Arterial reconstruction is sine qua non to reach the goals of treatment for critical limb ischemia (CLI). Surgical bypass is still the first option for patients with long life expectancy or with a large tissue loss, even in the era of endovascular treatment. It goes without saying that the key to success for treatment for CLI is in a preoperative deliberate plan. Therapeutic strategy including surgery should be determined with imaging examinations and clinical symptoms. The proximal anastomosis is selected in the artery with good inflow and the distal anastomosis is selected in the less diseased artery with good runoff vessels. However, the final decision regarding the site of distal anastomosis should be made after intraoperative angiography. Availability of saphenous vein for bypass conduit should be evaluated with ultrasound or computed tomography and it should be marked preoperatively for easy harvest. Optimal bypass route as well as bypass method is also decided preoperatively. Since it does not always proceed as planned, alternative plans should be prepared. The author herein described the knacks and pitfalls in the operative procedures of infrainguinal bypass with a non-reversed vein graft, which has been most often performed in our team.

About half of the thoracic endovascular aortic repair (TEVAR) cases require occlusion of major cervical branches. Therefore, the skill of debranching is essential to extend indication of TEVAR. It is not necessary to reconstruct the left subclavian artery (LSA) under other than special conditions, but it is safer to reconstruct the LSA in elective cases. The post-esophageal route of the common carotid artery bypass is cosmetically beneficial, but it has to pass behind the trachea membranous portion so as not to cause dysphagia. The triple vessels debranching from the ascending aorta for Zone 0 TEVAR with thoracotomy is not less invasive so that it’s not recommended much. Chimney method, in-situ fenestration (ISF), branched or fenestrated graft method could be used to avoid thoracotomy. For now there are no fenestrated nor branched grafts in Japan. ISF is a safe and effective way by employing our Squid capture method. During this procedure cerebral circulation is maintained by percutaneous cardiopulmonary bypass (PCPS). After deploying the stentgraft we stab it by a needle while squeezed by snare wire and stick a covered stentgraft eventually. Unlike chimney technique this method has no risk of gutter leak. The arch vessels’ debranching itself is not the risk factor of cerebral infarction. Pull-through is the strongest risk factor. The LSA blockade is most important in order to prevent cerebral complications. Complete isolation of cerebral perfusion with PCPS and the vertebral artery balloon protection is a final perfect way to prevent stroke.

Objective and Methods: The popliteal artery diseases except for the arteriosclerosis obliterans (ASO) are relatively rare, and they require multifaceted surgical strategies depending on an each cases. In this article, we reported 8 surgical cases of the popliteal artery lesions except the ASO in 7 patients. Results: The mean age of the patients was 64 years, 4 were male and 3 were female. Popliteal artery aneurysms were diagnosed in 4 legs in 3 patients. They all underwent bypass surgery used prothetic grafts. Two of three, medial skin incision around the knee joint was employed in 2 cases, and 1 case was operated through the posterior approach with S-shaped incision. Popliteal artery pseudoaneurysms associated with osteochondromas were diagnosed in 2 patients. We removed the osteochondroma through the lumen of the pseudoaneurysm and performed popliteal arterioplasty in both cases. 1 case was performed via medial incision and the other was a posterior approach. Popliteal artery pseudoaneurysm rupture after the total knee arthoplasty was diagnosed in 1 patient. A medial incision was performed below the knee and underwent bypass surgery used prothetic grafts. Adventitial cystic disease of the popliteal artery was diagnosed in 1 patient. With a posterior approach, the cyst removal and the bypass surgery using saphenous vein graft was performed. There were no cases required for amputation or resulted in limb necrosis, and all patients had uneventful postoperative course with good arterial perfusion. Conclusion: Considering for the popliteal artery lesions with various anatomical conditions, multifaceted surgical strategies with the approach method or a graft choice should be mandatory in patients with the popliteal artery diseases except for the ASO.

Objective: We examined the effects of the introduction of endovascular aortic repair (EVAR) on treatment for abdominal aortic aneurysms (AAAs). Subjects: We compared patients in the following three periods: period I (January 2002–December 2006, 105 patients), period II (January 2007–December 2011, 242 patients, duration of 5 years after the introduction of EVAR), and period III (January 2012–December 2016, 237 patients, duration of 5 years after period II). We used the American Society of Anesthesiologists (ASA) classification for risk assessment. Results: In the Open repaier (OR) group, the incidences of ASA class 2 increased and classes 3 and 4 decreased significantly in periods II and III compared with period I. In all periods, there were no in-hospital deaths. Suprarenal aortic cross-clamping was required in 18 patients (19.1%) in period III and 5 patients (6.3) in period I, and the difference was significant (P<0.05). In the EVAR group, no differences in age, sex, or ASA classification class were observed between periods II and III. In period II, one patient died due to aneurysm rupture during surgery. Significant differences were observed when comparing both groups in periods II and III: patients in the EVAR group were older (P<0.01) and the OR group had a higher proportion of ASA class 2 patients and the EVAR group had a higher proportion of ASA class 3 or 4 patients (P<0.01). Among all AAA surgeries, rupture occurred in 25 patients (23.8%) in period I, 18 patients (7.4) in period II, and 16 patients (6.8) in period III. The number of ruptures was significantly lower in periods II and III than in period I (P<0.01). Conclusions: The findings of this study suggest that EVAR should be indicated for high-risk patients and had the good outcome of AAA treatment.

Objectives: Uncomplicated type B aortic dissection is generally treated with medical management including antihypertensive therapy. The purpose of this study is to investigate risk factors associated with the aortic enlargement in medically treated patients. Methods: Between July 2004 and April 2016, 127 consecutive patients with acute type B aortic dissection were treated in our institution. Of these, 104 patients diagnosed with uncomplicated type B dissection were managed medically as an initial treatment. According to the diameter of the dissected aorta, these patients were retrospectively placed into 2 groups: 1) enlargement group (group E: n=36); and 2) unchanged group (group U: n=68). Results: There was statistically significant difference regarding the initial diameter of the dissected aorta (group E: 42±7 mm, group U: 36±7 mm) (p<0.01). As regards the aneurysm growth rate, a significant difference between both groups was noted (group E: 10±32 mm/half-year, group U −3±19 mm/half-year) (p<0.05). In all 104 patients, 42 patients (40.4%) had patent false lumen with the average number of 1.5 intimal tears. Multivariate analysis showed the relationship for aortic enlargement were patent false lumen (p<0.05, 95% CI 0.407–0.935) and initial aortic diameter (p<0.01, 95% CI 1.076–1.158). Aortic event free survival (1/5/10 years) was 100/86/77% in group E and 92/79/79% in group U, respectively no differences between two groups (p=0.747). Conclusions: The medically managed patients with uncomplicated chronic type B dissection showed excellent survival rate during long-term follow-up. The results of surgical or endovascular treatment in patients underwent initial medical therapy were also satisfactory. The patent false lumen and aortic diameter at the onset may impact on aortic enlargement. Considering our results, the feasibility of elective endovascular repairs in stable dissection remains controversial even in the endovascular era.

Objective: To discuss surgical procerdure of cases who required late open conversion (LOC) for endoleaks (EL) with aneurysmal sac expansion. Methods: Between January 2007 and August 2017, 185 EVARs were performed for Abdominal Aortic Aneurysm (AAA) in our hospital. We report surgical procerdure of six caces (3.2%) who required LOC for endoleaks. Results: In 3 cases (Type Ia/Type II/Type Ia+II; 1/1/1), a stent graft (SG) was completely explanted and graft replacement was performed. In residual 3 cases, SG was preserved. We performed proximal neck banding for one patient with type Ia EL, laparotomy and ligation of inferior mesenteric artery for one patient with type II EL, fibrin spray to SG and plication of aneurysmal sac for one patient with type V EL. Complete removal of SG and graft replacement was more invasive than preservation of SG, regarding operative time, amount of bleeding and postoperative hospital stay. Conclusion: Complete removal of SG and graft replacement is a large invasive and a poor early postoperative results, so we consider that less invasive preservation of SG is more appropriate.

A 69-year-old man was referred to our hospital because of sudden onset of abdominal pain. Computed tomography (CT) showed a ruptured abdominal aortic aneurysm (AAA), and an emergency endovascular abdominal aortic aneurysm repair (EVAR) was performed under local anesthesia. Postoperative CT showed Type II endoleaks from the lumbar arteries and the inferior mesenteric artery (IMA). Because no pulsation was detected in the aneurysm and he appeared to be in a stable general condition, he was followed up on an outpatient basis. CT obtained 6 months post EVAR showed a mass projecting into the retroperitoneum and an atheroma in the AAA, and he was diagnosed with a contained rupture of the AAA. Angiography showed Type II endoleaks from the lumbar arteries; however, no Type I endoleak was observed. We chose an open surgical repair procedure for definitive treatment of the Type II endoleak. Intraoperatively, the walls of the AAA were exfoliated from the right and left and lumbar arteries and the IMA was ligated from outside the aneurysm. A rupture was confirmed in the right posterior wall of the AAA. The atheroma and hematoma were removed from the AAA, and we confirmed no retrograde blood flow into the aneurysm sac. We successfully performed open surgical repair for re-rupture of an AAA associated with Type II endoleak after previous EVAR.

The 48 year-old-man who was urgently hospitalized with sudden chest pain, fever and dyspnea. According to laboratory findings, medical history and transthoracic echocardiography, we diagnosed acute heart failure due to Aorto–atrial fistula because of infectious endocarditis. His trachea was intubated at the emergency room, because respiratory failure and hemodynamic status was unstable. We transferred the patient to an operating room to perform emergency surgery. Saccular ascending aortic aneurysm pressed right atrium and superior vena cava.Under cardiopulmonary bypass, we made an incision in an aneurysm and detected a pseudo aneurysm from the posterior wall ruptured into left atrium. We performed m-Bentall’s operation, after left atrial fistula was closed direct suture. The patient was alive and free of disease 36 months after surgery. Because of our lack of experience, we were not able to definitively diagnose a syphilitic ascending aortic aneurysm ruptured into left atrium until confirmed postoperative pathological diagnosis. There have been only two cases reported, and one of whom underwent operation. We report this case including diagnosis, symptom and treatment, with bibliographical consideration.

A 24-year-old woman with an abdominal stab wound was found lying on the road and was admitted to the emergency room. Because she was in a state of hemorrhagic shock on her arrival, an emergency laparotomy with hepatorraphy and middle colic artery ligation was performed. On day 5 of admission, a superior mesenteric artery pseudoaneurysm (SMAPA) and arteriovenous fistula between the SMA and jejunal vein (SMAJVF) were discovered by computed tomography scan (CT). The size of the SMAPA gradually increased and a treatment to prevent SMAPA rupture was required. We decided to perform endovascular treatment, since 7 mm×25 mm VIABAHN endoprosthesis would cover the SMAPA without occluding the jejunal arteries. On Day 29 of admission, VIABAHN endoprosthesis placement to the SMA along with SMAJVF embolization was performed without complication. We report this rare case because this is the first report of VIABAHN endoprosthesis used for traumatic SMAPA with SMAJVF in Japan.

A 62-year-old man presented to our hospital complaining of an intractable foot ulcer. Angiography showed a disruption of the dorsalis pedis and posterior tibial arteries. Collateral circulation provided blood flow to the plantar artery. Endovascular therapy (EVT) for the occluded posterior tibial artery was unsuccessful, so a popliteal-plantar artery bypass was performed. Distal venous arterialization was chosen due to poor distal run-off preventing bypass flow immediately after declamping. Debridement and vacuum-assisted closure (VAC) for the ulcer were begun after the surgery. The foot ulcer had completely healed 6 months after the operation. DVA can be considered an option for cases with a difficult distal bypass.

Acute abdominal aortic occlusion (AAAO) is a rare and life threatening disease, and is associated with a high incidence of myonephropathic metabolic syndrome (MNMS). A 77-year-old man was referred our emergency department because of sudden bilateral lower extremity paralysis. Physical examination revealed a pulse deficit in the bilateral lower limbs, as well as motor and sensory disorder of the bilateral lower limbs. Enhanced CT revealed an abdominal aortic occlusion from the bifurcation of the right renal artery to the bilateral iliac arteries. We considered that emergent surgical revascularization was necessary. However, we feared that risk of MNMS after revascularization might be high because ischemia had persisted for 14 hours since onset. Therefore we performed left axillary artery–bilateral femoral artery bypass, intraoperative CHDF (continuous hemodiafiltration) and modified controlled limb reperfusion. Postoperatively, we continued CHDF for improvement from MNMS. Although the patient was at high risk for MNMS, using the above techniques we were able to save his life and legs.

Popliteal venous aneurysm is rare and usually asymptomatic. Here we report a case of surgically treated popliteal venous aneurysm diagnosed due to pulmonary embolism with cardiopulmonary arrest. A 50-year-old woman was admitted to our emergency service due to cardiopulmonary arrest. She was resuscitated with percutaneous cardiopulmonary support and CT scan demonstrated a pulmonary embolism. Ultrasonography and MRI revealed a right popliteal venous aneurysm, approximately 60 mm in diameter, filled with massive thrombi that caused a pulmonary embolism. Inferior vena cava filter was temporally placed and the venous aneurysm was successfully resected. Postoperative course was uneventful and the patient was admainistered anticoagulant therapy with warfarin. Once pulmonary embolism is diagnosed, a popliteal venous aneurysm should be ruled out as the precipitating cause.