Acute limb ischemia (ALI) is a rapid decrease in lower limb blood flow due to acute occlusion of peripheral artery or bypass graft, and in ALI not only limbs but also life prognosis will be poor unless quick and appropriate treatment is given. The etiology is broadly divided into embolism and thrombosis with various comorbidities. The symptoms of ALI are abrupt with pain, numbness, and coldness of lower limb, and paresthesia, contracture, and irreversible purpura will appear with the exacerbation of ischemia. Severity and treatment strategy should be determined based on physical findings and image findings. Considering life prognosis, limb amputation should be done without hesitation when the limb was diagnosed as irreversible. ALI can be treated by means of open surgical revascularization, endovascular, or hybrid approach with rapid systemic administration of heparin. In any cases, evaluating the lesions by intraoperative angiography and appropriate additional treatment are important. ALI is a serious disease requiring urgent treatment, and it is essential to promptly perform the best initial treatment that can be performed at each facility.

The preoperative and postoperative infection control measures for critical limb ischemia treatments were described. The treatment strategies for severe ischemic limbs were showed according to the presence and extent of infection. If the treatment strategy for a severe ischemic limb with infection is mistaken, infection will spread and make worse the situation of the ischemic limb, and eventually it can result not only in limb loss but also life threatening. A surgical strategy is very important in the bypass material, the selection of anastomotic site, the use of postoperative antibacterial drugs, and the wound treatment. Infection troubles are the most familiar and indispensable problem for surgeons, the countermeasures against infection especially in critical limb ischemia is the key point along with revascularization.

1. The exudative in chronic wounds works negatively in wound healing, although acute wounds positively. 2. There are various methods of debridement invasively to non-invasively. 3. There are two means in terms of debridement. The one is for removal of dead tissues, the other for clearance of the infected tissues.

Endovascular therapy for critical limb ischemia has been accepted in the real world clinical settings, due to development of devices and establishment of procedures. The indication should be decided by taking into account of the patient background and anatomical situation of the lesion artery. The author herein described the outlines of indication and management of endovascular therapy for critical limb ischemia.

Vascular diseases represented by obstructive arteriosclerosis(ASO) often cause resting pain or ulcer/necrosis as the disease progresses. The pain of critical limb ischemia (CLI) is severe and is difficult to control. In order to relieve pain, it is necessary to combine various treatment modalities such as drug therapy, regional anesthesia in the form of sympathetic ganglion block, epidural block, or peripheral nerve block (PNB), spinal cord stimulation, and hyperbaric oxygen therapy. Since patients are often elderly and may have severe heart disease, treatment modalities that have lesser effects on the circulatory system are desirable. Regional anesthesia is advantageous in that it exerts an anesthetic effect limited to the necessary region. This is particularly true of PNB performed under ultrasound guidance, wherein the effect of the PNB can be precisely limited to the necessary part. Furthermore, PNB is also effective in relieving pain during movement. In these respects, PNB is superior to analgesics delivered by systemic administration, such as opioids. It is also necessary to consider psychosocial factors as well as cognitive behavioral therapy and mirror therapy, in addition to drug therapy and ultrasound-guided PNB, in the management of pain in CLI.

A 73-year-old woman complained of muscle weakness and numbness of the left hip and thigh. Non-pulsatile mass in the left thigh, muscle weakness, and sensory disorder in the left lower thigh were observed. There were no symptoms of lower-limb ischemia. Contrast enhanced CT angiography revealed a thrombosed persistent sciatic artery aneurysm which was 60 mm in diameter, a hypoplastic superficial femoral artery, and collateral circulation from deep femoral artery to popliteal artery. She was diagnosed as sciatic nerve neuropathy caused by compression of thrombosed persistent sciatic artery aneurysm. Complete resection of the aneurysm was impossible due to the strong adhesion of tibial and peroneal nerve to the aneurysm, therefore, thrombectomy and partial resection of the aneurysm without a bypass procedure were performed. Lower extremity neuropathy was improved and no symptoms of lower-limb ischemia were observed postoperatively. She was discharged on postoperative day 18. The symptoms with the persistent sciatic artery aneurysm are divided into lower limb ischemia and the sciatic nerve compression. Revascularization is required for the treatment of lower limb ischemia, and resection or mass reduction is required for the treatment of the sciatic nerve compression. Preoperative evaluation of blood flow and neuropathy is essential for the choice of the operation.

We report a case of common femoral artery pseudoaneurysm caused by bone cement after total hip arthroplasty. The patient was an 83-year-old woman. She had undergone a right total hip arthroplasty for rapidly destructive coxarthropathy in November 2016. One month later, she presented with progressive anemia. Computed tomography revealed a right common femoral artery pseudoaneurysm. Bone cement was found within the pseudoaneurysm and near the injury site of the right the common femoral artery. We considered the cause of pseudoaneurysm to be repeated trauma by the protruding bone cement. We surgically removed the bone cement, and reconstructed the artery using a knitted Dacron graft.

Endograft collapse is a rare and severe complication after thoracic endovascular repair (TEVAR). We report a case of delayed endograft collapse after TEVAR using Najuta and Relay plus endograft. A 72-year-old woman with distal arch aneurysm underwent TEVAR. After Najuta was placed from Zone 0 to Zone 4 with the patency of the brachiocephalic artery and the left carotid artery, Relay plus was placed from Zone 2. Postoperative computed tomography (CT) confirmed patency of both grafts and no endoleak. She readmitted the hospital due to congestive heart failure 206 days after TEVAR. CT showed endograft collapse. We performed emergent re-expansion of the collapsed endograft and urgent operation of replacement of the ascending aorta. Because of its high mortality, graft collapse should be diagnosed and treated as soon as possible. In planning a treatment strategy, risk of bird-beak phenomenon and necessity of an additional device into Najuta should be considered according to anatomical assessment of the aortic arch in order to prevent such a lethal complication.

A 72-year-old female underwent thoracic endovascular aortic repair using the VALIANT endograft (Medtronic, Santa Rosa, CA, USA) and axillo-axillary bypass for saccular distal arch aortic aneurysm 2 years previously. Postoperative CT revealed no endoleak, but aneurysm sac enlargement had continued. The patient was scheduled to undergo open surgery, but she experienced left chest pain 2 months before surgery and enhanced CT showed a ruptured aneurysm. We therefore performed distal aortic arch repair by thoracotomy. Though there was a fingertip-sized hole and continuous oozing at the top of the aneurysm sac at the larger curvature, there was no endoleak, even during surgery. We diagnosed endotension-induced aneurysm sac rupture. Endotension is considered a continued expansion of the sac without leak with graft porosity contributing to aneurysm sac enlargement. Aneurysm sac rupture by endotension is not rare, and strict observation and addition of early endovascular treatment are useful strategies.

A tracheo-innominate artery fistula (TIF) is a relatively rare condition; however, it might present as a life-threatening complication of a tracheostomy procedure. Massive bleeding causing rapid airway obstruction leads to a rapid decline in the patient’s condition and prevents surgical intervention for the treatment of TIF. A 29-year-old woman revealed a history of having undergone a tracheostomy 14 years prior to presentation. She was transferred to our hospital due to massive bleeding from her tracheostomy site. However, over inflation of the cuff had achieved adequate hemostasis by the time she arrived at our hospital, and computed tomographic and angiographic examination did not reveal any bleeding points at the site of her tracheostomy. Careful bronchoscopic examination demonstrated a tracheal mucosal ulceration with a red bottom, suggesting an impending perforation of the TIF. Because the ulcer was in close proximity to the innominate artery, prompt transection of the innominate artery and tracheal repair were performed. We conclude that a careful bronchoscopic examination is a useful diagnostic method to effectively manage an impending perforation of a TIF.

A 49-year-old man admitted to our hospital for the acute progression of chronic pancreatitis. A clot-like mass was seen in the ascending aorta on the computed tomography image. Magnetic resonance imaging identified multiple cerebral infarctions. We considered that the clot-like mass was high risk of embolism. Therefore, we decided to perfom an urgent operation. Operative finding revealed a thrombus attached to the ascending aorta and we removed the thrombus from the aortic wall. Pathologically, the mass was a blood clot. We report a very rare case of thrombus in the ascending aorta which was decided to do early operation because of high risk of embolism.

A 77-year-old woman had history of chronic type B aortic dissection (CTBAD) with unknown timing of onset. She was admitted to our hospital for acute chest back pain. She was diagnosed with redissection of CTBAD. The dissected thoracoabdominal aortic aneurysm expanded rapidly despite the anti-impulse therapy for 2 weeks. The planned surgery was performed for impending rupture of CTBAD. We considered open surgery high invasive because of the obesity and the anatomical features of the descending aorta running in right thoracic cavity. Primary entry closure with TEVAR and embolization of false lumen with vascular plug were underwent. The computed tomography at 1 week after the operation revealed that the false lumen was thrombosed. She was discharged on the 10th postoperative day. The computed tomography at 1 year after the operation revealed that the diameter of false lumen was reduced. TEVAR for CTBAD is useful in high-risk patients and embolization of false lumen with vascular plug is also useful to control the false lumen flow.

Although the usual manifestation of secondary aorto-enteric fistula (sAEF) are gastrointestinal bleeding, it is difficult to suspect sAEF in the cases without any signs of hemorrhage. A 66-year-old man was admitted to our hospital with fever. He had undergone aortobifemoral bypass for aortoiliac occlusive disease 5 years ago. Enhanced computed tomographic scan revealed accumulation of perigraft fluid and gas without pseudoaneurysm formation. Gastroduodenoscopy revealed that a bile-stained aortic prosthesis was exposed into the third portion of the duodenal lumen. Fecal occult blood test was positive. We made a diagnosis of sAEF. Because the patient was hemodynamically stable without any signs of bleedings, infection control using an antibiotics was conducted in preference to surgery. We, then, performed partial duodenectomy, debridement, partial graft replacement with a rifampicin-soaked graft, and omentopexy 2 weeks later. We report a rare case of graft-enteric erosion which characterized by erosion of the gastrointestinal tract by an underlying prosthesis but absence of a true fistulous communication with the aortic lumen, and treated with elective graft replacement after an infection control.

Isolated brachiocephalic venous aneurysm is extremely rare. Only 23 cases have been reported in the literature. A 70-year-old woman referred to our hospital because of a mediastinal widening. A contrast enhanced computed tomography scan showed a saccular aneurysm of the left brachiocephalic vein. We performed aneurysmectomy and venous plasty using autologous pericardial patch because expansion of the aneurysm was noticed during follow-up. The patient had an uneventful postoperative course without recurrence. The surgical indication of brachiocephalic venous aneurysm is controversial, but surgical treatment is recommended for the saccular aneurysm with tendency for expansion.

We present a case of large vessel giant cell arteritis as an initial manifestation of an inflammatory abdominal aortic aneurysm. An 84-year-old woman, who had a persistent fever for one month, was transferred to our care. A computed tomography scan revealed a saccular abdominal aortic aneurysm with inflammation. A clinical diagnosis of inflammatory abdominal aortic aneurysm was established. Antibiotics were unable to control the fever and inflammatory reaction, so an abdominal aortic vascular prosthesis replacement was performed. Ten days after surgery, an active fever and inflammatory reaction recurred. Pathological examination of the aneurysm wall revealed giant cells in aortic intima. A postoperative diagnosis of large vessel giant cell arteritis was established. The fever and inflammatory reaction promptly improved with the administration of steroids. Large vessel giant cell arteritis diagnosed by pathological examination is rare, yet it is important to suspect giant cell arteritis in this situation.

Popliteal venous aneurysms (PVAs) are rare and in most cases the primary presentation includes pulmonary thromboembolism and post-thrombotic syndrome. Although few cases of PVA with pain in the popliteal fossa were reported, no previous case of PVA-related an ankle pain is known. We describe the case of a 70-year-old woman presenting with PVA-related ankle pain. Computed tomography revealed a 25×23 mm venous aneurysm of the distal popliteal vein. During surgery, the tibial nerve was found to be compressed between PVA and the gastrocnemius muscle. PVA was resected with a venous aneurysm of the small saphenous vein, which was 10 mm in diameter. The continuity of the deep venous system was restored upon transposition of the small saphenous vein. The pain in the right ankle resolved postoperatively, the patient received anticoagulation therapy and was treated with compression stockings. Venography was performed 54 months after surgery, which revealed a patent popliteal vein without any evidence of stenosis. This report shows that ankle pain can present as a symptom of a venous aneurysm in the distal popliteal vein.

Background: We present a patient with symptomatic aortic coarctation who underwent stent graft insertion. Case: A 70-year-old woman with no medical history had been complaining of a sensation of chest compression for several days. Enhanced computed tomography (CT) revealed an untreated descending thoracic aortic coarctation. Antihypertensive medication was administered but was later discontinued owing to loss of sensation in the lower limbs and general malaise. After consideration of the surgical treatment options, stent graft insertion was selected because of her advanced age. We surgically inserted a stent graft into the aortic coarctation site. Although there were no issues during advancement through the coarctation site, catching the top cap and passing it through during retrieval was challenging. The stent was passed through with its bottom fixed to the outer sheath. Immediately after dilation, the blood pressure difference between the upper and lower limbs remarkably decreased from 50 mmHg to 10 mmHg. The symptoms improved after surgery and she was discharged on postoperative day 8. An enhanced CT scan at the 5-month follow-up showed that the diameter at the coarctation site had further increased, and the ankle-brachial index improved to 1.02 on the right and 1.06 on the left. Conclusion: Aortic stent grafting was effective in adult patients with symptomatic aortic coarctation.

A 68-year-old man suffered from bilateral critical limb ischemia due to occlusion of the bilateral iliac and bilateral superficial femoral arteries after undergoing Hartmann’s operation for rectal cancer. We performed endovascular therapy for the bilateral iliac arteries using self-expandable bare-metal stents. During the procedure for the left iliac artery lesion, a guide-wire passed through the subintimal plane, proximal to the adventitia. Follow-up computed tomography revealed a pseudoaneurysm of the left common iliac artery and external iliac artery, in which contrast staining was observed outside the stents. We performed a stent-graft placement using GORE VIABAHN for the left iliac artery. Postoperative contrast-enhanced computed tomography revealed regression of the left iliac artery pseudoaneurysm. Postoperative imaging surveillance is necessary when subintimal angioplasty was performed, particularly, in case of a guide-wire passing via adventitia. GORE VIABAHN is useful for treating iliac pseudoaneurysms after endovascular treatment.

Treatment of venous stasis ulcers includes improvement of venous hypertension and wound management of the ulcer. Herein, we report on a case of multiple relapses of a skin ulcer on the dorsum of the foot. The patient was diagnosed with a plantar arteriovenous fistula and was successfully treated with coil embolization and vacuum-assisted closure (VAC) therapy. A 56-year-old woman with a history of plantar injury in early childhood had developed multiple relapses of an ulcer on the dorsum of the foot over the past 25 years. The patient was referred to our hospital for treatment of the refractory ulcer. Venous ultrasonography showed dilatation of the posterior tibial vein and an increase in venous flow velocity. Lower-extremity computed tomography angiography showed a plantar arteriovenous fistula. The patient was diagnosed with a venous stasis ulcer due to a plantar arteriovenous fistula and underwent coil embolization. After the surgery, the ulcer was managed with combined VAC therapy. No relapse has been observed since the surgery. Our results suggest that coil embolization for the treatment of fistula and VAC therapy for wound healing are very effective in patients with refractory skin ulcers induced by a plantar arteriovenous fistula.