Chronic mesenteric ischemia (CMI) is defined as insufficient blood supply to the gastrointestinal tract, most often caused by atherosclerotic stenosis of one or more mesenteric arteries. Patients classically present with postprandial abdominal pain and weight loss. The diagnosis of CMI is based on the triad of clinical symptoms and radiological evaluation of the mesenteric arteries. Revascularization of CMI is considered for improving quality of life and preventing bowel infarction in patients with advanced clinical symptoms. Endovascular revascularization has surpassed open surgery as the most commonly used treatment for patients with CMI, allocating open surgical bypass to patients in whom mesenteric artery stenting fails or who have lesions unsuitable to stenting.

Guidelines for diagnosis and treatment of aortic aneurysm and aortic dissection were revised in 2020. Among them, I would explain the part of “epidemiology, pathology, definition, diagnosis and examination,” which have changed compared with previous guidelines; 1) Terminology: Intramural hematoma (IMH), Penetrating atherosclerotic ulcer (PAU), Ulcer-like projection (ULP) have been defined again. IMH was approved as clinical term in this guideline, which was not accepted in previous one. 2) Classification of aortic dissection according to status of false lumen: Upper limit size of ULP in ULP type was defined. 3) Risk classification of saccular aortic aneurysm: sac depth/neck width >0.8 was presented as one standard of high-risk saccular aneurysm.

We will introduce and outline some points regarding the diagnosis and treatment of non-dissecting thoracic aortic aneurysms from JCS/JSCS/JATS/JSVS 2020 Guideline on Diagnosis and Treatment of Aortic Aneurysm and Aortic Dissection.

The current article summarized the section of thoracic aortic dissection in Japanese guidelines on the diagnosis and treatment of aortic aneurysm and aortic dissection revised in 2020, which could be helpful to make decisions in daily clinical practice. The revised version covered the wide spectrum of aortic dissection including the classical classification of aortic dissection, clear definition of intramural hematoma (IMH), ulcer-like projection (ULP) , penetrating atherosclerotic ulcer (PAU) to meet the needs of the times. With regard to current topics for acute type A aortic dissection, the guidelines focused on the extent of the replacement such as hemi arch replacement or total arch replacement, the utility of frozen elephant trunk, selection of surgical modes for aortic root replacement, and optimal treatments for organ malperfusion. Since the evidence for the treatment of acute type B dissection using thoracic endovascular aortic repair (TEVAR) have been accumulated, the recommendation of treatments for both complicated and uncomplicated type B dissection corresponding to the phase of time course (acute, subacute, and chronic phase) have been more clearly described compared with the previous guidelines.

The guidelines for aortic aneurysm and aortic dissection in Japan have been revised for the first time in 9 years since the previous guidelines. This manuscript not only focuses on changes in the abdominal area from the previous guidelines but also describes the comparison with the US and European guidelines for abdominal aortic aneurysm (AAA) that have been revised recently (2017 Society for Vascular Surgery, 2019 European Society for Vascular Surgery). According to the guidelines, this manuscript includes screening, surveillance, medical treatment for cardiovascular risk management of patients with AAA, and surgical treatment such as EVAR (Endovascular aortic repair) and open surgical repair. In the last decade, the endovascular treatment for the aortic disease has been developed dramatically, and its indication has expanded, but on the other hand, there have been a series of reports on the problems of its long-term results. The treatment strategy for the patient with AAA must be determined in consideration of early and long-term outcomes.

Objectives: Pulmonary thromboembolism (PTE) has a poor prognosis, and 90% of all PTE cases are caused by deep vein thrombosis (DVT). The presence of cancer is one of the risk factors of DVT. This study aimed to evaluate the association between DVT, PTE, and presence of cancer. Methods: From January 2018 to December 2018, 668 patients who underwent ultrasound examination for DVT screening were enrolled. We evaluated the following associations: (1) thrombus location and PTE; (2) thrombus characteristics and PTE; (3) DVT and presence of cancer; and (4) DVT and molecular targeted agents. Results: The prevalence of PTE according to its location was significantly different; the presence of DVT in the iliac vein to the femoral vein was higher than in the lower limbs. The prevalence of PTE according to the characteristics of the thrombosis on the duplex ultrasound was also significantly different; that of acute and subacute DVT was higher than that of chronic DVT. In contrast, DVT and presence of cancer or molecular targeted agents were not significantly associated. Conclusion: Our data indicate that the location and characteristics of DVT on the duplex ultrasound may be helpful in predicting the occurrence of PTE.

Viabahn stent graft has been reported with good patency in the long Superficial Femoral Artery (SFA) occlusive lesion. However, this treatment is not adapted for the SFA lesion with continuous concomitant Common Femoral Artery (CFA) lesion, since Viabahn stent graft needs at least 1 cm landing zone at the ostium of SFA. On the other hand, Thrombo-Endarterectomy (TEA) for the CFA lesion is an established treatment. We present three cases of hybrid treatment using Viabahn stent graft for the SFA occlusion with continuous concomitant CFA lesion by performing TEA from the CFA to the ostium of SFA, thus creating landing zone at the ostium of SFA. Case1 was a 70-year-old-man with intermittent claudication, case2 was an 83-year-old-man with intermittent claudication and case3 was a 60-year-old-man with a toe ulcer. The average SFA lesion length was 27.8 cm. After the treatment, their symptoms disappeared and have had a favorable outcome so far. By performing TEA from the CFA to the ostium of SFA, Viabahn stent graft seems to be effective for the long SFA occlusive lesion with continuous concomitant CFA lesion.

Total knee arthroplasty (TKA) is a relatively safe surgical procedure, but arterial injury has been reported as a rare complication. A 73-year-old woman presented with swelling in her left lower limb two weeks after left TKA. Her symptoms gradually worsened, and she was referred to our hospital 101 days later. Contrast-enhanced CT showed a giant hematoma of about 12×18 cm in size from the popliteal to the posterior side of the lower limb, and angiography revealed leakage of the contrast medium behind the popliteal artery. She was diagnosed with a pseudoaneurysm of the left popliteal artery caused by TKA. Endovascular repair was performed using a VIABAHN stentgraft placed at the perforation site of the popliteal artery, and hematoma drainage was performed simultaneously. The postoperative course was uneventful and she was discharged 11 days after the operation. The 6-month follow-up angiography showed no contrast staining within the wall of the pseudoaneurysm and no significant stenosis in the popliteal artery. The patient has been asymptomatic for 36 months since the operation. Stentgraft insertion for the popliteal artery is not covered by insurance, but may be an effective treatment in some cases.

The basic treatment for infected aneurysm is administration of antibacterial agents and extensive removal of infected tissue with revascularization by open surgery. Stent graft treatment is relatively contraindicated and has been considered as a bridge to radical surgery. However, in recent years, there have been some case reports of infected aneurysms that could be saved by stent graft treatment alone. We report a rare case of an infected pseudoaneurysm of the brachiocephalic artery after 2-debranching+single chimney TEVAR successfully treated with a Double D technique using VIABAHN endoprosthesis.

We experienced a case of IgG4-related abdominal aortic aneurysm (IgG4-related IAAA) developing 2 years after endovascular aortic repair (EVAR) which was successfully treated by steroid administration. An 82 years old male who underwent EVAR has been regularly followed up at outpatient clinic. At 2 years follow-up post EVAR, inflammatory changes of abdominal aorta (Mantle sign) were accidentally identified by CT scan. Further investigation revealed IgG4 positive, then diagnosed as IgG4-related IAAA. He had no symptoms and there were not any complications of endoleak and/or migration of the stent graft except of 2 mm enlargement of aneurysm diameter, therefore, the surgical intervention did not seem necessary. Steroid administration therapy was commenced at starting dose 30 mg, then followed up by CT scan and laboratory evaluation. Thickened adventitia and periaortic tissue almost disappeared 2 months later. Steroid administration was reduced gradually down to 5 mg in 6 months. Serum IgG4 level was also normalized in 6 months. Neither recurrence of inflammatory abdominal aneurysm nor post EVAR complications have been detected at 1 year follow up stage.

A 71-year-old woman presented with severe chest pain persisted for one week. Her medical history included Stanford type B aortic dissection 10 years prior, obesity hypoventilation syndrome and chronic renal failure. CT revealed a diagnosis of ruptured post dissection thoraco-abdominal aortic aneurysm (TAAA). Because of the respiratory insufficiency, we abandoned open surgery and endovascular repair was performed. First, the primary entry tear was closed by TEVAR, and then the major re-entry tear at the site of detached right renal artery was closed using a covered stent bridged from the aortic true lumen to the right renal artery. There still remained false lumen backflow through another re-entry tear at detached intercostal artery, and we embolized false lumen with NBCA-Lipiodol. The false lumen was completely thrombosed, and remained nonrecanalized at one year follow-up.

We report a rare case of idiopathic omental hematoma with some literature review. A 60-year-old man visited our hospital complaining of sudden abdominal pain. Abdominal ultrasonography and computed tomography revealed a omental hematoma. Angiography showed findings suggestive of the bleeding from a branch of the right gastroepiploic artery. Embolization was attempted, but abandoned due to the technical difficulties, therefore surgery was performed. Laparotomy showed a massive hematoma in the omentum. After the hematoma was removed, active bleeding from a branch of the right gastroepiploic artery was identified and was controlled with ligation. Although re-hospitalization was required due to intestinal obstruction, conservative treatment was performed and the patient was discharged from the hospital 64 days after the operation.

A 68-year-old man, who had undergone total laryngectomy for laryngeal cancer and had a terminal tracheostoma, was admitted to our hospital with a diagnosis of acute type A aortic dissection. Pre-operative chest CT revealed a dissected ascending aorta with thrombosis in a false lumen and significant pericardial effusion. We performed ascending aorta replacement. For the surgical approach, partial sternotomy was applied to avoid a deep wound infection. Surgical repair of acute type A aortic dissection in a patient with terminal tracheostoma was rare, and partial sternotomy seemed a beneficial alternative approach.