Objective: Coil embolization of aortic side branches has been additionally performed to prevent type II endoleak during EVAR in our institute. In this study, we evaluated the predictive factors of the possibility for coil embolization of the inferior mesenteric artery (IMA) and lumbar artery (LA) during EVAR. Methods: Seventy-four EVAR patients during June 2015 and April 2019 were included in the study. The coil embolization procedural time for one vessel is limited to 10 minutes. Aortic side branches were selected with 4Fr Shepherd hook type catheter (Medikit, Tokyo, Japan) and were embolized with Interlock (Boston Scientific, MA, USA) via microcatheter. As predictive factors, internal diameter of aortic side branches and the aortic diameter perpendicular to the origin of LA (aortic diameter) were evaluated. Results: Coil embolization was tried for 52 patent IMAs and all IMAs except two IMAs with ostial stenosis were successfully coil embolized (96.2%). Totally 190 LAs were patent and coil embolization was tried for 144 LAs. Among 144 LAs, 106 LAs (73.6%) were successfully coil embolized and the diameter was significantly longer (2.30±0.51 mm vs 2.04±0.41 mm, p=0.007) and aortic dimeter was significantly shorter (30.0±8.1 mm vs 40.5±11.6 mm, p<0.001) in successfully embolized LAs. Cut off value of successful LA coil embolization was 2.06 mm for internal diameter and 36.1 mm for aortic diameter by receiver operating characteristic curve analysis. Successful coil embolization rate for LAs with internal diameter longer than 2.0 mm and aortic diameter less than 36.2 mm was 90% (72 among 80 LAs). Conclusion: Coil embolization during EVAR for IMA was highly successful, if there was no calcified ostial stenosis. LA embolization was feasible especially for LAs with internal diameter ≥2.0 mm and aortic diameter ≤36.1 mm. This information would be useful to select the target vessel for aortic side branches coil embolization during EVAR.

A 93-year-old woman visited our hospital for the treatment of a juxtarenal abdominal aortic aneurysm (JAAA), which was 54 mm in diameter. The angle of the neck and axis of the JAAA was 100 degrees. Because of the patient’s age, it would be risky to perform open surgery; however, standard endovascular aneurysm repair (EVAR) might result in increased high risk for type Ia endoleak or obstruction of the renal artery. Thus, a wait-and-see approach was adopted. However, after half a year, the JAAA was already 59 mm in diameter. To reduce the risk of a ruptured aneurysm, we performed EVAR with the snorkel technique using a covered stent. Afterward, the patient achieved good progress without complications, such as renal dysfunction. After 2 years, the JAAA has shrunk to 36 mm in diameter. Therefore, EVAR with the snorkel technique is effective for the treatment of JAAA.

Different approaches and surgical positions are available for approaching the popliteal artery depending on lesion location. A posterior approach in the prone position is most frequently used for treating cystic adventitial disease (CAD) of the popliteal artery. Herein, we report a case that was effectively managed using the modified Sims’ position as a surgical position for a wide range of CADs of the popliteal artery, extending from the distal part of the superficial femoral artery to the total length of the popliteal artery. The patient was a 64-year-old woman who complained of intermittent claudication 6 months ago. She was diagnosed with arteriosclerosis obliterans for which she underwent endovascular treatment. At that time, she underwent an intravascular ultrasonography (IVUS) which detected multiple cystic lesions around the popliteal artery. Thus, endovascular treatment was discontinued and she was subsequently discharged. During an outpatient follow-up, she underwent contrast-enhanced computed tomography and magnetic resonance imaging, which revealed that the polycystic lesion compressed the right popliteal artery and caused complete occlusion of the lumen. Therefore, she was diagnosed with CAD of the popliteal artery. The proximal portion of the cystic lesion was extended to the superficial femoral artery, which was thought to be inaccessible using the posterior approach alone. The use of both the anterior and posterior approaches using the modified Sims’ position allowed extensive arteriectomy and revascularization without changing intraoperative posture. In cases of extensive lesion developing beyond the popliteal artery, the modified Sims’ position may be useful.

Subclavian artery aneurysms are rare, and the therapeutic strategy used in patients varies across hospitals depending on surgeons’ preferences. Vascular graft replacement and stent-grafting are among the various therapeutic options available in such cases. However, no gold-standard technique is established to treat patients with this uncommon clinical presentation. We present the case of 59-year-old woman in whom chest radiography performed during a medical check-up led to a high index of clinical suspicion for mediastinal tumor. Therefore, she underwent contrast enhanced computed tomography, which revealed a left subclavian artery aneurysm. She was subsequently referred to the Department of Cardiovascular Surgery for surgical treatment. Following through review and assessment, we concluded that she was relatively young to undergo stent-grafting, and assessment of anatomical suitability for repair revealed a steep aortic arch. Therefore, we decided to perform total arch replacement with median sternotomy. The patient’s postoperative course was uneventful. We report a case of subclavian artery aneurysm in a patient who showed a favorable outcome following total aortic arch replacement. Therefore, we propose that appropriate surgical alternatives including total arch replacement should be considered in patients presenting with this condition.

EXOSEAL, a vascular closure device, is a passive approximator that deploys a synthetic, bioabsorbable polyglycolic acid (PGA) plug to the extravascular space just adjacent to the arteriotomy site. We experienced a case of embolectomy for acute right popliteal artery occlusion caused by the PGA plug. An 84-year-old female had percutaneous endovasucular treatment for left superficial femoral arterial stenosis through right femoral artery. After the treatment, EXOSEAL was used for the puncture site in right groin. Soon after she went back to the ward, she complained discomfort in her right limb. As the time went by, the complaint changed to severe pain. After the examination, we made a daiagnosis of acute right popliteal arterial occlusion. We emergently exposed her right common femoral artery, and succeeded embolectomy using Fogarty catheter. She comes to our hospital regularly without sequelae 1 year after the treatment. The event found in this case was rare, but a specific complication after the use of EXOSEAL. Understanding of structure as well as mechanism of the vascular device including EXOSEAL is crucial for those involved in endovascular treatment in unexpected situations.

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 2017, 1137 CLI limbs (male 760 limbs: 67%) were registered by 84 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.