A 78-year-old man with back pain went into cardiopulmonary arrest while being transferred by ambulance to our hospital. After performing cardiopulmonary resuscitation, his heartbeat restarted. Enhanced CT scans demonstrated non communicating aortic dissection from the ascending to the descending thoracic aorta and a slight contrast enhancement in the distal aortic arch. Following the CT screening, he again had a cardiac arrest due to the cardiac tamponade. His heartbeat subsequently restarted after performing subxiphoid pericardial fenestration drainage. However, massive bleeding from the pericardium continued. We immediately performed an endovascular procedure in Zone 2 to close the entry site on the distal aortic arch. This successfully controlled the bleeding. The postoperative course was uneventful and a CT scan performed after three months showed no endoleak. However, after four months, he again had a back pain, and a CT revealed retrograde type A aortic dissection (RTAD). He subsequently underwent emergent total arch replacement. Thus, although the endovascular procedure was effective and life-saving for a Stanford type A aortic dissection, the possibility that RTAD could occur should be considered.

A 50-year-old man presented with severe intermittent claudication of the left lower limb. An enhanced CT and MRI demonstrated occlusion of the left popliteal artery due to malposition of the medial head of the gastrocnemius muscle. Popliteal artery entrapment syndrome (PAES) was diagnosed. Surgical procedure was performed with posterior approach, and the accessory slip of the medial head of the gastrocnemius muscle was removed, which compressed the popliteal artery. Intraoperative indocyanine green (ICG) fluorescence angiography demonstrated the popliteal artery was occluded, therefore it was replaced with the great saphenous vein. The postoperative course was uneventful, and intermittent claudication completely disappeared. Intraoperative ICG fluorescence angiography was useful in determining whether revascularization should be performed during surgery for PAES.

Profunda femoris artery aneurysms are uncommon and its postoperative recurrence is also rare. Arteriomegaly is diffuse ectasia of arteries from the abdomen to the lower limb and is often complicated with peripheral aneurysms. We report a case of recurrent profunda femoris artery aneurysm with arteriomegaly. A 74-year-man had aneurysmal repair with bypass using a great saphenous vein for a left profunda femoris artery aneurysm 15 months ago. At follow-up a pulsating mass in the left femoral region was occurred and computed tomography arteriography showed the recurrence of a profunda femoris artery aneurysm and digital subtraction angiography revealed diffuse ectasia of peripheral arteries below iliac regions. Prosthetic graft replacement of the left profunda femoris artery aneurysm was performed. Good patency of the graft was confirmed on the postoperative imaging and the patient has been well with no recurrence for 3 years.

A 70-year-old male was admitted with acute left-sided lumbago after hemodialysis. He underwent endovascular aneurysm repair (EVAR: ENDURANT II, Medtronic, Santa Rosa, CA, USA) approximately five years previously for an infrarenal abdominal aortic aneurysm (AAA) of 71×78 mm in size followed by two additional endovascular treatments by coil embolization for progressive sac enlargement due to a residual type II endoleak. However, AAA expanded and, thus, impending rupture was suspected at that time. Urgent open conversion was performed and dissection around AAA was challenging due to dense adhesions. Since the proximal neck and bilateral common iliac arteries were tightly tied down with a tape tourniquet to prevent bleeding from an occulted type I endoleak, bleeding from the landing zone was not detected. Bleeding from two lumbar arteries was readily sutured with a bloodless surgical field following the incision of AAA and removal of a hematoma within AAA. The inferior mesenteric artery was easily detected and also ligated outside the aneurysmal wall. Extraction of the EVAR device was not required and the aneurysmal wall was resected and tightly sutured as much as possible. Proximal and distal banding was performed to prevent further type I endoleaks. Since intraoperative blood salvage was performed, the patient did not receive blood transfusion. Although the approach to each patient requiring delayed conversion must be individualized, the complete preservation of endografts is possible, similar to the present case. Surgery was performed without any hemodynamic compromise and the postoperative clinical course was good. We herein report a surgical case of the urgent open conversion for the impending rupture of AAA due to a type II endoleak following EVAR and additional coil embolization twice. We also reviewed and summarized the strategies from previous domestic case reports of this complex condition.

We herein report on a case of buttock claudication, associated with occlusion of the internal iliac artery, which was successfully treated with high-load exercise therapy. The case involved a 61-year-old male. His chief complaint was of right buttock claudication. His medical history included chronic atrial fibrillation, acute arterial occlusion of the lower extremities, and contrast medium allergies. He was referred to our department with pain in the gluteus muscles and fatigue when walking, symptoms which had continued for over half a year. The appearance of buttock claudication was observed when climbing up and down a singlefloor. An MRI of the lower limbs revealed poor visualization of the right internal iliac artery. An 8-week program of exercise training under strengthening instructions, with a focus on strength training and placing a high-load on the gluteus muscles, made it possible for the buttock claudication caused by climbing stairs to improve significantly and nearly disappear. High-load exercise therapy for the gluteus muscles is non-invasive and its effect can be highly predictable, suggesting that going forward, it may be the focal point of treatment for buttock claudication.

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 2018, 1145 CLI limbs (male 758 limbs: 66%) were registered by 90 facilities. ASO has accounted for 97% of the pathogenesis of these limbs. In this manuscript, the background data and the early prognosis of the registered limbs are reported.