In addition to traditional open surgical repair (OSR), endovascular aneurysm repair (EVAR) is currently another strong option to treat RAAA. All vascular surgeons who try to save RAAA patients must be deeply versed in both OSR and EVAR. In this article, current trend of RAAA treatment and abdominal compartment syndrome, which has been most important postoperative complication, are reviewed.

Eversion endarterectomy for femoral artery is reported to be a useful surgical treatment method. Advantages of eversion endarterectomy are unnecessary to use artificial materials, reduce the risk of infection and pseudoaneurysm formation. In addition, postoperative anastomotic stenosis is less likely to occur because the anastomosis is carried out in end to end fashion. After this procedure the groin puncture can be used for arterial access. In this study, we performed eversion endarterectomy in 4 cases, 5 limbs with common femoral arteriosclerotic lesion. All patients suffered ischemic limbs with Rutherford stage 2 before operation. All cases showed clinical improvement, and postoperative ABI was elevated (mean 0.35) after surgery. Complications including early occlusions were not observed. It is necessary to evaluate the presence or absence of intimal dissection by intraoperative angiography and echo due to the possibility of uncertain intimal flap fixation. Median follow-up was 23.8 months (range, 22–25 months).We treated common femoral artery arteriosclerosis by eversion endarterectomy and the postoperative course was uneventful without recurrence.

Visceral artery aneurysms are relatively rare. Most of them are incidentally found asymptomatic. We report a case of transcatheter coil embolization using balloon neck plasty for a wide-necked aneurysm of the common hepatic artery originating from the superior mesenteric artery. A 55-year-old-woman with the hepatitis B carrier was referred to our hospital due to a mass which was identified on abdominal ultrasonography. Computed tomography showed a wide-necked saccular aneurysm measuring 20 mm in diameter on the common hepatic artery which arose from the superior mesenteric artery. Coil embolization using balloon neck plasty was performed to prevent from coil protrusions and preserve the flow of parent artery. Postoperative magnetic resonance angiography showed the good patency of the common hepatic artery and no evidence of aneurysm sac flow.

A 68-year-old man underwent high tibial osteotomy of the left lower leg for knee osteoarthritis at a hospital. He complained of pain and swelling of his left lower leg since the early postoperative period, which aggravated with time. A pulsating mass was recognized at the lateral side of the lower leg. Imaging studies revealed a pseudoaneurysm connected to the left anterior tibial artery. Endovascular repair was performed using two VIABAHNs placed from the left tibioperoneal trunk to below-the-knee popliteal artery, with simultaneous coil-embolization of the proximal left anterior tibial artery. Completion angiography revealed no contrast staining at the pseudoaneurysm.

Endovenous laser ablation (EVLA) is thought to be a safe treatment for vcaricose veins and is currently performed widely. In this report we describe two cases with ventricular arrhythmia during EVLA procedure for bilateral great saphenous varices caused by saphenofemoral junction (SFJ) reflux. Cases were 67 years old and 71 years old females. Under the diagnosis of both lower limb varicose veins (C3) due to SFJ reflux, we planned to perform both sides EVLA. After EVLA for right limb, ventricular arrhythmia appeared when the left great saphenous vein was punctured and a guide wire was inserted. Arrhythmia appeared reproducibly as the guidewire passed SFJ and disappeared when it was removed. Since the chest discomfort was accompanied, EVLA for left limb was suspended in both patients. Postoperatively, no ventricular arrhythmia was seen and no organic heart disease was found in both cases. In addition, EHIT (endovenous heat-induced thrombus) and venous thromboembolism were not confirmed. Intraoperative findings strongly suggested that observed arrhythmia was induced by the EVLA procedure, but at the present time reports of ventricular arrhythmia during EVLA operation were not found as far as possible to search. The causes of arrhythmia ocurrence were discussed.

Endovascular repair of abdominal aortic aneurysm (AAA) have been accepted widely as a less invasive treatment, but with a potentiality of a development of endoleaks, which can be a cause of AAA rupture after the treatment. We describe endovascular repair combined with Upside-down technique to treat common iliac artery aneurysm. A 76-year-old man was referred because of a 40 mm left common iliac artery aneurysm. His weight was 111 kg, more than average fatness, this case was delicate to performed an open surgery. Because of that, we selected endovascular surgery. The diameter of the proximal sealing zone was 16 mm, larger than that of the distal sealing zone, 14 mm. A reversed taper device was needed. We used the Gore Excluder contralateral leg endoprosthesis in a reversed (the Upside-down technique). Further, the coil embolization of the left internal iliac artery was carried out to prevent type 2 endoleaks, before endovascular repair of common iliac artery aneurysm. The aneurysm was totally excluded postoperatively without endoleaks.

A 71-year-old man suffered a blunt aorta injury and unstable pelvic fracture in a car collision. Five days after the incident, follow-up computed tomography (CT) revealed that the diameter of the false lumen of the aorta was enlarging compared to the initial CT, and the patient underwent thoracic endovascular aneurysm repair. The following day, an external fixator was applied to stabilize his pelvic fracture. Postoperatively, the patient was infected with methicillin-resistant Staphylococcus aureus (MRSA), causing arthritis of the right hip and an iliopsoas abscess. His general condition recovered under antibiotic therapy over a five-month period. Six months after the operation, he presented with a fever (39°C) and high levels of inflammatory markers. CT revealed a fluid collection around the stent graft. MRSA was isolated from blood cultures, so we suspected a stent graft infection. Our strategy was to first control the inflammatory reaction before undertaking an operation. After four weeks of antibiotic therapy, we proceeded with complete removal of the stent graft through an antero-lateral partial sternotomy, followed by graft replacement of the ascending aorta, aortic arch, and descending aorta. We further covered the new graft with a pedicled omentum flap to prevent infection. The patient received antibiotic therapy for six weeks and experienced no recurrence of infection during a two-year follow-up.

A 76-year-old man who had undergone percutaneous angioplasty in bilateral iliac arteries 1-month ago referred to our hospital because of sudden low back pain. Computed tomography demonstrated the pseudoaneurysm of left common iliac artery. We performed the removal of stents and reconstruction of bilateral iliac arteries with Y prosthetic graft. His postoperative course was uneventful. A pseudoaneurysm formation after percutaneous endovascular treatment in iliac artery is relatively rare in comparison with other peripheral artery. Moreover, dual antiplatelet therapy might have affected the gradually developing pseudoaneurysm formation.

There are few previous reports of valve-sparing aortic root replacement (David Procedure) in the setting of annuloaortic ectasia with an anomalous right coronary artery origin. A 45 year-old male with an abnormal mediastinal silhouette on screening chest X-ray was found to have a dilated aortic root with valvular regurgitation. Preoperative contrast-enhanced CT revealed that the right coronary artery arose from the left sinus of Valsalva and traversed between the aortic root and pulmonary trunk. Given his age and relatively normal appearing valve leaflets, the above operation was chosen. Regarding the anomaly, the two coronary ostia were in close proximity resulting in a practically single trunk. Excision of the left coronary button was manageable, but the right coronary artery was completely exposed and was implanted directly into the prosthetic graft. Of note, the aortic cross-clamp was removed temporarily to allow the graft to fill with blood allowing selection of the most suitable location for the anastomosis. In planning the coronary reconstruction, the preoperative coronary CT was quite useful.

We report the case of a 49-year-old man who received surgery for a Stanford type A aortic dissection. His height was 176 cm and his weight was 120 kg. He suddenly had strong chest and back pain and was urgently transported to our hospital. We diagnosed Stanford type A acute aortic dissection by enhanced computed tomography (CT) scan and performed an urgent operation. An arterial cannula was placed in the right axillary artery(direct cannulation) and right femoral artery. After extracorporeal circulation had been started, cooling was started. After the rectum temperature was cooled to 27°C, circulatory arrest was induced. We performed total arch replacement with selective cerebral perfusion and open distal anastomosis. After surgery, serum creatine kinase (CK) increased to max 57455 U/L. Serum creatinine (Cr) increased from 1.63 mg/dL (preoperative) to 4.07 mg/dL (peak). Enhanced CT did not show significant ischemic changes in the internal organs or lower limbs. However, the right upper limb was enlarged. We considered that the patient had developed myonephropathic metabolic syndrome from ischemia in the right upper limb, caused by right axillary artery cannulation and perfusion during surgery. We performed blood purification for postoperative oliguria. Acute renal failure improved over the course of time. In the early postoperative stage, the patient could not lift the right upper limb, and had sensation disorder. However, the symptoms improved through rehabilitation and he could return to work.

Open surgeries for 11 limbs of eight patients with popliteal artery aneurysms were performed. The medial approach with the supine position was performed for only one case with obstruction of the femoral artery to the popliteal artery. All others were performed using the posterior approach with the prone position. Grafts were five prosthetic grafts, four great saphenous veins (GSV), and two small saphenous veins (SSV). Preoperatively, patients had mapping of the GSV and SSV on the skin with duplex ultrasonography. GSV or SSV harvesting was done with the prone position in all cases of the posterior approach. Endoscopic GSV harvesting was performed in three cases. A case with bilateral prosthetic grafts soon seceded from the follow-up. One prosthetic graft was occluded 7 days postoperatively in the case of chronic obstruction. Other grafts were patent and the longest observation period was 3376 days. We assured that open surgeries as treatment for popliteal artery aneurysms had excellent results. Among them, we had an impression that if we choose the proper cases, using SSV or endoscopic GSV harvesting with the prone position may be meaningful to the point that the surgery could be completed within the S-shaped incision of the popliteal fossa.

Vascular leiomyosarcomas are rare with poor prognosis. Leiomyosarcomas of veins are extremely rare, and the long-term prognosis is unclear. We report a case of a leiomyosarcoma of the femoral vein in a patient who underwent 5-year follow-up. A 75-year-old woman visited our hospital with right leg edema. Ultrasonography showed a mass in the femoral vein. Contrast-enhanced computed tomography (CT) showed a mass measuring 2×3 cm with heterogeneous enhancement of the femoral vein. We resected the tumor and the femoral vein, and she was diagnosed with primary leiomyosarcoma of the femoral vein. CT performed 3 years and 10 months postoperatively showed a low-density area in the thyroid gland. Thyroidectomy was performed, and the tumor was diagnosed as leiomyosarcoma with vertebral, lung, pulmonary vein, and cutaneous metastasis. No local recurrence was observed. However, she died of multiple organ failure 5 years postoperatively.

The symptoms of persistent sciatic artery aneurysm are sciatic nerve compression and lower limb ischemia, but no standard operation method has been established. A 77-year-old female was admitted to our hospital with suspected right lower limb ischemia because she has coldness and pain in her right leg. Pulsatile masses in her right hip and thigh were observed. There was no intermittent claudication, and the ankle brachial index (ABI) was normal. Preoperative contrast enhanced CT angiography revealed a 32 mm diameter persistent sciatic aneurysm with thrombus, and a thoromboembolism in the peripheral artery. The aneurysm terminated at the upper thigh, and blood flow extended to the peripheral artery. She was diagnosed with acute right limb ischemia caused by an embolism from a thrombus in the complete type sciatic artery aneurysm. The sciatic artery aneurysm was ligated at the right pelvis and the upper thigh, and revascularization was performed with a bypass grafting between the common iliac artery and the distal sciatic artery. Postoperative CT indicates that the sciatic artery aneurysm was completely thrombosed, and the bypass graft was patent. The method mentioned above is useful for the treatment of complete type sciatic artery aneurysm, which requires a procedure for the aneurysm, as well as the revascularization.

Periaortitis is a rare condition whose etiology, aneurysm formation mechanism, and clinical features remain undefined. Here, we report the case of a 71-year-old Japanese male with a 5-year history of suspected and untreated primary abdominal periaortitis that was complicated by inflammatory abdominal aneurysm rupture. The patient underwent an endovascular aneurysm repair (EVAR) procedure at 14 days after initial admission, because consent for surgery was not obtained at initial admission. The patient remains well and without any complications at the recent follow-up visit at 6 months after the surgery; however, long-term follow-up is required to validate the efficacy of EVAR for inflammatory abdominal aortic aneurysm.