The first commercially available endograft for the treatment of an abdominal aortic aneurysm (AAA) was approved in Japan in 2006. Recently, endovascular aneurysm repair (EVAR) has been developed as a standard procedure for AAA. However, several trials have reported that there was no advantage of EVAR in long-term outcomes compared with open repair. It is necessary to understand device characteristics and to perform accurate procedure, in order to stabilize long term results. In this paper, I describe the tips and pitfalls for EVAR.

Peripheral arterial disease (PAD) continues to grow and contributes to increase in medical costs required for PAD treatment accordingly. PAD represents a broad spectrum of disease from asymptomatic through severe limb ischemia, and their treatment should be multidisciplinary. However, the diagnostic ability of each physician in charge of PAD care and the treatment chosen are not uniform. In 2015, the Society for Vascular Surgery (SVS) Lower Extremity Practice Guidelines committee made guidelines to support clinical care in the treatment of asymptomatic PAD and intermittent claudication. This guideline states that invasive treatments for patients with asymptomatic PAD should not be performed with some exceptions, that invasive treatments for intermittent claudication should provide predictable functional improvements with reasonable durability for at least 2 years, and that common femoral artery disease should be treated by surgical therapy (endarterectomy).

Objective: The perfusion index (PI) is a physiological marker for evaluating the peripheral circulation. We explored the possibility of using PI as a screening tool for development of critical limb ischemia in peripheral artery disease (PAD). Method: We measured the PI in 79 limbs of 70 PAD patients. Data were analyzed to find a correlation between the PI and PAD severity. Result: The PI tended to be lower as PAD became severer. Especially, there were significant differences between the Fontaine 1 and Fontaine 4 groups in average PI and minimum PI, and between Fontaine 1 and two other groups (Fontaine 2 and Fontaine 4 groups) in maximum PI. A mild correlation was found between PI and the ankle brachial index. These data were used to calculate an average PI of 0.27 as a cut-off value for critical limb ischemia (CLI). In 65 asymptomatic PAD patients and claudication, significantly more patients with a PI value greater than the cut-off value developed CLI than those with a PI lower than the cut-off. Conclusion: The PI can be a useful tool for evaluating the development of CLI in mild PAD patients, and patients tended not to progress to CLI when their average PI was higher than 0.27.

With recent progress and advancements in devices and techniques, endovascular therapy is now being frequently used for high-risk patients. We experienced case of a bilateral renal artery aneurysm in a 55-year-old male patient undergoing hemodialysis for renal failure. Computed tomography (CT) revealed left and right renal artery aneurysms with dilatations of 51 and 13 mm in diameter, respectively. Because of several comorbidities, such as renal failure and systemic lupus erythematosus (SLE), renal artery embolization with stent graft therapy (Pincer Exclusion Technique) was chosen. The postoperative CT showed no endoleaks, and the patient was discharged 10 days after the operation. Overall, this case suggests that the total occlusion of bilateral renal artery is feasible and effective when the patient is under hemodialysis for renal dysfunction. Furthermore, this is the first reported case for successful treatment of a bilateral renal artery occlusion in a patient undergoing hemodialysis for renal failure.

We report our experience with performing interposition surgery using the great saphenous vein for a popliteal venous aneurysm in a patient with pulmonary embolism. A 75-year-old woman with a complaint of chest tightness and dyspnea was admitted to our hospital. Contrast-enhanced computed tomography (CT) revealed a pulmonary embolism and right popliteal venous aneurysm. After treatment with anticoagulation therapy, diuretics, and inferior vena cava filter placement in our department of cardiology, we performed surgery for the popliteal venous aneurysm. During surgery, the great saphenous vein was collected from the left thigh in the supine position and then the patient was placed in the prone position. The venous aneurysm was 3 cm in diameter and 4 cm long, and was resected and replaced with the great saphenous vein. The postoperative course was good, and the patient returned to the hospital 18 days after the surgery for follow-up examination. In the contrast-enhanced CT evaluation, the great saphenous vein graft was patent and the anastomosis was good.

We report endovascular stentgrafting to treat an inferior pancreaticoduodenal artery aneurysm with significant stenosis of the celiac artery. A 60-year-old man was diagnosed with an inferior pancreaticoduodenal artery aneurysm on abdominal computed tomography performed at another hospital and was referred to our department for further evaluation. An aneurysm (maximal diameter 20 mm) was identified at the origin of the inferior pancreaticoduodenal artery. The celiac artery was significantly stenosed secondary to compression of the median arcuate ligament. The operation was performed via a bilateral brachial artery approach, and a Viabahn VBX stent-graft was placed in the superior mesenteric artery to seal the origin of the inferior pancreaticoduodenal artery, and a microcatheter was inserted from the celiac artery. Interlocking detachable coils were used to isolate and pack the central aneurysm. Finally, a Viabahn VBX stent-graft was placed at the origin of the celiac artery, which was significantly stenosed. Magnetic resonance imaging performed 6 months postoperatively revealed that the stent-graft was patent, there was no blood flow to the aneurysm, and no increase in the diameter of the aneurysm.

There have been only a few survivors who underwent repair surgery for aortoesophageal fistula (AEF) because preoperative acute circulatory failure and postoperative infection carry a poor risk. Especially, AEF due to rupture of dissecting aortic aneurysm is really rare. Herein, we report on a patient who was successfully treated with surgery for AEF due to chronic dissecting aortic aneurysm. A 60 year-old-woman with a history of type B aortic dissection at the age of 51 was admitted to our hospital with hematemesis and melena. A contrast computed tomography (CT) showed a dissecting aortic aneurysm 68 mm in diameter and esophageal compression. She was diagnosed with AEF because contrast medium was stored in the esophagus and stomach. We performed replacement of the descending thoracic aorta with a prothetic graft, omentopexy, and esophagectomy emergently. Esophageal reconstruction as secondary procedure was performed 63 days later. Thereafter, her postoperative course was uneventful and she was discharged on the 23rd day after the secondary procedure.

A 58-year-old man, who had undergone axillo-bifemoral bypass at another hospital 10 years previously for atypical coarctation, has repeated hospitalization for hypertensive cardiac insufficiency since last year. He was referred to our university hospital for surgical revascularization of the renal arteries (RAs) to improve the prognosis of cardiac insufficiency. In surgery, descending aorta-abdominal aorta bypass with revascularization of bilateral RAs was performed via left thoracotomy and retroperitoneal approach. He had an uncomplicated postoperative course. The serum renin activity, which was 10.6 ng/mL/h before surgery, markedly decreased to 1.1 ng/mL/h after surgery and the left ventricular ejection fraction was improved from 28% to 40% a month after surgery. In patients with atypical coarctation and visceral malperfusion, hypertensive heart failure may worsen after axillo-bifemoral bypass, and revascularization of the RAs was effective to improve heart failure.

86 year-old male was referred to our institution complaining of edema of face and right upper extremity. A cardiac pacemaker was implanted due to complete atrioventricular block 4 years ago, and arteriovenous shunt for blood dialysis was created on the right forearm 2 years ago. Venography and enhanced computed tomography showed a thrombotic occlusion at the left innominate vein and distal of superior vena cava, which led to a diagnosis of superior vena cava syndrome caused by pacemaker lead. A single bypass surgery between right innominate vein and superior vena cava was performed by partial sternotomy incision using superficial femoral vein graft. There was no complication, and the face and right upper extremity edemas were improved immediately.

An 81-year-old woman with senile dementia was transferred to our hospital due to the right popliteal aneurysm rupture. The patient was hemodyanamically stable. However, the standard operation, consisted of the aneurysmoraphy and a bypass surgery, seemed a highly invasive treatment with a long duration of hospital stay. The patient was treated with an endovascular treatment. Gore Viabahn stent grafts (W. L. Gore and Associates, Flagstaff, AZ) were deployed from the superficial femoral to the below-the-knee popliteal artery. The aneurysm was completely thrombosed and started to decrease in volume. The stent-grafts remain patent for 24 months after the procedure.

Aortocaval Fistula (ACF) is a rare complication of abdominal aortic aneurysm rupture. We report a case of ACF with concomitant acute heart failure. Case: A 49-year-old man was referred to our hospital for abdominal aortic aneurysm with exertional dyspnea. He did not have any abdominal symptoms, however, pulmonary congestion, pleural effusion and hepatic dysfunction were observed. Transthoracic echocardiography revealed normal functioning cardiac valves and normal left ventricular wall motion. Diagnosis of ACF was suspected at this point, thus, contrast-enhanced CT scan was obtained. It showed ACF caused by a rupture of abdominal aortic aneurysm. We performed emergent open surgical repair. There was no hematoma in the retroperitoneum. Fistula was found in a right side of aneurysmal wall. Through fistula, there was a massive retrograde venous bleeding coming from inferior vena cava. We tried to separate inferior vena cava from aneurysm, however, there was a tight adhesion in between. Fistula and wall of inferior vena cava were sutured jointly, and operation was completed successfully. His heart failure and liver function improved immediately after operation and postoperative course was uneventful. He was discharged on postoperative day 17. ACF is associated with high morbidity and high mortality due to preoperative organ failure. Although precise diagnosis of ACF is required, delayed diagnosis occurs occasionally because symptoms of ACF are often non-specific and variable. Diagnosis of ACF should be elicited in case of abdominal aortic aneurysm with concomitant symptoms of heart failure.

Inferior Mesenteric Artery (IMA) Aneurysm is a rare disease among visceral aneurysms. We present the case of a 62-year-old man with an asymptomatic IMA aneurysm accompanied with severe stenosis of the left external iliac artery (EIA) and occlusion of the superior mesenteric artery (SMA), celiac artery (CA), and right EIA. The IMA was the only provider of blood flow to the intra-abdominal organs. We conducted the revascularization of the SMA with an 6-mm expanded polytetrafluoroethylene (ePTFE) graft and bilateral EIA with bifurcated graft before resected IMA aneurysm to avoid intra-abdominal organ and limb ischemia. During the procedure, we confirmed arterial flow of bilateral lower limbs and the good color of the small intestine before closing the abdomen. Postoperative CT showed intact arterial flow of the intra-abdominal organ. Postoperative course was uneventful and the patient was discharged on POD 11. We follow up the patient because it is possible of recurrence of visceral aneurysms.

The spontaneous rupture of an ovarian artery aneurysm is extremely rare and can be fatal. A 72-year-old woman, gravida 2 para 2, who had not undergone cesarean section, presented with disturbance of consciousness and shock. Contrast-enhanced computed tomography (CT) revealed rupture of a giant right ovarian artery aneurysm with a maximum minor axis diameter of 71 mm. It originated from the right accessory renal artery and the pelvic arteriovenous fistula with feeding arteries including the right ovarian artery. She was transferred to our institution, and we considered that it would be difficult to perform coil embolization because both the proximal and distal blood vessels of the aneurysm were not suitable due to their large diameter. Therefore, she underwent ligation of the proximal and distal blood vessels through a median laparotomy on an emergent basis. Her postoperative course was uneventful and contrast-enhanced CT did not show inflow of contrast medium into the aneurysm. However, the pelvic arteriovenous fistula was reduced but still remained; therefore, coil embolization was performed. This is a very rare case of a patient who had a ruptured ovarian artery aneurysm with a pelvic arteriovenous fistula.

A 63-year-old woman underwent ascending aortic graft replacement for acute type A aortic dissection at the age of 62. The dissecting aortic aneurysm of distal arch gradually expanded. An entry was found in the distal aortic arch, and the celiac artery, superior mesenteric artery, and right renal artery arosed from the false lumen. Entry closure with TEVAR was underwent while measuring the false lumen pressure. She was discharged without complications on the 11th postoperative day. The computed tomography at 1 year after the operation revealed that the false lumen in the distal arch was occluded by thrombus, and the diameter of the aneurysm was reduced. Measurement of false lumen pressure in TEVAR for chronic dissecting thoracic aortic aneurysm with the abdominal branches arising from the false lumen was useful in assessing mesenteric ischemia during the operation.

Internal iliac artery (IIA) embolization is often performed in endovascular aorto-iliac aneurysm repair to prevent type II endoleak, which can be associated with pelvic ischemia. An 82-year-old man presented with abdominal aortic aneurysm and bilateral common iliac artery aneurysms on abdominal computed tomography (CT). He underwent right IIA occlusion before endovascular aortic repair (EVAR), and EVAR and left IIA embolization were performed in 7 days. Postoperatively, he had severe left gluteal muscle pain at rest and immediate severe cyanosis. We performed an emergency left external-internal iliac artery bypass using a knitted dacron prosthesis. After surgery, the pain at rest and cyanosis resolved. A postoperative abdominal CT revealed no endoleak and the external-internal iliac artery bypass was patent without any problems. If severe pelvic ischemia is caused by the EVAR with IIA embolization, iliac artery revascularization should be performed as soon as possible.