Treatment of thoracoabdominal aortic aneurysm (TAAA) remains a challenging pathology. Technologies and innovations of endovascular treatment, in particular the evolution of fenestrated and branched stentgraft for complex aortic pathologies such as TAAA have provided excellent short-term results. However, the mid-term and long-term results of endovascular treatment for TAAA including endoleaks and branch patency are still unclear. This article provides an overview of available devices and results of endovascular treatment for TAAAs.

While surgical treatment for abdominal aortic aneurysm (AAA) is a standard operation, prevention of complication is important. Intestinal ischemia of the sigmoid colon and/or rectum after AAA surgery is severe and has a high mortality rate although occurrence frequency is low. The most important thing to prevent is the preoperative and intraoperative evaluation of the left hemicolon and rectal circulation. Measurement of inferior mesenteric artery stump pressure is also useful. From the viewpoint of prevention of buttock claudication, it is desirable that internal iliac artery (IIA) blood flow is preserved, but aggressive IIA reconstruction adaptation is considered to be low. For erectile function, it is important that the antegrade blood flow from the IIA to the internal pudendal artery on at least one side is preserved or reconstructed. To prevent retrograde ejaculation, it is important to preserve the superior hypogastric plexus and one side of the lumbar splanchnic nerve, and the hypogastric nerve. Understanding and mastering local anatomy and pathophysiology is important in preventing complications, and we must also remember that we always keep watchful surgical operations in mind in order to prevent tissue damage.

The open surgical repair is still a first-line treatment for the abdominal aortic aneurysm in the endovascular era. We should have various knowledge of the procedure including the transperitoneal and retroperitoneal approach to improve the surgical skill. Herein, the procedure steps, knack and pitfall, and the review of the outcomes were described.

Objectives: The optimal surgical management for primary infected abdominal aortic aneurysm (IAAA) is controversial. Here, we report the early and long-term results of surgical treatments with the resection of the IAAA and in situ graft reconstruction with pedicled omental coverage that was performed at out hospital. Methods: Between 2010 and 2017, 27 consecutive patients (26 males, 1 females, median age 69 years) with IAAA were surgically treated with the resection of the IAAA, in situ graft reconstruction and covered with a pedicled omental flap. Perioperative and long-term outcomes were reviewed retrospectively by medical records. Results: Clinical manifestations, including pyrexia, fever and abdominal pain, were observed during the treatment of the patients. Aneurysm excision and in situ graft reconstruction with omental coverage were performed for all cases. In 13 cases (48.1%), tissue culture was positive. The antibiotic was administered intravenously for 9 to 47 days (median 18 days) postoperatively, and after confirming the reduction of the inflammatory response, it was administered as oral agents for 24 to 443 days (median 169 days).There was no perioperative death or re-infection. Perioperative complications were found in 8 cases (29.6%) of minor spinal cord infarction, ileus, chylous ascites, and cholangitis due to choledochlithiasis. During the observation period of median 1147 days, there was no recurrence of infection, graft infection, or disease-related death. There were six deaths due to other diseases. And the overall survival rate was 76.2%. Conclusion: According to our study, the long-term outcomes of surgical treatment with in situ graft reconstruction for IAAA were considered satisfactory.

Objective: This study aimed to evaluate the clinical course of primary management without anticoagulants or antiplatelet agents of isolated superior mesenteric artery dissection (ISMAD). Methods: Between January 2015 and May 2018, all ISMAD patients were enrolled consecutively. The diagnosis was established using enhanced computed tomography (CT). Anticoagulants and antiplatelet agents were not administered, and fastening with infusion. Results: Nine men and a woman, with a mean age of 55.7±7.9 years (range, 46–72 years), presented with sudden onset of abdominal pain. One male patient refused hospitalization. The other nine patients were hospitalized. The abdominal pain was relieved 2.3±2.1 days later (range, 1–8 days). Early follow-up enhanced CT revealed the start of the remodeling of ISMAD in six of seven cases, and neither new dissection nor aneurysm was found in all seven cases. None of the patients died and required surgical treatment in the short term (1.88±0.96 [range, 0.2–3.6 years]). Conclusion: Primary management without anticoagulants or antiplatelet agents is generally useful for ISMAD. However, an ischemic abdominal and aneurysmal sign must be observed attentively.

When treating a thoracic arch aneurysm (TAA) with the need to preserve the left subclavian artery (LSA), there are occasions where the chimney technique is combined with a Zone 2 thoracic endovascular aortic repair (TEVAR). In an orthodox chimney technique, the graft is deployed towards the proximal end, which results in a shorter overlap with the main stent graft, hence leaving a risk of gutter leakage. We hereby report a case treated with the periscope endograft (PG) technique, which could compensate for this disadvantage by deploying the chimney graft towards the peripheral end. The case is a 76-year-old male, with a TAA right after the LSA. The aneurysm was saccular towards the left anterior chest wall with two blisters, and its maximum diameter was 65 mm. The patient requested a minimally invasive treatment, so zone 2 TEVAR performed with a PG technique was planned. The postoperative course was uneventful, and the postoperative CT showed no endoleak. Although the long term prognosis has not been documented, this method could be minimally invasive and useful, especially in case of emergency. There are only a few reports concerning the PG technique to maintain perfusion to the LSA, and reports concerning the PG technique using heparin-bonded covered stent (VIABAHN) could not be found.

We report the treatment of two cases of iliac compression syndrome (ICS) with severe complications, including hemorrhage, swelling, and a refractory skin ulcer. One patient was a 76-year-old woman with severe left leg swelling and a hemorrhage in her left thigh, due to ICS, and femoral and iliac arteriovenous fistulas. Transcatheter arterial embolization for femoral arteriovenous fistula and stent implantation for left iliac vein obstruction both failed, after which we performed a femoral vein-to-vein cross bypass with PROPATEN. The other patient was 82-year-old woman with severe left leg swelling and refractory skin ulcer due to ICS and iliac arteriovenous fistula. We performed an iliac vein-to-vein cross bypass with PROPATEN. PROPATEN is a ringed, expanded polytetrafluoroethylene(ePTFE) graft that anchors heparin to its luminal surface. Both patients showed improvement in their symptoms and graft patency was maintained with preserving the arteriovenous fistula. We suggest that the vein-to-vein cross bypass with GORE PROPATEN is an effective treatment for ICS.

We report a case of delayed diagnosis of Buerger disease with bilateral intractable foot ulcer accompanied by spina bifida occulta. The patient was 33-year-old man who was diagnosed as spina bifida occulta from at his birth. At the aged 30, he had foot ulcer which might be caused by spina bifida occulta. His ulcer was cured by the treatment with debrisis of wound and the surgical treatment for the tethered cord syndrome. After the 2 years, intractable foot ulcer recurred, and he was referred to our hospital for the further examination and treatment. He was diagnosed as Buerger disease due to the findings of characteristic lower extremity angiography and physical examination. We treated the patient by cessation of nicotine and intravenous iloprost and usage of ArtAssist which enhances the angiogenesis.

A 57-year-old man with Behçet’s disease was admitted to our hospital for lumber pain. Behçet’s disease with a saccular aneurysm of the abdominal aorta was diagnosed. Elective straight graft replacement was performed. Seven days after the operation, the patient’s consciousness suddenly deteriorated. An emergent brain MRI revealed high intensity signal in the brain stem, and that surrounding brain tissue was compressed by edema associated with the lesion. Acute neurological Behçet’s disease was diagnosed by a rheumatologist. After high-dose methyl prednisolone and immune suppressive therapy, the patient could be discharged without neurological deficit, and remained asymptomatic for 2-years thereafter.

When an artificial vascular graft is exposed, it is difficult to decide whether to revascularize a new route or to close the wound, preserving the exposed graft. We report a case of exposed prosthetic graft at the median chest and its preservation using a pectoralis major muscle flap. A 69-year-old woman underwent ascending and aortic arch graft replacement for acute ascending aortic dissection. Two months later, she underwent thoracic endovascular aneurysm repair (TEVAR) for residual aortic dissection in the aortic arch and descending thoracic aorta in order to prevent the enlargement of the false lumen. She also received embolization of the left subclavian artery and subclavian-subclavian bypass using an expanded polytetrafluoroethylene graft on the same day. A few days after the last operation, skin necrosis caused wound dehiscence, which resulted in exposure of the prosthetic graft at the median chest. Wound cultures were negative during the perioperative period. Therefore, we tried to retain the exposed graft. We decided to perform transposition of the pectoralis major muscle flap because it has rich blood flow. We rotated the flap toward the site of the defect and covered the exposed graft. During 6 months of follow-up, no infection or exposure of the graft was observed. This case indicates that using the pedicle of the pectoralis major muscle flap is an effective surgical option, under certain conditions, to protect or safeguard the exposed prosthetic graft in front of the chest.

Venous aneurysms are a focal dilatation of the veins and are distinct from varicose veins. They may occur in any part of the vascular system, but their etiology remains unknown. We report a rare case of a venous aneurysm in the upper extremity. An 80-year-old woman presented to our hospital with a non-tender focal mass in her right elbow. She had first noticed this focal mass 10 years ago. Blood samples had been repeatedly drawn from her right elbow during the course of treatment for multiple myeloma. A computed tomography scan showed a 55×33×22 mm aneurysm of the cephalic vein. Ultrasonography did not detect an arteriovenous fistula. We surgically resected the venous aneurysm under general anesthesia. Histological examination revealed that the aneurysm consisted of a partial thin wall with a thickened tunica intima and exhibited a marked reduction in the number of smooth muscle cells in the tunica media. Part of the sample showed proliferation of capillary vessels in the tunica media and tunica adventitia. We strongly suspected that frequent venous puncture was the underlying etiology of the aneurysm in this case. This is the first report of a venous aneurysm with histological findings resembling that of a hemangioma.

Free-floating thrombus of the ascending aorta is a rarely encountered entity. We report a case of a free-floating thrombus in the ascending aorta in a patient undergoing chemotherapy for an underlying malignancy. A 61-year-old man who underwent surgery for colorectal cancer two years earlier and undergoing adjuvant chemotherapy presented with a sudden onset of vertigo and impaired muscle coordination He was diagnosed with an acute cerebellar infarction. A mass in the ascending aorta was confirmed via contrast-enhanced computed-tomography. As the mass presented with a risk for future complications, an emergency ascending aorta replacement was performed. The mass was loosely attached to the penetrating atherosclerotic ulcer in the ascending aorta. Pathology ruled the mass to be a mixed thrombus that formed in a rapid manner. Thromboembolism is a well-documented pathological feature associated with cancer patients undergoing chemotherapy; however, the present case highlights the importance of exploring aorta other than the heart chambers when confronted with thrombogenic pathologies occurring in such patients.

The patient was a 30-year-old male undergoing treatment for neurofibromatosis type 1 under the department of orthopedic surgery. A retroperitoneal neoplasm was discovered by computed tomography (CT). A follow-up CT demonstrated progressive growth of the tumor. In view of abnormal uptake in the tumor via positron emission tomography CT, malignant transformation of the retroperitoneal fibroma was suspected and excision of the tumor was planned. As the tumor was located close to the abdominal aorta, there was concern for a potential risk for aortic injury during the operation. During tumor excision, the aortic wall was carefully dissected. However, pin-hole injury to the aortic wall occurred. Primary suture of the aortic wall caused rupture of the wall resulting in massive bleeding. Endovascular repair of the injured aorta was performed using a Powerlink device. Although the aorta was successfully repaired and the tumor was completely resected, he lost a lot of blood. In patients with neurofibromatosis type 1, suturing the aortic wall may cause massive bleeding. Endovascular repair using stent-grafts is a useful alternative in such situations. Care should be taken when performing invasive procedures involving vascular tissues.

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 2016, 1,092 CLI limbs (male 755 limbs: 70%) were registered by 91 facilities. ASO has accounted for 98% of the pathogenesis of these limbs. In this manuscript, the background data, the early prognosis, and 6-months’ prognosis of the registered limbs are reported.