Critical limb ischemia (CLI) is a severe blockage of the arteries to the lower limbs characterized by poor prognoses for both salvage of the lower limb and patient survival. Accordingly, CLI must be diagnosed and treated appropriately from the earliest possible stage. To do so, multidisciplinary treatment not only by vascular surgeons but also by many other doctors and medical staff is necessary. Accurate diagnosis is indispensable to appropriate treatment of CLI; thus, the definitions in the recently issued new guidelines for CLI treatment are reviewed. The multidisciplinary treatment of CLI should be recognized as three elements: namely, multidisciplinary treatment to salvage the lower limb, to improve of survival prognosis, and to prevent CLI occurrence. In all of these events, team medicine administered by expert staff is indispensable. The specialist must have not only profound knowledge of his / her field of specialty but also professional skills and the ability to cooperate with other departments. A multidisciplinary treatment approach that combines the abilities of many specialists for treating severely ischemic limbs in patients with peripheral arterial disease is expected to improve both limb salvage and patient survival and should be promoted in daily clinical settings.

Objective: To clarify the localization of and surgery for atypical incompetent perforating veins (IPVs) other than Dodd, Boyd, Cockett perforators, which have not been previously discussed. Methods: Forty-three atypical IPVs, diagnosed by venous ultrasonography and treated surgically from January 2014 to June 2018, were analyzed from the viewpoint of localization and surgical treatment. Results: All atypical IPVs passed through the fascia in the area between the muscle compartments in the same way as the typical IPV. The IPVs were most commonly located in the posterolateral part of the lower thigh (16), around the popliteal fossa (9), and in the posterolateral part in the lower calf (7). For 42 IPVs, surgery consisted of direct ligation and resection at the fascia level, and foam sclerotherapy was performed for 1 IPV. The blood flow of the perforating vein was blocked under the fascia in 40 IPVs, but to and fro flow at the fascia level remained in 3 IPVs. Conclusion: Atypical IPVs causing varicose veins were most common in the posterolateral part of the lower thigh. For treatment, it is important to ligate and cut them without leaving stumps with related branches outside the fascia under precise ultrasonic observation.

Objective: We assessed the effectiveness and appropriateness of our original Off-the-Job Training (Off JT) system using data acquired from recruited medical students and doctors. Materials and Methods: We presented our original homebuilt Off JT system, which is simple and inexpensive. In our unique system, we performed the anastomosis at the bottom of a plastic pot, which mimics the actual open surgical procedure in a deep site. There were 4 evaluation points: (A) the operative time, (B) the performance of the anastomosis evaluated by analyzing the image semi-automatically with the coefficient of variation (standard deviation/length) of the “bite” and the “pitch”, (C) the scoring of the total surgical skill evaluated by the trainers according to the Operative Performance Rating System (OPRS), and (D) the relationship of these 3 factors (A, B, and C). Results: The procedural time and the coefficient of variation of the bite and pitch decreased, and the OPRS increased after training. There was a strong correlation between procedural time, anastomotic performance, and OPRS. Conclusion: The effectiveness of our original homebuilt system was shown by the reduction in the procedural time, improvement in the anastomotic quality, and OPRS.

(Objectives) In this study, we analyzed anatomical factors in additional proximal intervention, such as aortic cuffs, covered abdominal branches or stents, in emergent endovascular aneurysm repair (EVAR) for ruptured abdominal aortic aneurysms (RAAA). (Methods) We analyzed 28 EVARs for RAAA at the Jikei University Kashiwa Hospital, Chiba, Japan, between November 2011 and September 2017 were retrospectively collected. The relationship between anatomical features and additional proximal treatments were analyzed. (Results) There were eleven cases with Fitzgerald 1 (F1), two with F2, eleven with F3, four with F4. We performed nine cases (32.1%) with additional proximal treatment for proximal endoleak. There were significant difference between additional treatment and neck length (42 mm vs 14 mm, p=0.013). The patients with short neck less than 15 mm were performed additional treatments significantly (p=0.001). Five cases (17.9%) died within perioperative periods and none of them was not performed any additional treatment. (Conclusion) As an EVAR for RAAA especially with a short proximal neck, preparation of additional devices, such as aortic cuffs and stents for abdominal branches, may be important.

We report a case of huge abdominal aortic aneurysms with systemic lupus erythematosus (SLE) of a 37-year-old woman, successfully treated by endovascular aortic repair (EVAR). The patient was introduced to our hospital due to an enlarging AAA measuring 90 mm in diameter. She had been diagnosed as SLE at the age of 12, and since then, taking steroids. She had been under maintenance hemodialysis for 20 years due to Lupus nephritis. A 60 mm AAA had been diagnosed at the age of 30, and open repair had been offered to her due to angulated aneurysm neck and calcified iliac access, however she had not wanted to have abdominal operation. Although she was young, considering her complications, the risk of open repair was determined to be high. Therefore, we selected EVAR technique. Her aneurysm was successfully treated by EVAR with some technical twists with no endoleak, and angioplasty was performed for occluded right external iliac artery. Postoperative course was uneventful and to date, two years after surgery, no endoleak has appeared and the diameter of aneurysm tends to reduce.

Popliteal venous aneurysm (PVA) is a rare disease that may lead to the potentially fetal pulmonary thromboembolism (PTE). PVA should be treated surgically because of preventing PTE. We describe here a very rare case of recurrent popliteal venous aneurysm. A 64-year-old woman had a right PVA repair 7 years 7 months ago. A year later after the operation, contrast-enhanced computed tomography (CT) demonstrated a slight dilatation of the site of operation. Follow-up CT showed gradually increasing PVA. She subsequently underwent aneurysm resection with interposed small saphenous vein. Our case demonstrates the need for long-term follow-up considering occlusion and recurrence.

A 25 year-old man had his legs injured by a steal pipe during his work and was brought to our emergency department. He had left knee swelling, pulseless left dorsal artery without Doppler blood flow, and pulseless left posterior tibial artery with poor Doppler blood flow. He had no other ischemic signs such as pain, pallor, and paresthesia. X-ray showed left knee dislocation. Computerized tomography with contrast following left knee diaplasis revealed a 2.5-cm occlusion of left popliteal artery, and 3 branches with poor blood flow from the collateral circulation. He started complaining of ischemic signs 5 hours after his visit. Thus, he underwent emergency surgery, a left above-the-knee popliteal artery to below-the-knee popliteal artery bypass with saphenous vein graft, using intraoperative angiography. The time until reperfusion was about 8 hours. Postoperatively, the left dorsal artery and the left posterior tibial artery had good pulses and his ischemic symptoms resolved. Traumatic popliteal artery injury is rare, and quick, correct surgical treatment is essential to avoid a high risk of amputation. Careful and sequential clinical examinations are the most important, even when the initial symptoms are not significant. The authors report a case of traumatic popliteal artery injury with knee dislocation together with a review of the literature.

Thoracic Endovascular Aortic Repair (TEVAR) has been conducted on high-risk patients because of its minimally invasive. The femoral artery is usually used as the access route of TEVAR, making it necessary to insert a sheath having a relatively large diameter. I herein report two cases of emergency TEVAR in which the abdominal aorta was used as the access route since the femoral artery could not be used due to strong arteriosclerotic changes. Case 1: An 86-year-old female patient with fistula from the aorto-esophageal fistula (AEF). Because the abdominal aorta was significantly tortuous and the bilateral iliac artery diameter was small, the approach from the femoral artery was difficult, making it necessary to use the abdominal aorta as the access route. Case 2: An 89-year-old male patient who developed a rupture of a thoracic aortic dissection. The right femoral artery approach was attempted, but the 22 Fr. sheath did not pass due to the tortuousness and stenosis of iliac artery, thus I changed to the abdominal aorta as the access route. Because the method using the abdominal aorta as the access route is a relatively easy approach, it is considered to be a useful method when other access routes cannot be selected.

We report on a case having a recurrent femoral artery (FA) pseudo-aneurysm treated successfully with a coronary stent covered with a great saphenous vein (GSV). The patient was a 74-year-old gentleman who had undergone a right femoro-popliteal artery bypass due to peripheral artery disease one year before. Six months after surgery, a pseudo-aneurysm developed on the proximal anastomosis site of femoro-popliteal bypass on the right common FA with complete occlusion of the prosthetic bypass graft. An open repair of the pseudo-aneurysm with direct aneurysmorrhaphy was performed. In another six months, the patient was again suffered from a recurrent pseudo-aneurysm on the same site. The patient and his family consistently refused its redo open repair, although the pseudo-aneurysm was gradually enlarged. It was also expected that its direct repair would be extremely difficult because of dense adhesion due to the several-times previous surgeries. Consequently, an endovascular repair using a coronary stent covered with GSV was attempted. The postoperative course was uneventful with remarkable reduction of the size of pseudo-aneurysm. Endovascular repair with a vein-covered coronary stent for a recurrent FA is a good treatment option with less-invasiveness.

A 72-year-old man was admitted for the purpose of surgical and endovascular treatment for profunda femoris artery aneurysm (PFAA) associated with abdominal aortic aneurysm (AAA) and common iliac artery aneurysm. The patient had undergone surgical treatment for thoracic aortic aneurysm 1 year ago. This patient had arteriomegaly which is defined as the diffuse ectasia of arteries with or without aneurysmal disease. We simultaneously performed endovascular abdominal aortic repair (EVAR) and profunda femoris artery interposition with expanded polytetrafluoroethylene (ePTFE) ringed graft and could preserve distal blood flow of profunda femoris artery. In the outpatient follow-up, the bypass graft of profunda femoris artery was patent for 4 years after surgery. Although some cases of PFAAs are reported recently, PFAAs are still rare entity in the peripheral artery aneurysms. There is no report of concomitant treatment of endovascular repair for AAA and open surgery for PFAA, we report this case and review some literature of PFAA.

Superficial venous aneurysm (SVA) is a rare but potentially life-threatening disease because it can be a source of pulmonary embolism(PE). We present a case with SVA associated with PE after ultrasonography. An 81-year-old woman underwent surgery for left inguinal swelling that was diagnosed as a hernia, but a hernia was not recognized intraoperatively. The ultrasonography revealed left superficial venous aneurysm, which was followed conservatively. Two years later, she visited again with marked enlargement of the left groin. After repeated manipulation during ultrasonography, cardiopulmonary arrest occurred. Successful resuscitation was performed, and then an emergency CT indicated a PE. A permanent inferior vena cava filter was implanted to prevent a fatal PE. We performed a complete resection of the aneurysm. The patient did not experience a recurrence of thrombus for 1 year after the surgery. To our knowledge, this is the first case of a cardiopulmonary arrest caused by a superficial venous aneurysm. We would like to emphasize the two factors in this case; 1) confusion between a great saphenous vein aneurysm and an inguinal hernia, 2) the risk of fatal complications such as PE due to manipulation during the ultrasonography.

Trauma of the femoral artery caused by a nail gun is rare. We herein report a case of successfully treated traumatic superficial femoral artery (SFA) injury caused bya nail gun.A 56-year-old man drove an 85-mm long nail mistakenly into the right thigh with a nail gun. Vascular echo revealed that his right superficial femoral artery was penetrated by a nail. Emergency operation was performed. We inserted the Fogarty catheter from the right common femoral artery to control bleeding of the femoral artery. We removed the nail. After resection of the injured femoral artery, end-to-end anastomosis was performed. The patient was discharged to home on postoperative day 11. Follow-up CT confirmed patency of the right SFA.

Hepatic artery aneurysms are rare, and recently, endovascular treatment has proven useful for managing abdominal visceral aneurysms. However, there have been few cases of the combination of endovascular treatment with surgical treatment. We herein report a case of endovascular treatment combined with surgery to manage a giant common hepatic artery aneurysm. A 79-year-old woman with anorexia and weight loss was found to have a mass on the posterior wall at the body of the stomach on gastroscopy. Abdominal enhanced computed tomography showed a splanchnic artery aneurysm of 10 cm. We diagnosed this mass as a common hepatic artery aneurysm because celiac angiography showed the presence of a giant aneurysm in the distal celiac artery located at the splenic artery bifurcation, and the giant aneurysm diverged into both the right hepatic artery and the gastroduodenal artery. We performed coil embolization of the splenic artery before laparotomy due to concerns that bleeding might become impossible to control. We made a gastrocolic ligament incision to reach the aneurysm and using sutures successfully closed the inflow pore from the celiac artery in the aneurysm. We then exfoliated the gastroduodenal artery and right hepatic artery of the outflow pore and performed reconstruction, successfully maintaining the blood flow of the liver. At two years after surgery, the patient has shown no liver damage or aneurysmal relapse. This surgery was able to be performed safely by combining the operation with endovascular treatment.

Objectives: This is an annual report indicating the number and early clinical results of annual vascular treatments performed by vascular surgeons in Japan in 2012, as analyzed by database management committee (DBC) members of the JSVS. Materials and Methods: To survey the current status of vascular treatments performed by vascular surgeons in Japan, the DBC members of the JSVS analyzed the vascular treatment data provided by the NCD vascular surgery data analysis team, including the number of treatments and early clinical results such as operative and in-hospital mortality. Results: In total 95,979 vascular treatments were registered by 1,043 institutions in 2012. This database is composed of 7 fields including treatment of aneurysms, chronic arterial occlusive disease, acute arterial occlusive disease, vascular injury, complication of previous vascular reconstruction, venous diseases, and other vascular treatments. The number of vascular treatments in each field was 19,600, 13,141, 4,600, 1,623, 1,973, 30,725, and 24,332, respectively. In the field of aneurysm treatment, 15,745 cases with abdominal aortic aneurysms (AAA) including common iliac aneurysms were registered, and 47.6% were treated by stent graft. Among AAA cases, 1,704 (10.8%) cases were registered as ruptured AAA. The operative mortality of ruptured and non-ruptured AAA was 17.8%, and 0.8%, respectively. Regarding chronic arterial occlusive disease, open repair was performed in 7,859 cases, including 1,173 distal bypasses to the crural or pedal artery, whereas endovascular procedures were performed in 5,282 cases. Venous treatment including 30,088 cases with varicose vein treatments and 395 cases with lower limb deep venous thrombosis were registered. Regarding other vascular operations, 22,654 cases of vascular access operations and 1,390 amputation surgeries were included. The number of lower limb amputations was still increasing and the mortality rate of amputation surgery was also still high; both of these issues require improvement. Conclusions: The number of vascular treatments increased since 2011, and the proportion of endovascular procedures increased in almost all fields of vascular diseases, especially endovascular aneurysm repair (EVAR) for aneurysms and endovenous laser ablation (EVLA) for varicose veins.