In this article, we briefly describe the etiology, indications for treatment, and treatment methods for visceral aneurysms. Visceral arteries include the celiac artery, superior mesenteric artery, renal artery, inferior mesenteric artery and their branches. Although evidence has been lacking for this relatively rare disease, it is often encountered in daily clinical practice, as with recent advances in diagnostic imaging modality. Moreover, guidelines have been recently proposed from overseas, and we vascular surgeons need to deepen our understanding of this disease.

Visceral arterial diseases include aneurysms, dissection, stenosis and occlusion. Open surgery is sometimes required for these diseases. The difficulty of approaching the visceral arteries varies depending on their adjacent organs and the anatomical variations. In particular, carefully approach is required for the visceral arteries around the pancreas to avoid pancreatic injury. Understanding the surgical anatomy and pursuing the etiology of the diseases are important for selecting surgical methods and safe procedure.

The superior mesenteric artery (SMA) is the most important artery in aortic branches beyond the left subclavian artery. Rapid diagnosis and proper intervention are mandatory for its acute ischemia. There exist several pathological conditions belong to, or related to the SMA ischemia; SMA embolism, chronic mesenteric ischemia, SMA-malperfusion by acute aortic dissection, isolated superior mesenteric artery dissection, segmental arterial mediolysis, non-occlusive mesenteric ischemia, mesenteric venous thrombosis, etc. In 2017, guidelines for management of the diseases of mesenteric arteries and veins were published from the European Society of Vascular Surgery (ESVS), which was translated to Japanese. And guidelines for management of descending thoracic aorta diseases were also published from the ESVS. The present lecture is described along these guidelines.

Objective: We investigated long term results and pattern of recurrence after bare metal stent (BMS) placement in the treatment of resistant and recurrent venous anastomotic stenoses in arteriovenous graft (AVG) and elucidated the pattern of recurrence. Methods: Fifty-eight patients (30 failing and 28 failed access) who underwent first BMS placement for venous anastomotic stenosis of AVG were included. Operative results and patency of hemodialysis access and freedom from target lesion revascularization (TLR) were investigated retrospectively. Places of recurrence after first BMS placement were analyzed from radiology records. Results: All BMS were self-expanding stent. Operative time was 26±10 minutes for failing cases, and 47±17 minutes for failed cases. Initial success was 100%. Intraoperative complication (extravasation of contrast medium) occurred in 3 cases (5.1%). Three month-postintervention primary patency before and after first BMS placement was 21.1% and 75.6% respectively (p<0.001). Postintervention primary, assisted primary, secondary patency, and freedom from TLR were 51.7%, 73.6%, 96.5% and 61.8% at 6 months, and 30.3%, 67.3%, 96.5% and 35.2% at 1 year, respectively. About half of recurrence after BMS placement developed in-stent and 17% of recurrence developed remote downstream from the BMS. Conclusions: BMS placement is safe and effective treatment for recurrent or resistant venous anastomotic stenoses in AVG. During the observation period, only 17% of recurrence after first BMS placement developed remote downstream from the BMS.

An 11-year-old boy had undergone a Norwood procedure at infancy for functional single ventricle and systemic ventricular outflow tract obstruction, and a total cavopulmonary connection (i.e., Fontan procedure) with an extracardiac conduit at the age of 2 years. Residual aortic coarctation was detected by catheterization at the age of 11 years, which indicated surgery. Contrast-enhanced computed tomography revealed archery hypoplasia after the bifurcation of the brachiocephalic artery, narrowing of the aorta to the minimal diameter of 5 mm after the bifurcation of the left subclavian artery, and dilatation after the stenotic segment. An ascending–descending aortic bypass via a posterior pericardial approach was performed through median sternotomy under partial extracorporeal circulation using the off-pump technique. The postoperative course was uneventful without complications. Advantages of ascending–descending aortic bypass for residual aortic coarctation include prevention of recurrent laryngeal nerve injury, alleviation of respiratory complications, and avoidance of highly invasive assisted circulation such as deep hypothermia-induced circulatory arrest. On the other hand, the disadvantages specific to this procedure include esophageal injury, phrenic nerve injury, and steal phenomenon in the cerebral or coronary circulation. In addition, late follow-up is necessary because of concerns about size mismatch of blood vessel prostheses in association with somatic growth of children.

We report two cases of superior mesenteric artery syndrome (SMAS) after Y-Graft replacement (Y-GR) for a juxta-renal abdominal aortic aneurysm (jAAA).

Case 1 was a 70-year-old man referred to our department for jAAA surgery (maximum jAAA diameter, 48 mm). Y-GR was performed and required clamping of the supra-renal aorta. At 10 postoperative days (POD) he vomited and developed potential postoperative ileus. Computed tomography (CT) and upper gastrointestinal fluoroscopy (UGF) revealed an expanded duodenum with severe stenosis of the horizontal portion. On the basis of the interposition of the stenotic duodenum between the superior mesenteric artery and the prosthesis overlap with the aneurysmal wall, he was diagnosed with SMAS. Although a gastrojejunal bypass operation was considered, his symptoms gradually improved and he was discharged at 39 POD. Case 2 was an 80-year-old man admitted to our institute for jAAA surgery (maximum diameter, 76 mm). The patient underwent Y-GR with clamping of the infra-renal aorta. He vomited at 8 POD. CT and UGF showed severe stenosis in the horizontal portion of the duodenum. He was diagnosed with SMAS based on similar findings to case 1. Following persistent conservative treatment (based on our experience from case 1), his symptoms gradually improved and he was discharged at 49 POD. These cases of postoperative SMAS may be related to surgical manipulation of tissue and organs around the supra-renal aorta and we can do conservative treatment for SMAS.

Recently, endovascular treatments and open surgical repairs for visceral artery aneurysms have been reported. However, both approaches have not proven their superiority due to the lack of randomized clinical studies. In this report, the case of a giant hepatic artery aneurysm treated by embolization with a vascular plug and coils was introduced. A woman in her 70s was referred to our hospital because a hepatic artery aneurysm with a size of 80 mm was detected by computed tomography scan. As she had a medical history of necrotic cholecystitis and abdominal incisional hernia, open repair was high risk. There would be a risk of slipping of embolus to the aneurysm if coils were deployed in the proximal side of the hepatic artery aneurysm due to its short length and the wide diameter of the common hepatic artery. Therefore, a vascular plug was chosen. After twice embolization, the blood flow to the hepatic artery aneurysm was completely blocked without ischemic complication.

Endovascular procedures, such as transcatheter aortic valve implantation, thoracic endovascular aortic repair (TEVAR) and endovascular abdominal aortic repair, have been established as promising, less invasive therapeutic options. However, insertion of large sheaths through the common femoral artery (CFA) in endovascular surgery is sometimes problematic, and major and minor access route complications reported in 10–15% of patients. We experienced a successful case of embolectomy for acute superficial femoral artery occlusion caused by sloughed intima from the external iliac artery (EIA) after TEVAR. A 79-year-old woman underwent TEVAR through the CFA for a descending thoracic aortic aneurysm with a maximum diameter of 60 mm, using a 22 Fr sheath. After the TEVAR procedure, angiography performed immediately before removal of the sheath showed localized arterial dissection in the left common iliac artery. After removal of the sheath, we extracted the sloughed intima from the puncture site of the CFA, and repaired it under CFA clamping. Postoperative ultrasonography and contrast-enhanced computed tomography examination showed occlusion of the left superficial femoral artery. We performed emergency embolectomy surgery in the left superficial femoral artery, and confirmed pulsation of the left popliteal, dorsalis pedis and posterior tibial arteries immediately after embolectomy. The extracted specimen was the sloughed intima, 6 cm in length, from the left EIA. In this report, we discuss about the mechanisms and treatments of distal peripheral arterial occlusion caused by sloughed intima from the EIA as an access route complication after endovascular surgery.

Thrombectomy for acute arterial obstruction of the upper limb is a useful method, but it can sometimes cause serious complications of vertebral artery embolism. A 52-year-old man was referred to our department for coldness and numbness of the right upper limb for three days. Contrast enhanced computed tomography revealed thrombosis of the right subclavian artery and a thrombus in the ascending aorta and the aortic arch. The thrombus in the right subclavian artery was located just distal to the right vertebral artery branch. To prevent right vertebral artery thromboembolism, we performed thrombectomy via the right subclavian artery through the supraclavicular incision. Since the vertebral artery can be dissected by supraclavicular incision, cerebral infarction due to vertebral artery embolism can be prevented by clamping the vertebral artery during thrombectomy. Postoperative course was uneventful. We advocate thrombectomy by supraclavicular incision for acute arterial obstruction of the upper limb that is considered to be at risk of the vertebral artery embolism in surgical procedure.

A 67-year-old woman underwent emergent EVAR using Endurant II for ruptured abdominal aortic aneurysm. The postoperative course was uneventful, but CT scan 4 month later revealed a saccular protrusion of 25 mm in height on the anterior wall of the abdominal aortic aneurysm. Contrast-enhanced CT did not show any obvious endoleak, but we decided to perform prosthetic graft replacement by laparotomy. When the aneurysm was opened without clamping the aorta, a yellow fluid flowed out. Neither hematoma nor endoleak was observed in the aneurysm. The stent graft was resected as much as possible, and graft replacement was performed. The postoperative course was uneventful.

Spontaneous isolated dissection of the superior mesenteric artery (SMA) is an uncommon phenomenon that rarely leads to a dissecting aneurysm. We herein report a case of a dissecting aneurysm of the SMA, which expanded rapidly and was successfully treated in emergency surgery. A 48-year-old male patient presented acute Type B aortic dissection in July 2012, since then he received annual to semi-annual follow-up computed tomography (CT) scans. Although the patient was asymptomatic, a CT in May 2017 revealed an isolated dissection of the SMA with a diameter of 14 mm. Approximately 17 months later, the SMA had dilated to 26 mm, forming a dissection aneurysm. One month later, the patient presented with epigastralgia, and the aneurysm was found to have further dilated to 32 mm. Emergency surgery was then undertaken for the rapid expansion of the aneurysm, and both the SMA and the second jejunal artery were reconstructed using the great saphenous veins. The surgery resulted in the patient recovering without any symptoms associated with intestinal ischemia. Since dissecting SMA aneurysms can expand rapidly, it is our view that careful observation should be mandatory for the patients with isolated SMA dissection.

We report a case of superior mesenteric vein thrombosis (SMVT) secondary to diverticulitis in the ascending colon which was diagnosed with contrast enhanced abdominal CT scan and treated conservatively. The patient is a 78-year-old male who was admitted to a hospital since his symptom worsened despite the use of oral antibiotics prescribed by his GP for his right abdominal pain and mild fever. A blood test demonstrated elevated CRP and WBC, and a plain CT scan showed signs of appendicitis, for which intravenous antibiotics were commenced. A contrast enhanced CT scan was performed to further investigate the cause of his persistent symptoms after the commencement of intravenous antibiotics, which revealed SMVT. He was transferred to our unit and started on conservative anticoagulation therapy, considering that his symptoms had almost disappeared, and hemodynamics were stable. Continuous infusion of heparin was started and changed to oral warfarin therapy. As we confirmed a significant decrease in the size of a thrombus in the SMV on a contrast enhanced CT scan and improvements of his data and symptoms on the 5th day of admission, he was discharged on the 7th day. A CT scan taken 2 months after discharge showed no thrombus in the SMV. The ascending colon was considered the most common site of diverticulitis that can lead to mesenteric vein thrombosis on literature searches. The incidence of SMVT is considered higher compared to that of IMVT.

We herein describe a case of symptomatic improvement and diverticulum shrinkage that lasted 24 months after chimney thoracic endovascular aortic repair (TEVAR) for a Kommerell’s diverticulum (KD). A 61-year-old man presented with dysphagia lusoria due to a KD involving an aberrant right subclavian artery with a left-sided aortic arch. The patient underwent TEVAR and right subclavian artery coil embolization. His dominant left vertebral artery was transplanted for the left common carotid artery, and the left subclavian artery was stented (chimney technique). The preoperative diameter of the KD was 43.5 mm, and the distance to the opposite aortic wall was 54.5 mm. The postoperative diameter of the KD was 33.0 mm. The patient developed no spinal cord ischemia or right arm ischemia postoperatively. His symptoms of dysphagia and right arm claudication improved throughout the 1-year follow-up period. At the 24-month follow-up assessment, the patient had no symptoms and the size of the KD had not changed.

Radiation therapy has become an important treatment modality for malignant tumors. However, it causes radiation-induced vascular disease in the late stages. A 57-year-old woman was suspected of having osteosarcoma at age 9 and received radiation therapy in the distal part of her left femur. She developed acute limb ischemia when she was 55 years old, and her limb was salvaged by endovascular therapy (EVT). Subsequently, early occlusion occurred repeatedly despite additional EVT. Therefore, she was referred to our department for the treatment of critical limb ischemia with rest pain. We found that the subcutaneous and soft tissues of her left distal thigh had atrophied, and she had lower-leg lymphoedema. We avoided an in-situ bypass because of concern about delayed wound healing or infection at the radiation-damaged skin and subcutaneous tissue site. Instead, we performed an autologous vein graft bypass using the contralateral great saphenous vein from the superficial femoral artery to below the knee popliteal artery. Lower limb blood flow was restored, and the patient’s recovery course was uneventful. We successfully treated critical lower limb ischemia due to radiation-induced vascular disease with autologous vein bypass surgery.

Aorto-Duodenal Fistula (ADF) is a critical disease in which aorta communicates with duodenum as causing massive gastrointestinal hemorrhage or hemorrhagic shock, and it eventually results in a high rate of death if left untreated. The case is for male at the age of 62 and vomited blood at the previous medical institution. He was diagnosed as ADF in upper gastrointestinal endoscopy and contrast-enhanced CT scan. The patient was transferred to our institution after Intra-Aortic Balloon Occlusion (IABO) was inserted by a radiologist at the previous medical institution. We performed emergency Endovascular Aortic Repair (eEVAR). Later, we also performed stent graft removal, blood vessel prosthesis implantation, and partial duodenectomy. Revascularization can be a principle for the treatment of ADF, but since hemostasis by EVAR has been recently reported in some cases, it was considered that our case was successfully treated with bridged therapy.