arterial run-off. Several tips regarding anastomosis to heavily calcified artery have been established including how to create bloodless operative field without arterial clamps. Adequate wound management after bypass surgery is also important. Detection of deep infection such as osteomyelitis and the adequate treatment may avoid major amputation of salvageable limbs. In the era of endovascular treatment, the evidences guiding how to select dialysis patients suitable for bypass surgery are awaiting.

Takayasu arteritis (TAK) remains an intractable disease with an unidentifiable cause involving inflammation of the aorta and its major branches, despite the many studies since the first case report by Dr. Mikito Takayasu in 1908. Although a rare disease, the estimated number of existing TAK patients is relatively large in Japan, a little over 6000. Female patients with early onset, the classic icon of TAK, still compose a major proportion; however, the proportions of male patients differ among countries. Even in current new Japanese patients, the male:female ratio has increased to 1 : 5. Presently, patients with elderly onset are also reported across the world. Patients in the initial stage of onset often complain of pains in various body regions and have systemic manifestations. Vascular lesions commonly involve branches of the aortic arch. Localized cervicobrachial involvements frequently occur in young female patients, whereas localized abdominal lesions tend to be observed in male patients. Current imaging techniques are useful for detecting signs of arterial inflammation prior to the development of a significant artery stenosis or dilatation. Nevertheless, surgery still has an important role for patients with critical vascular disorders. Surgical interventions, namely, endovascular treatment and open surgery, should ideally be avoided during the active phase of TAK owing to considerable risk of postinterventional failure. To achieve a favorable long-term outcome, an adequate anti-inflammatory treatment is essential. Optimal surgical management can improve life expectancy of patients. However, the high frequency of arterial restenosis after revascularization is still a significant problem in TAK. Restenosis occurs more frequently after endovascular treatment than after surgical bypass treatment generally. Based on these premises, and for assessing the immune status and the expected natural prognosis of the patient, the indication and strategy of vascular interventions should be carefully discussed by a multidisciplinary team.

Vascular closure devices have been developed in recent years. Although the safety and efficacy of Angioseal are confirmed, there are some specific problems such as stenosis, occlusion, or peripheral embolism. We report on a case of vascular claudication following use of the Angioseal closure device. A 70-year-old man with arteriosclerosis obliterans and performed stenting to right common iliac artery 13 years ago underwent Carotid Artery Stenting. Angioseal closure device was deployed at end of the procedure, but failed to hemostasis, so we added mechanical compression and succeeded to hemostasis. Three days after the procedure, he developed persistent right groin pain and sensory disturbance with clinical signs of vascular claudication in the right leg. Duplex ultrasound and computed tomography angiography of the right femoral artery showed the worsening of right common femoral artery stenosis. Vascular surgery was performed and anchor of Angioseal device was explanted. The patient had stable post-operative condition.

We report a surgical case of abdominal aortic aneurysm (AAA) and right internal iliac artery aneurysm (IIAA) causing sciatica-leg pain that starts in the lower back and travels down the sciatic nerve. A 74-year-old woman was referred to our hospital for aneurysmal repair. Her chief complaint was sciatica on the right leg. Preoperative computed tomography showed an AAA (maximal diameter of 50 mm) and right IIAA (maximal diameter of 54 mm). The AAA was replaced by an artificial graft and the IIAA was ligated and plicated. Her sciatica totally disappeared after surgery. When we see those with sciatica, we should rule out IIAA. The symptoms due to nerve compression by an aneurysm can be reversible after aneurysmal repair.

2D perfusion angiography is a useful tool in terms of visualization and quantitative evaluation of blood perfusion. It can be applied to the evaluation of the bypass surgery for critical limb ischemia (CLI). Herein, we described a 49-year-old man presented with CLI. On preoperative angiography, the right anterior tibial and peroneal arteries were obstructed at proximal site. We performed bypass procedure; right popliteal–dorsalis pedis artery bypass with a saphenous vein graft. During the bypass surgery and after anastomosis of bypass, we evaluated peripheral perfusion with 2D perfusion angiography. We could confirm improved peripheral perfusion with colored mapping image. In addition, all of the functional parameters were improved compared with preoperative values. At 2 month postoperatively, the patient underwent skin grafting surgery for preserving the ankle. This is the first case report regarding bypass surgery evaluated by 2D perfusion angiography.

Four-channel aortic dissection is rare. We reported our experience that we had performed an operation for four-channel aortic dissection because the aortic dissection had gotten worse from a three-channel aortic dissection and its diameter had extended. Our case was a 44-year-old woman with Marfan syndrome. She undewent a Bentall procedure and total arch replacement for Stanford A aortic dissection in 2008. Her postoperative course was uneventful. So, we requested observation of her condition to a local doctor. She underwent a CT in 2014. We found her descending aortic dissection changed to a three-channel aortic dissection. Next year, she was taken to another hospital via ambulance for sudden back pain. Then, her descending aorta’s diameter extended and her three-channel aortic dissection changed four-channel aortic dissection. A week later, her descending aortic diameter extended further. So she was transferred to our hospital. We performed a thoracoabdominal aortic replacement. Her postoperative course was uneventful, and she was discharged without incident. Four-aortic dissection is high risk of rupture, so we think such cases need surgical treatment as soon as possible.

An 85-year-old woman was introduced to our hospital due to her complain of abdominal pain after eating and bloody stool. We took contrasting CT and found superior mesenteric artery occlusion. We diagnosed intestinal ischemia. After following it up by fast, a symptom did not develop, but after starting a meal, abdominal pain developed again. After that, because the symptom was getting worse we decided to do an emergency surgery. We underwent left external iliac and superior mesenteric artery bypass using a prosthetic graft. Ischemic enterocolitis was prolonged after surgery, but there is not the appearance of abdominal pain. And one year passed after surgery, the graft performs patency. We underwent retrograde bypass using prosthetic graft, but the technique for the superior mesenteric artery occlusion has not been established. Because the state of a usable graft and the blood vessel of the central side varies according to a case, it is important to choice the technique depending on a case.

A 68-year-old woman with rest pain in the left foot was transferred to our hospital. She had a history of subarachnoidal hemorrhage with mild permanent disability. The enhanced CT revealed extensive iliofemoropopliteal arterial disease with total occlusion of the common femoral artery and the left deep femoral artery. The left popliteal artery was also occluded below the knee. Only the posterior tibial artery was patent below the ankle. The ipsilateral femoral artery was not available as an inflow site for surgical arterial reconstruction. Long distal bypass to the left ankle was made from contralateral femoral artery for critical limb ischemia. Femoropopliteal crossover bypass was made using a heparin bounded polytetrafluoroethylene (PTFE) graft between the right common femoral artery and the left popliteal artery above the knee. The great saphenous vein was taken from the right leg. The distal bypass was made between the distal portion of the PTFE graft and the left posterior tibial artery at the ankle using the reversed saphenous vein graft in the subcutaneous tunnel. Postoperative angiography showed all the graft were widely patent. The left leg perfusion was dramatically improved after the operation. The patient has been doing well for 12 months since the operation. Long distal bypass from the contralateral femoral artery as an inflow site can be an option for peripheral arterial revascularization in patients who are not suitable for angioplasty or abdominal surgery and where the ipsilateral femoral artery is not available.

Retrograde type A aortic dissection following endovascular treatment for thoracic aortic disease is not uncommon. We report the case of an 81-year-old woman who was admitted to our hospital for a distal aortic arch aneurysm with a penetrating atherosclerotic ulcer. As the patient was not medically fit for sternotomy and repair of the aortic arch, she selected thoracic endovascular aortic repair (TEVAR). Just after TEVAR, a retrograde type A aortic dissection occurred. Since her vital signs, such as blood pressure, were stable, a conservative approach was adopted, and the progression of the retrograde dissection was monitored with serial computed tomography scans. This case report suggests that, for select patients who are poor candidates for major aortic surgery, a conservative approach can be effective.

This is an annual report indicating the number and early clinical results of annual vascular treatments performed by vascular surgeons in Japan during 2011, as analyzed by database management committee (DBC) members of the Japanese Society for Vascular Surgery (JVS). Materials and Methods: To survey the current status of vascular treatments performed by vascular surgeons in Japan, the DBC members of the JVS analyzed the vascular treatment data provided from National Clinical Database (NCD), including the number of treatments and early clinical results such as operative and in-hospital mortality. Given that NCD data were prospectively built by a nationwide registration, this annual report reports prospective clinical data. Results: In total 71,707 vascular treatments including open repairs and endovascular treatments were registered by 992 institutions in 2011. This database is composed of 7 fields including treatment of aneurysms, chronic arterial occlusive disease, acute arterial occlusive disease, vascular injury, complication of vascular reconstruction, venous diseases, and other vascular treatments. The number of vascular treatments in each field was 17,524, 11,278, 3,799, 1,030, 1,615, 19,371, and 17,510, respectively. In the field of aneurysm treatment, 13,218 cases with abdominal aortic aneurysms (AAA) including iliac aneurysms were registered, including 1,253 ruptured cases. Forty-five percent of AAA cased were treated by stent graft. The operative mortality of ruptured and non-ruptured AAA was 18.8%, and 0.8%, respectively. Regarding chronic arterial occlusive disease, open repair was performed in 7,115 cases including 984 distal bypasses to the crural or pedal artery, whereas endovascular procedures were performed in 4,163 cases. For acute arterial occlusive disease, more than 90% of cases were treated with open repair. Vascular injury treatment included 81 venous injury cases and 949 arterial injury cases, and 60% of arterial injuries were iatrogenic. Treatment for complication of previous vascular treatment included 445 cases of graft infections, 240 cases of anastomotic aneurysms, and 811 cases of graft revision operations. The venous treatment included 18,864 varicose vein treatments, 343 cases with lower limb deep venous thrombosis, and 67 cases with vena cava reconstructions. Regarding other vascular operations, 16,296 cases of vascular access operations and 1,037 amputation surgeries are included. Conclusions: This vascular surgery database indicates not only the number of vascular treatments but also the early clinical outcomes for each treatment procedure, thereby representing a useful source for researching the clinical background of poor outcomes and for finding improvements in the quality of treatment. Continuing this work will provide information regarding changing the treatment modality in response to the changing structure of disease and societal needs.