Peripheral arterial disease (PAD) of the superficial femoral artery (SFA) often include complex lesions; in the past, endovascular treatment (EVT) of these lesions led to poor outcomes. Recent advances in endovascular procedures and devices have led to significant improvements, including both initial success and long-term patency. The 2015 Society for Vascular Surgery guidelines for PAD patients with claudication recommended EVT for focal SFA lesions up to 15 cm that did not involve the femoral bifurcation. Likewise, in 2017, the European Society of Cardiology recommended EVT as first-line therapy for lesions shorter than 25 cm. Currently, numerous EVT devices are available for treatment of femoropopliteal artery lesions; early and mid-term results have been reported. However, it is necessary to have a full understanding of each device and its characteristics due to several associated advantages and disadvantages. The long-term impact of any intervention must be considered, particularly for patients with claudication. The choice of intervention must be determined for each patient in accordance with the guidelines for PAD and in compliance with the instructions for use of each device.

Objective: We investigated the effectiveness of Dynamic Volumetric Computed Tomography Angiography (DVCTA) detection for endoleak (EL) after endovascular aneurysm repair (EVAR). Methods: Between January 2015 to November 2018, 50 consecutive patients who underwent both CTA and DVCTA. We evaluated the maximum diameter of the aneurysm and the presence and classification of EL. Results: The maximum minor axis of the aneurysm was well-matched between the two examinations (R²=0.94, P<0.05). DVCTA provided useful information about detecting the direction of blood flow and the origin blood vessels that let the blood flow into the EL. Furthermore, DVCTA predictability for ELs is as high as DSA. Because DVCTA has possibility to identify the origin blood vessels as type 2 EL which would make EL expand, we have decided to additional coil embolization for those high risk ELs. In one lesion that were diagnosed as type 2 EL using CTA were revealed type 3 EL by determining the blood flow direction using DVCTA. In such cases, physicians have decided to make additional treatment, and DSA in operation showed similar result to DVCTA. The stent graft was placed from the inside. Because the stent graft was fractured, we recognized an EL from there. The additional stent graft was placed inside of the prior stent graft that has type 3b EL. Conclusion: Dynamic image information by DVCTA provides much more information for both EL detection and EL classification comparing to conventional CTA.

A 54-year-old man with chronic type B aortic dissection was referred to our hospital complaining of hematemesis and melena. Upper endoscopy revealed a spot defect in esophageal mucosa covered with blood clot. Contrast enhanced CT showed a ruptured descending aorta adjacent to the mid-esophagus. Right-sided aortic arch and aberrant left subclavian artery from Kommerrell’s diverticulum were also revealed. Descending aortic replacement and left subclavian artery reconstruction via right thoracotomy and omentopexy were performed. Cervical esophagostomy and gastrostomy were performed, simultaneously. The postoperative course was uneventful. We report a rare case of an aortoesophageal fistula associated with a ruptured chronic type B aortic dissection and right-sided aortic arch.

Syphilitic aortic aneurysm has been considered to be a rarely diagnosed disease because of antibiotic therapy. However, the number of patients with syphilis is recently increasing. Therefore, syphilis should be taken into consideration of as a cause of aortic aneurysm. A 63-year-old man admitted to our cardiology department due to dyspnea. Close examination revealed moderate aortic valve regurgitation and ascending aortic aneurysm. The values of both non-treponemal and treponemal quantitative serologic test were high. After medical treatment of heart failure and syphilis, we performed replacement of aortic valve and ascending aorta. Pathologic findings of the aortic specimen were compatible with syphilitic aortic aneurysm. Postoperative course was uneventful. No anastomotic problem was observed on postoperative CT scan. There has been no clinical problem for one year after operation.

This report presents a rare case of angioleiomyoma originating from the radial artery. A 42-year-old female presented with a pulsatile and painful mass in the right wrist. The patient was diagnosed as a pseudoaneurysm based on physical findings and contrast-enhanced CT findings, and surgery was performed. However, postoperative pathological examination revealed angioleiomyoma. Angioleiomyoma is a relatively rare, benign, vascular soft tumor originating the tunica media of a blood vessel. The tumor tends to occur in the lower extremities and rarely in the upper extremities. The definitive diagnosis by image inspection is difficult before surgery and most cases were diagnosed by postoperative histopathological examination. This mass may present with localized pain. Therefore angioleiomyoma should be considered in a patient presenting with a painful small tumor along a blood vessel.

A 70-year-old woman with history of uterine cancer presented with fever and abdominal pain was diagnosed with infected abdominal aortic aneurysm (AAA) and treated with endovascular aneurysm repair (EVAR) followed by open surgery using bilateral femoral veins. Her infected AAA was diagnosed through aneurysm wall culture and computed tomography. Antibiotic therapy was initiated; however, abdominal pain persisted; and, she was referred to our institution. Further, she was treated with EVAR during chemotherapy, but could not completely control the infection. Therefore, aneurysmectomy and in situ reconstruction of the abdominal aorta were performed using bilateral femoral vein graft with omentopexy. Infection did not recur at 7 months postoperatively.

Endovascular aortic aneurysm repair (EVAR) for the treatment of AAA is minimally invasive compared to open repair, however in patients with iliofemoral occlusive disease, conventional approach from the femoral artery may be difficult. We herein report a case of EVAR using an internal iliac access conduit in a patient with bilateral external iliac occlusion. A 77-year-old man was hospitalized for an AAA with a diameter of more than 50 mm. He had a medical history of total gastrectomy at the age of 42, and axillo-bifemoral bypass grafting for bilateral external iliac occlusion at the age of 74. Overall patient’s clinical status was in favor for endovascular repair, however recanalization of the external iliac arteries was impractical. Thus we anastomosed an 8-mm polyester graft through a retroperitoneal route, and used this as a conduit to coil-embolize the right common iliac artery and complete an aorto-uni iliac EVAR. In patients with access problems for EVAR, internal iliac conduit is a valuable access route that can be obtained with minimal invasion.

If venous stasis ulcer is accompanied by deep vein thrombosis after endovascular ablation for varicose vein, the symptoms are severe and intractable. We experienced a case of severe leg ulcer completely cured by compression therapy and exercise therapy with receiving an anticoagulant drug. A 62-year-old man with hemorrhagic gastro-duodenal ulcer required emergency hemostasis treatment. He complained asthma taking steroids, diabetes, chronic renal failure and a hyper-obesity body with a body mass index of 42.2. Bilateral lower leg intractable stasis ulcers were observed. Five months ago, he underwent endovascular ablation therapy for venous stasis skin ulcer at a special vein clinic. At the time of visit to our hospital, an old thrombus in both popliteal vein and severe leg skin ulcers were found. MRSA infection was also present. Daily compression therapy with elastic bandage, daily lavage and appropriate debridement of the wound, weight loss and daily locomotion exercise resulted in complete healing of ulcers by 4 months. We report that tenacious compression therapy and exercise therapy are effective for lower leg stasis skin ulcer.

Intercostal artery aneurysms have been reported to occur in some underlying diseases such as neurofibromatosis, and rupture of an intercostal aneurysm can be life-threatening. It is very rare to see intercostal artery aneurysms without any associated conditions. We report this case and review the literature. A 69 year old man presented with right lumbar pain and a contrast enhanced CT scan was carried out. The cause of the lumbar pain was not revealed, but resolved spontaneously. The patient was diagnosed with a left intercostal artery aneurysm. He had no medical history, no operations or trauma, no family history, and the physical findings were unremarkable. He had no skin lesions. The thoracoabdominal CT scan did not detect any other aortic or visceral artery aneurysms. We performed coil embolization, and the postoperative course went uneventfully. 5 years later, there is no enlargement of the aneurysm, and he remained asymptomatic. Endovascular management of intercostal artery aneurysms has performed successfully in some of the patients reported in the literature. Most of these reports were treatments for ruptured aneurysms, and sometimes it is difficult to perform coil embolization because of vessel fragility due to underlying diseases. We successfully embolised an unruptured aneurysm using endovascular technique. This case report suggests that some patients may have intercostal artery aneurysms without any underlying diseases, but there is no criteria for the intercostal aneurysms. Further researches are needed.

Here, we report a case of a 67-year-old male who presented to our hospital with a sinus of Valsalva aneurysm (SVA). His history included of hepatectomy resulting from hepatocellular carcinoma, as well as an asymptomatic left SVA discovered approximately two years prior. Computed tomography (CT) indicated SVA expansion and the presence of a new mural thrombus with no evidence of coronary artery compression or aortic valve regurgitation. The SVA was resected, and we repaired the orifices of the SVA and the left coronary artery with a Hemashield patch. We then reconstructed a single coronary artery bypass graft to the left main trunk (LMT) using the great saphenous vein. The patient’s recovery was uneventful after surgery and he was discharged on postoperative day 11. SVA is a rare condition that occurs in 0.1–3% of patients undergoing cardiac surgical procedures, more frequently in the right or noncoronary sinus of Valsalva, making a left SVA exceedingly rare. Our report describes an unusual case of extracardiac unruptured left SVA that we successfully treated with resection, cardiac patching, and reconstruction of the LMT.

Endovascular aortic repair (EVAR) of inflammatory abdominal aortic aneurysms (IAAAs) avoids injury to organs adherent to the aneurysms during open surgery, but the long-term results and effects on urinary obstruction remain unclear. A 71-year-old man presented with IAAA, 44 mm in diameter, and a bilateral common iliac aneurysm, 42 mm in diameter. Both ureters exhibited perianeurysmal fibrosis, triggering hydronephrosis. Preoperative serum IgG4 level was high (147 mg/dL). Despite immediate reductions in aneurysm diameters and CRP level after EVAR, neither the perianeurysmal thickening nor hydronephrosis nor serum IgG4 level improved. We prescribed an oral steroid; the thickening gradually regressed. The aneurysm diameter fell immediately after EVAR, but the perianeurysmal thickening of the patient did not. A course of oral steroids was important in ensuring eventual perianeurysmal thickening regression.

A 38-year-old man was referred to our hospital for sudden onset of intermittent claudication (IC) with decreased ankle-brachial pressure index (ABI) of 0.64. Enhanced computed tomography (CT) showed cystic adventitial disease of the right popliteal artery with no arterial stenosis. He was observed carefully because of symptom regression and non-stenosed popliteal artery. One week later, however, severe IC with no arterial pulsation relapsed. Enhanced CT revealed severe stenosis of the affected popliteal artery with increased adventitial cyst. He received continuous intravenous administration of heparin (10,000 units/day) and the symptom disappeared the next day with normal ABI of 1.0. Considering the high risk of progression to critical limb ischemia, we performed surgical intervention including excision of the affected popliteal artery and interposition with an autologous saphenous vein graft. Neither leakage of the mucinous contents from the adventitial cyst nor connection between the adventitial cyst and the knee joint was recognized intraoperatively. He had no recurrence of the symptom thereafter.