In 2006, commercially produced endovascular aneurysm repair (EVAR) devices were approved by the Japanese Ministry of Health, Labour and Welfare, and their cost began to be covered by Japanese medical insurance. Meanwhile, the number of juxtarenal abdominal aortic aneurysms (AAA) to need the suprarenal clamp are increasing and the number of infra-renal AAAs are decreasing for open repair. In this era when EVAR has been growing rapidly for 11 years, it is a good opportunity to learn the surgical repair of AAA. I review the basic and advanced anatomy and physiology concepts which are needed for abdominal aortic repair, which are the proximal site (exposure of the proximal site, variation of renal arteries, variation of inferior vena cava and left renal vein, arcade of visceral branches of abdominal aorta, and coeliac plexus) and distal site (iliac artery, superior hypogastric plexus, ureter, inferior mesenteric artery, and lumbar arteries) separately.

Objectives: We aim to investigate the results of stenting for central venous occlusions and stenoses in the hemodialysis patients. Methods: Twenty-nine cases treated with endovascular recanalization with deployment of bare metal stent (BMS) for central venous occlusions (24 cases) and recurrent stenoses (5 cases) between 2014 and 2018 were retrospectively analyzed. Results of these procedures including success rate, operative time, estimated blood loss, morbidity, primary patency, assisted primary patency and freedom from target-lesion revascularization (TLR) were evaluated. Results: Nine lesions were in brachiocephalic vein (Occlusion/Stenosis: 8/1) and 20 lesions were in subclavian vein (Occlusion/Stenosis: 16/4). Procedural success was 94% (29/31 cases) and operation time/estimated blood loss was 68±39 min/28±54 g. Symptom were relieved or disappeared in all successful cases. Morbidity (extravasation of contrast medium) was 3% (1/29). During the period of observation, 1 stent fracture with occlusion and 1 stent migration to periphery were recognized. 1-year primary patency, freedom from TLR, and assisted primary patency were 40% (median patent time: 256 days), 67% (median patent time: 524 days), and 77%, respectively. Conclusion: Stenting for central venous occlusions and stenoses in the hemodialysis patients is safe and durable treatment option. However, considering its off-label use and potential hazard including vessel rupture, stent migraion, and stent fracture, the indication for BMS deployment should be conservative, and interventionist should be well acquainted with prevention and measures to these complications.

Objective: We aimed to study the clinical features and outcomes of patients with suspected primary upper extremity deep vein thrombosis (UE-DVT). Methods: We retrospectively reviewed cases of 10 consecutive patients who were suspected to have primary UE-DVT. Results: Two patients had a history of effort-related events. These two patients showed a thrombosis in the subclavian vein, and one of them had a pulmonary embolization. Neoplastic diseases were detected after the development of UE-DVT in 3 of the 8 patients who did not have any effort-related history. The neoplastic diseases were gastric cancer in 2 patients and hyper eosinophilic syndrome in 1. The three patients who had neoplastic diseases showed a high level of D-dimer at the first visit. The two patients with gastric cancer died within 7 months after developing UE-DVT. Conclusion: When primary UE-DVT is suspected, careful screening for malignancies or neoplastic diseases is mandatory, even if idiopathic thrombosis is most likely.

Persistent sciatic artery is a very uncommon congenital malformation. Its incidence is estimated to be 0.01–0.06%. This case report described a patient who underwent operation for acute arterial occlusion of persistent sciatic artery. The patient was a 73-year-old woman presenting with a right lower limb ischemia. Preoperative CT scan showed persistent sciatic artery with aneurysm and thrombosis. Surgery was performed in a supine position. The internal iliac artery was exposed retroperitoneally, and the popliteal artery was exposed through a medial approach. To restore the blood flow to the right lower extremity, an obturator foramen bypass was performed from the internal iliac artery to the popliteal artery using a artificial graft. Both of the proximal and distal porsion of the persistent sciatic artery were ligated. Postoperatively, the graft was patent and the aneurysm was occluded.

A 72-year-old female admitted to our emergency unit complaining severe lumbar and abdominal pain. She underwent a living renal transplant form her husband 13 years prior to admission. Computed tomography demonstrated ruptured right common iliac aneurysm (35×52 mm in diameter) and extensive retroperitoneal hematoma. Emergent surgery was performed and ruptured common iliac aneurysm was replaced by 8 mm vascular prosthesis. After 37 days of maintenance hemodialysis, she recovered from renal failure and discharged from hospital with good health.

We encountered an extremely rare case of splenic artery aneurysm with vascular branching abnormality in which the splenic artery branched from the superior mesenteric artery. The aneurysm was resected and a revascularization procedure was subsequently performed. This case concerned a 66-year-old woman in whom a splenic artery aneurysm with a maximum transverse diameter of 32 mm was found during abdominal contrast-enhanced computed tomography (CT) performed as part of a comprehensive investigation into potential causes of decreased appetite. A saccular aneurysm with no neck had developed at the splenic artery immediately after its bifurcation from the superior mesenteric artery. Endovascular treatment while preserving intestinal blood flow was therefore determined to be difficult. Aneurysm resection and a revascularization procedure (common hepatic artery-splenic artery anastomosis) were performed without any complications arising. Only 42 cases of a splenic artery aneurysm developing at the splenomesenteric trunk have been reported. Of these, 23 received surgical treatment, 14 received endovascular treatment, and two received both surgical and endovascular treatment. No complications developed in any of the cases. Three cases were only diagnosed and were left untreated. Here, we report the characteristics and treatment approaches for the 43 reported cases (including the present case) of splenic artery aneurysm with this type of vascular branching abnormality.

Pancreaticoduodenal artery is a branch of superior mesenteric artery (SMA). Although pancreaticoduodenal artery aneurysm (PDAA) is a rare disease, treatment is required because of the risk of rupture. A 46-year-old man has visited other hospital for type1 diabetes. He had a PDAA with a maximum minor-axis diameter of 20 mm pointed out by abdominal contract-enhanced computed tomography (CECT) and was admitted to our hospital. Preoperative CECT and angiography demonstrated severe stenosis of the celiac artery (CA) and the common hepatic artery (CHA) and the splenic artery were supplied through the PDA from SMA by collateral circulations. An open surgical repair was selected because of anatomical limitations of the aneurysm. The CA had difficulty of repair since the artery was atrophied, and the clamp test of PDA indicated beat attenuation of the CHA, resulting that we performed an abdominal aorta-CHA bypass followed by aneurysmectomy. PDAA is often caused by the development of collateral circulation route with CA stenosis. The treatment strategy of PDAA depends on several anatomical factors including relationship between aneurysm and SMA trunk, suitability of endovascular treatment in addition to involvement of CA stenosis.

The patient was a 48-year-old man taken who presented with hemorrhagic shock and a self-inflicted abdominal injury. Injuries to the intestines, pancreas head, and inferior vena cava (IVC) were identified on computed tomography (CT). We planned to establish a hemostasis of the IVC before performing a pancreaticoduodenectomy and intestinal repair via digestive surgery. We selected stent graft treatment without cardiopulmonary bypass and heparin because his vital signs were unstable owing to hemorrhagic shock. Digestive surgery was performed subsequently. Since only one stent graft was available and considering the IVC diameter as noted on the CT scan, we chose Zenith TX2 extension TBE-24-80-PF (Cook Medical, Japan). We deployed the stent, after we identified the injured part of the IVC using intra-operative angiography. The operation concluded after confirming via angiography that no leakage persisted. The patient was transferred to another hospital for rehabilitation without any infection.

A 76-year-old female suffered from Stanford type B aortic dissection 20 years ago. During the follow-up, the false lumen gradually expanded, and its maximum diameter became to be 55 mm at the level of abdominal aorta. Contrast enhanced CT showed the entry at distal descending aorta and reentry at bilateral distal common iliac arteries. The visceral branches arose from the true lumen, and the artery of Adamkiewicz was not identified. Endovascular treatment was indicated. Entry closure was performed with thoracic stent graft, and then closure of right-sided reentry was done with a stent graft concomitantly with coil embolization of the right internal iliac artery. Thereafter, the false lumen of the left common iliac artery was embolized via left-sided reentry using coilsand n-butyl-2-cyanoacrylate glue, preserving the left internal iliac artery. Intravascular ultrasound imaging was used to inspect thrombotic formation of the false lumen. She went an uneventful postoperative course and discharged lively 12 days after operation. Contrast enhanced CT showed complete thrombosis of the false lumen One year later, aortic diameter at the abdominal aorta level reduced to 22 mm.

A 75 years-old man presented with the edema and cyanosis of the right lower extremity. A lower limb ultrasound and Enhanced CT revealed the 31 mm right popliteal artery aneurysm with thrombus which caused blue tow syndrome. Endovascular repair with insertion of a stent graft Gore VIABAHN was performed. Angiography was performed with and without the knee bent, and an appropriate landing zone was confirmed to select the device size. No complication was observed even after operation, and the 9-month follow-up Enhanced CT showed the aneurysm well-thrombosed and no endoleak.

A 79-year-old man with a 2-week history of fever and lower back pain was referred to our hospital for a left common iliac artery aneurysm with rapid enlargement. On admission, inflammatory markers were elevated, and computed tomography revealed a giant lobulated aneurysm with a contained rupture and destructive changes to the lumbar vertebral body. On the basis of the clinical and imaging findings, a diagnosis of mycotic aneurysm with pyogenic vertebral spondylitis was made. We resected the aneurysm and adjacent infectious tissue, including a vertebral lesion, and performed a femoro-femoral artery bypass with an artificial graft and omentopexy. The aneurysmal wall culture yielded Klebsiella pneumoniae, although the blood culture was negative. The postoperative course was uneventful, though the patient underwent anterior and posterior lumbar interbody fusion because of instability of the vertebral bodies. Mycotic aneurysm with pyogenic vertebral spondylitis is rare, and, in the majority of cases, vertebral involvement is managed conservatively. However, orthopedic surgical intervention might be an important treatment in cases of osseous instability.

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 endovascular treatment. The basic and early prognostic data of CLI, registered during the 4 years from 2013 to 2016, have been reported as annual reports. In this paper, for the purpose of clarifying the whole picture of clinical practice of CLI in Japan, we have compiled these data over the past 4 years.