There were three epoch making events in therapy of varicose veins. The first one is that the endovascular heat ablation (EVHA) using diode laser was authorized by the Ministry of Health Labor and Welfare in January 2011. The second one is that Subfascial Endoscopic Perforator Surgery (SEPS) was also authorized in April 2014. All of the therapies which were covered by the national insurance system had been the procedures for superficial veins but the SEPS is procedure for the perforating veins. The third one is that the foam usage of Polidocasklerol was listed formally at the medical package insert in September 2016. Moreover stub avulsion was introduced as figure-related improvement method with a smaller operation wound instead of conventional varicectomy and the other existing therapies are progressing every day. Therefore, by this education seminar, I lecture mainly on the EVHA, SEPS and foam sclerotherapy in varicose vein treatment. Finally I show one case which you should remember.

We report a case of a 30-year-old man who presented with sudden-onset right leg pain. The patient had a past medical history of dendriform pulmonary ossification, dural arteriovenous malformation, left carotid-cavernous sinus fistula, and symptomatic epilepsy. After presenting at our hospital, he was diagnosed with right posterior tibial artery rupture associated with type IV Ehlers-Danlos syndrome (EDS). He was then successfully treated with transcatheter coil embolization and underwent several rehabilitation sessions. However, he died suddenly as a result of a rupture of the right external iliac artery 23 days after transcatheter treatment. EDS is an uncommon inherited disease that has many connective tissue complications, such as hyperextension of the joint and arteriovenous malformation. Most notably, type IV EDS causes massive complications, including aortic and visceral arterial ruptures, aneurysms, dissection, and gastrointestinal perforation. When encountering patients with a significant past medical history of tissue complications, it is important to be aware of the possible symptoms of EDS and to perform urgent and appropriate investigations and treatments if necessary.

A 41-year-old woman with a history of multiple osteochondromas developed swelling, dull pain and subcutaneous hemorrhage in her right thigh. Magnetic resonance imaging (MRI) revealed a pseudoaneurysm of the right popliteal artery caused by femur exostosis. The false aneurysm was repaired with direct closure of the arterial defect in the semi-prone position. In this position, both the posterior and the medial approaches can be applied to safely access to the proximal and the distal popliteal artery without reposition.

A 70-year-old man who had a history of coronary artery bypass grafting via median sternotomy admitted for the treatment of huge intrathoracic left subclavian artery (SCA) aneurysm. Preoperative computed tomography revealed a 52 mm sized SCA aneurysm. An aneurysm was located at the proximal portion of the left SCA. Coronary angiography showed the left circumflex artery perfused the patent left internal mammary artery (IMA). Open repair requiring re-sternotomy or thoracotomy may be too invasive. Therefore, we employed endovascular treatment to avoid the injury to the left IMA graft and the risk of myocardial ischemia during open revascularization of the left SCA. A reversed Zenith iliac leg whose third portion was stripped of the covering fabric, were placed in the left SCA for preserving the left IMA graft. Postoperative course was uneventful. The isolation of the aneurysm could be achieved without a myocardial and cerebellar ischemia. Endovascular treatment should be considered as a less invasive alternative to conventional surgical repair in this selected patient with the intrathoracic SCA aneurysm.

Brachial artery aneurysms are rare in children. A 13-year-old girl was referred to our hospital with a mass on her right upper arm. A brachial artery aneurysm measuring 3×5 cm was diagnosed on CT scan, with no signs of peripheral ischemia or embolism. At the age of 12, she had a short history of crutch-assisted gait for an ankle sprain, but she had experienced no other significant trauma. There was no evidence of collagen diseases or vasculitis. Arteriography of her upper limbs showed no antegrade blood flow beyond the aneurysm, and peripheral blood flow was maintained by collateral circulation from the developed humerus circumflex artery and brachial deep artery. The operation involved aneurysmectomy without revascularization of the brachial artery. Histopathological findings of the aneurysm demonstrated disappearance of the media and destruction of the three-layer structure of the arterial wall, and was thus diagnosed as a pseudoaneurysm. Six months after surgery, there was no decrease in her right arm blood pressure, and she presented no symptoms of ischemia.

A 60-year-old man was referred to our hospital because of sudden onset of back pain and numbness of his lower limbs, associated with loss of consciousness. Computed tomography (CT) showed a ruptured juxtarenal abdominal aortic aneurysm (AAA) and a double inferior vena cava (IVC), and an emergency operation was performed. Intraoperatively, the aortic clamp was placed above the left renal artery and the abdominal aortic aneurysm was repaired with a woven straight graft. Although the left IVC crossed over the neck of the AAA anteriorly, we could perform a proximal anastomosis to retract the IVC in either a cephalad or caudad direction without injuring the vein. The patient was discharged from hospital on the 20th postoperative day. We report a case of ruptured AAA with a double IVC.

Lower limb swelling is commonly observed in clinical practice. Here, we experienced a rare case in which lower limb swelling was due to external iliac vein compression caused by a ganglion cyst arising from the hip joint. A 64-year-old man visited a nearby clinic with chief complaints of swelling and pain of the left lower limb. Ultrasonography revealed severe iliac vein stenosis, and thus, the patient was referred to our hospital. Contrast-enhanced computed tomography showed a cystic mass approximately 2.5 cm in diameter in the left retroperitoneal space, compressing the left external iliac vein from the outside. The symptoms improved after ultrasound-guided needle aspiration of the mass, but similar findings were observed 6 days later. Thus, surgical indication was determined. The patient underwent surgery, and pathological diagnosis was a ganglion cyst. As fine-needle aspiration of a ganglion cyst is associated with a high recurrence, surgical incision is recommended. However, even when patients present with similar symptoms associated with lower limb swelling, disorders arising from different causes have been reported. Therefore, special attention is required at the time of surgery.

Profunda femoris artery aneurysms are rare, and clinical form is various. We experienced a case of profunda femoris artery aneurysm with gait disturbance by femoral nerve compression. An 80-year-old man presented with left leg muscle weakness and gait disturbance. He was transferred from previous hospital on the basis of the suspect of femoral artery aneurysm because of a mass in left inguinal region. The enhanced CT scan showed a left profunda femoris artery aneurysm measuring 54 mm. We judged that the gait disturbance was caused by femoral nerve compression from the aneurysm. We performed graft replacement and femoral nerve release. Postoperatively the patient became ambulant by himself after improvement of the symptom from the femoral nerve compression and discharged on 9th postoperative day.

A 67-year-old man was injured his right lower extremity by cultivator. Emergent operation was performed and operative finding revealed his right popliteal artery and vein were completely resected. Injured popliteal artery and vein were repaired by end-to-end anastomosis, respectively. Seven months later, he had numbness of right foot sole and swelling of right lower thigh. The contrast enhanced computed tomography showed 4.5 cm saccular aneurysm of right popliteal artery. Surgical treatment was performed for popliteal pseudoaneurysm by aneurysmectomy and autologous graft replacement via posterior approach. The graft was patent with no additional intervention at 4.1 years after operation.