With the global epidemic of diabetes, diagnosis of critical limb ischemia (CLI) has become very complex due to mixture of microangiopathy, infection and sometimes neuropathy with the pure ischemia. We still sometimes encounter the patients with extensive tissue loss due to misdiagnosis of ischemia or infection in previous hospital. For adequate decision making of proper treatment selection for each critical ischemic limb without missing the adequate intervention timing, a new classification system good for not only vascular specialists but also gate keeping clinicians working in the era of diabetes has been desired. Responding to marked demographic shift, Society for Vascular Surgery issued new classification named WIfI system which evaluate the foot lesion comprehensively by three factors; Wound (W), Ischemia (I), and foot Infection (fI). Guidelines for peripheral arterial disease recommend use of WIfI classification system. To decide treatment strategy of CLI as well as managing those limbs after revascularization, it is important to popularize adequate diagnostic system using WIfI classification as common language by not only for vascular specialists but also other clinicians facing CLI patients.

Objective: This study aimed to analyze disruption of the autologous vein grafts caused by surgical site infection (SSI) after distal bypass. Methods: We retrospectively analyzed infectious disruption of five grafts out of 361 distal bypass grafts from April 2009 to December 2017 in our hospital. Results: Disruption of four grafts occurred within 1 month. The sites of disruption were the graft body in 3 cases and the distal anastomosis in 2 cases. The most common cultured pathogen was methicillin resistant staphylococcus aureus. All grafts were ligated at the disrupted site. Three patients underwent major amputation and one died of sepsis. One patient avoided major amputation by rebypass. Conclusion: Graft disruption caused by SSI became fatal complication. When SSI occur after distal bypass, we should pay attention to the graft disruption especially within 1 month.

We report a case in which ruptured abdominal aortic aneurysm with aortocaval fistula associated with serious congestive heart failur was successfully managed by only endovascular aortic repair. After this treatment, the hemodynamics dramatically improved. The blood in the aneurysm sac has been completely thrombosed and type II endoleak has disappeared in a year and six months follow-up. And the diameter of the aneurysm has been significantly getting smaller. Only Endovascular aortic repair is an incomplete treatment, but the operation must be effective as an initial treatment in an emergency. After the operation, it is expected that the remaining fistula will close and type II endoleak will disappear.

A native arteriovenous fistula (AVF) and an arteriovenous graft (AVG) in the upper extremity are generally accepted as the first and second choice, respectively, for chronic hemodialysis access. However, the number of patients whose upper extremity vessels are not suitable for vascular access (VA) has been increasing. For such patients, we created the dorsalis pedis artery-great saphenous vein fistula in the lower extremity. A 50-year-old woman with chronic kidney disease due to diabetic nephropathy initially underwent creation of an ulnar-cephalic AVG using an autologous vein graft at the left wrist joint. However, maturation of the cephalic vein was poor, and the vein was insufficient as VA for hemodialysis. Next, an AVG was created using a polytetrafluoroethylene graft in the left forearm, but it caused dialysis access-associated steal syndrome. An AVF was then created at the contralateral wrist joint, but it was insufficient due to poor blood flow. Finally, we selected the ankle and created a dorsalis pedis artery-great saphenous vein fistula. An AVF at the ankles is more advantageous than an AVG in terms of the low risk of infection and technically it is not difficult for vascular surgeons. The AVF in this patient has been working well for more than 1 year. The dorsalis pedis artery-great saphenous vein fistula is one option for VA for patients in whom conventional VA has failed.

A 75-year-old man, who had been using a crutch for assistance with walking from early childhood because of poliomyelitis, was referred to our department with numbness and a cold sensation that suddenly emerged in the left upper extremity. A brachial artery aneurysm and occlusion from the site to the radioulnar artery bifurcation were confirmed by CT angiography findings. Patency could not be restored even after attempting thromboembolectomy, thus bypass surgery with an autogenous vein was performed. An arterial aneurysm in an upper extremity is relatively rare. True aneurysms occasionally develop as the result of repeated blunt injuries. Our patient had been using a crutch for approximately 70 years, thus we considered that repeated injuries caused by the crutch might have induced a brachial artery aneurysm. Furthermore, we speculated that thrombus formation in the aneurysm and resulting distal thromboembolism might lead to acute ischemia. In patients with such an arterial aneurysm, prognosis is sometimes poor, as a microembolism can develop as a chronic occlusion of the smaller vessels. For this reason, it is desirable to perform surgical intervention as early as diagnosis is confirmed.

Axillary artery aneurysm is rare. Although there were some reports that this disease was caused by repeated trauma and iatrogenic factor, thoracic outlet syndrome and systemic disease like Marfan syndrome, the cause by fibromuscular dysplasia (FMD) is extremely rare. A 68-year-old woman had complaint of a fever and she was diagnosed as bilateral axillary artery aneurysms by contrast-enhanced computed tomography in another hospital, she was referred to our hospital. On general anesthesia and supine position, we achieved replacement of both aneurysms with 8 mm externally supported knitted Dacron grafts (Gelsoft ERS) using the subclavian approach. Histopathological examination revealed the aneurysm wall had neither arteriosclerosis nor arteritis. The elastic fibers of intima were thickened (intimal fibroplasia), those of media were irregular and sparse (medial fibromuscular dysplasia), adventitia was normal, these findings corresponded to FMD. At first year after operation, there is no recurrence of aneurysms, grafts are patency.

We herein present a rare case of an abdominal aortic aneurysm (AAA) in association with a left pelvic kidney. Preoperatively, a 3D-CT demonstrated a left pelvic kidney and an aberrant left renal artery originating from the aneurysm itself. We replaced the abdominal aorta with a graft, and reconstructed the aberrant left renal artery on the graft. During surgery, the left kidney was perfused with cold Ringer’s acetate. The patient had an uneventful postoperative course showing no signs of worsening renal function. A postoperative 3D-CT demonstrated the patent left renal artery reconstructed on the graft, and showed no signs of renal infarction. In cases of AAA associated with a pelvic kidney and an aberrant renal artery, 3D-CT is essential in assessing the origin and course of the aberrant renal artery. During surgery, reconstruction of the aberrant renal artery and perfusion of the kidney with cold Ringer’s acetate can preserve renal function.

A 54-year-old man was referred to our emergency room due to upper abdominal pain. Computed tomography revealed celiac artery dissection, the dissecting aneurysm of the splenic artery and bloody ascites. The patient was diagnosed with rupture of the dissecting aneurysm of the splenic artery due to isolated spontaneous celiac artery dissection (ISCAD). He underwent laparotomy and ligation of the splenic artery emergently. We report a rare case of ISCAD with rupture of the dissecting aneurysm of the splenic artery.

A popliteal vein aneurysm (PVA) could be an important pathology causing pulmonary thromboembolism (PTE). We report a rare case of traumatic PVA. A 59-year-old woman presented an onset of syncope and hypoxemia. The Computed tomography and ultrasonography revealed PTE and PVA. Because she had a risk of repetive PTE, she was refered to our department for surgery. We performed PVA resection and closure of the aneurysm ostium, which was followed by anticoagulant therapy for one year. To date there is no recurrence of vein thrombosis or PTE.

Unsuitable anatomy of the proximal aortic neck is the most common reason for endovascular aneurysm repair ineligibility and subsequent surgical repair. We present a case of a frail 86-year-old patient with refractory type IA endoleak after EVAR, which was unable to be treated by re-endovascular repair using proximal cuff extension because of an incomplete stent-graft fixation. We performed successful aortic banding for reshaping hostile neck anatomy, followed by additional cuff extension, which had resulted in a complete disappearance of type IA endoleak. This method of bidirectional reinforcement could be the durable treatment of high-surgical-risk patients who would otherwise not be treated.

The deep femoral artery aneurysm is a rare disease. Because of anatomical and pathological characteristics, it is quite difficult to detect in early phase. We present a case of the deep femoral artery incidentally detected by echography when it was used to examine peripheral artery aneurysm. A 76 year-old-man was referred to our hospital with a diagnosis of the left deep femoral artery aneurysm. He had undergone coronary-artery bypass surgery at age 71, and abdominal aortic aneurysm replacement with a vascular prosthesis at age 72. The dilatation of bilateral common femoral artery was detected by abdominal computer tomography of routine pre-operative examination of coronary artery bypass. Echography to the artery of the lower extremity taken 5 years later incidentally detected the deep femoral artery aneurysm. Contrast enhanced computer tomography showed the left deep femoral artery measuring 42 mm and arterial bifurcation between the left common femoral artery and the deep femoral artery were also dilated. We performed lower limb artery aneurysm replacement with vascular prosthesis to the left common femoral artery aneurysm and the left deep femoral artery aneurysm. Post-operative course was well and he was discharged 10 days after operation. We report this case including diagnosis, symptom and treatment, with bibliographical consideration.

Deep femoral aneurysm has been reported to comprise 0.5% of all peripheral aneurysm cases and is considered to be a rare disease. We had a case involving an aneurysm of the perforating artery, which is a branch of the femoral artery. The patient was an 81-year-old woman presenting with a pulsatile mass and pain on the posterior aspect of her right thigh. We believed that surgical intervention to prevent major arterial rupture was indicated due to the presence of a large aneurysm measuring 50 mm in diameter and 110 mm in length. However, as reaching the aneurysm site via an anterior approach proved difficult, we used a posterior approach with the patient in a prone position. Due to the possibility that centrally securing the lesion or blocking blood flow could become unstable, a percutaneous transluminal angioplasty(PTA) balloon catheter was indwelled in the femoral artery in the deflated state immediately prior to surgery. We believe that this method may be a useful treatment option when blocking is impossible under direct view. Only the lesion present in the perforating artery was excised in the present case; postoperative symptoms disappeared, and no blood flow disturbances were observed.

Disseminated intravascular coagulation (DIC) is a rare complication of dissecting aortic aneurysm. It is often difficult to perform hemostasis when unexpected bleeding appears in these patients. One of these patients was a seventy-nine years old female who suffered from DIC caused by dissecting aortic aneurysm. Four months after her thoracic aortic surgery, she had symptoms of coagulopathy such as prolonged bleeding from venipuncture. The results of her blood test showed that DIC was worse. Administration of heparin for 5 days improved DIC but massive hematoma appeared on her right chest wall. Continuous bleeding persisted after hemostasis. We suspected that bleeding was due to coagulation factor XIII (FXIII/13) deficiency. The administration of FXIII/13 immediately stopped the bleeding and improved DIC. It was later noted through the blood test that FXIII/13 decreased to 46% of normal. We observed that bleeding in the patient with DIC was caused by dissecting aortic aneurysm. Bleeding tendencies were associated with FXIII/13 deficiency and giving FXIII/13 was an effective hemostasis.

An 84-year-old male visited a nearby clinic with chief complaints of bilateral lower limb edema. Ultrasonography revealed the right internal iliac artery aneurysm, and thus, the patient was referred to our hospital. Contrast-enhanced computed tomography showed a right isolated internal iliac artery aneurysm 40 mm in diameter and his external artery was chronic total occulusion. And additionally, collateral vessels developed from the right inferior gluteal artery to the right deep femoral artery. We performed endovascular aortic repair with only straight stent-graft and femoro-femoral bypass, successfully. The postoperative course was uneventful and he was discharged on the 10th day on the foot. The important issues in isolated internal iliac artery aneurysm repair are the method of surgical approach. Therefore, careful preoperative assessment should be undertaken for each case.

Traumatic aortic arch rupture is a rare but life-threatening condition. A 78-year-old man was admitted to our hospital due to a traffic accident. Contrast-enhanced computed tomography showed an aortic intimal tear at the ostium of the left common carotid artery with pseudoaneurysm expanding into the descending aorta. In addition, a mesenteric injury with a hemorrhage and left femoral head fracture were observed. An urgent operation of total arch replacement was performed with the aid of the J-graft open stent graft. The hemostatic procedure for the mesenteric injury was also performed simultaneously. Although long term rehabilitation was required, the patient was discharged and returned home 97 days after the operation. Total arch replacement using the J-graft open stent graft may be a valuable therapeutic option for a traumatic aortic arch injury with multiple organ injuries.

Since 2013, the Japanese Society for Vascular Surgery has started the project of nationwide registration and tracking database for patients with critical limb ischemia (CLI) who are treated by vascular surgeons. The purpose of this project is to clarify the current status of the medical practice for the patients with CLI to contribute to the improvement of the quality of medical care. This database, called JAPAN Critical Limb Ischemia Database (JCLIMB), is created on the National Clinical Database (NCD) and collects data of patients’ background, therapeutic measures, early results, and long term prognosis as long as five years after the initial treatment. The limbs managed conservatively are also registered in JCLIMB, together with those treated by surgery and/or EVT. In 2015, 1138 CLI limbs (male 796 limbs: 70%) were registered by 92 facilities. ASO has accounted for 98% of the pathogenesis of these limbs. In this manuscript, the background data and the early prognosis of the registered limbs are reported.