Although immediate revascularization is the first-line treatment to save the life and legs of patients with chronic limb-threatening ischemia, revascularization is not an option for some patients. In such situations, nonsurgical treatment should be administered if possible. Nonsurgical treatments include medications, exercise therapy, low-density lipoprotein apheresis, artificial carbon dioxide foot bathing, intermittent pneumatic compression, spinal cord stimulation, and therapeutic angiogenesis. Importantly, these therapies must be applied to the appropriate patients with the aim to save their life and legs. Close monitoring of these critically ill patients until the end of treatment is also crucial.

RTAD (retrograde type A aortic dissection) associated with stent-graft insertion is a condition in which intimal tear occurs due to a stent-graft inserted into the aortic arch and the descending aorta, and new dissection extends retrogradely to the ascending aorta. While the indications for TEVAR are expanding, the frequency of occurrence is as low as 1–2%, but the mortality rate is as high as 30–40%, RTAD has become an important problem. Risk factors for its occurrence include the presence of a bare stent on the proximal side of the stent-graft, oversize, touch-up balloon dilation, the bird beak phenomenon on the lesser curvature side, and zone 2 or more proximal placement. Treatment of RTAD requires replacement of the ascending aorta and aortic arch using the indwelling stent-graft as a frozen elephant trunk. In TEVAR, it is important to familiarize yourself with the characteristics of various devices, become familiar with the appropriate placement method, and continue long-term follow-up to improve treatment results.

Stent grafting for aortic aneurysm and aortic dissection has excellent initial results, however, reinterventions during follow up have become concerns. The most cause of reintervention is endoleak. We have reviewed the evidence or treatment of endoleaks except for type II endoleak.

Brain complications after TEVAR are non-fatal but significantly reduce ADL and worsen long-term prognosis. Cerebral infarction due to porridge embolism is the main cause of them and it occurs several times more often than overt cerebral infarction. Diagnosis of the location of atheroma by preoperative CT and protective catheter and device manipulation considering it are important for prevention, but embolization cannot be completely prevented by those. Balloon occlusion or direct blockage of the cervical branch are effective as prophylaxis, and extracorporeal circulation can be used to completely separate the cerebral circulation from the systemic circulation. Treatment is different from normal cerebral infarction and thrombolysis or removal of emboli is not effective. Edaravone administration reduces the degree of brain damage and improves prognosis and should be used without hesitation immediately after onset.

The antiphospholipid antibody syndrome (APS) causes thrombosis in arteries and veins throughout the body. Cases of aortoiliac thrombosis caused by APS are relatively rare. Herein, we report a case wherein a bifurcated graft was used for recirculation to treat critical limb ischemia and aortoiliac thrombosis due to APS. A 55-year-old man had previously developed a pulmonary embolism, for which he was admitted to another hospital, where he was diagnosed with APS. During follow-up for APS, the patient’s right fifth toe had turned gangrenous and fallen. He presented to our hospital with left leg pain at rest and gangrene of the fourth and fifth toes. The patient was on anticoagulant medication, which was stopped when the gangrene appeared. Angiography findings revealed terminal aortic stenosis and right external iliac arterial obstruction; however, no significant stenosis was observed distal to the popliteal artery. For the limb ischemia caused by the terminal aortic stenosis and right external iliac arterial obstruction, we performed open surgical recirculation using a bifurcated graft. The patient’s pain at rest and gangrenous left toe improved postoperatively.

IgG4 related disease (IgG4-RD) is clinically characterized by elevated serum levels of IgG4, dense lymphoplasmacytic infiltration of IgG4 positive plasma cells, and fibrosis of the affected organs. Regarding IgG4-RD related cardiovascular lesions, while reports have predominantly focused on cases involving the abdominal aorta or the iliac artery, the literature on thoracic aortic aneurysms is limited. We herein present a case of an oddly shaped, lumpy thoracic aortic aneurysm associated with IgG4-RD. A 69-year-old male presented to our facility with pyoderma on his hip. Preoperative contrast enhanced computed tomography (CT) showed an oddly shaped aneurysm extending from the ascending aorta to the aortic arch, and subsequent blood tests showed elevated CRP and IgG4 levels (CRP 8.1 mg/dL, IgG4 207 mg/dL). Since the aneurysm was determined to be at a high risk of rupture, we performed a prosthetic graft replacement of the aorta from the ascending aorta to the aortic arch after resecting the aneurysmal aortic wall. On distal anastomosis of the graft, an open stent graft was deployed into the descending aorta to reinforce the anastomosis. According to the results of the pathological study of the resected aortic wall, which showed an abundant infiltration of IgG-positive plasma cells, the CT findings, and elevated serum IgG4 levels, we confirmed the definite diagnosis of IgG4-RD. In considering the increased risk that corticosteroid therapy brings to both the aortic wall’s fragility and the associated postoperative infectious complications, corticosteroid therapy was not introduced. We conclude that careful long-term follow-up should be mandatory, especially paying attention to exacerbation of the inflammation or the development of a pseudoaneurysm at the anastomotic sites.

Popliteal venous aneurysms (PVAs) are a rare venous disease that may lead to deep vein thrombosis (DVT) and pulmonary embolism (PE). Surgical treatment is recommended because anticoagulation alone is inadequate to prevent DVT and PE. We report a case of an asymptomatic PVA that was detected incidentally and successfully treated with open surgical repair. A 64-year-old woman presented to our department because of varicose veins in the lower extremities. Duplex ultrasound examination revealed a PVA in the right popliteal fossa. Despite the absence of thrombosis associated with the PVA and asymptomatic presentation, we performed tangential aneurysmectomy with lateral venorrhaphy to prevent life-threatening thromboembolic events. One year after the surgery, we did not observe recurrence of the PVA or complications. Surgical intervention for PVAs is safe and effective to prevent thromboembolic complications and is considered first-line treatment for PVAs.

Pancreaticoduodenal artery aneurysm (PDAA) is a rare visceral aneurysm. Since the rupture risk of PDAA is reportedly unrelated to aneurysmal diameter, early diagnosis and appropriate therapeutic intervention are required. Aneurysmal dilatation is related to mechanical stress due to increased flow through the pancreaticoduodenal arcade caused by celiac axis stenosis or occlusion. Tran-scatheter arterial embolization (TAE) is the first line treatment for PDAA. However, TAE itself leads to organ ischemia in the celiac region in some cases. We report four cases of PDAA treated by surgical revascularization and catheter intervention. Hybrid treatment was performed by surgical bypass grafting for the common hepatic artery (CHA) and TAE for the aneurysm in cases 1 and 2. Postoperative CT showed no enhancement of the aneurysm and sufficient collateral blood supply via the patent bypass graft. Aneurysm resection was performed with bypass grafting for the CHA in case 3, with artery reconstruction in case 4. Small-diameter aneurysms were left untouched in cases 3 and 4 due to anatomical reasons. In case 3, however, which was able to reduce mechanical stress, the residual aneurysm decreased in size. In case 4, on the other hand, persistence of mechanical stress led to an increase in size of the residual aneurysm. This suggests that the presence of mechanical stress in the pancreaticoduodenal arcade might affect the change in the residual aneurysm diameter, and hence, it is necessary to determine the operative method in each case considering the patient background factors and surgical invasiveness.

The patient was a 63-year-old woman who experienced fever and chills during maintenance dialysis and was transferred to the emergency unit of our hospital because her symptoms did not subside. She was admitted on suspicion of bloodstream infection due to shunt puncture. Due to gradually worsening back pain, she underwent thoracoabdominal computed tomography (CT) on the fifth day of admission, which showed imminent rupture of an infected aneurysm of the thoracic aorta. We decided to perform thoracic endovascular aortic repair (TEVAR) to prevent the rupture but encountered difficulty choosing an access route because she had a porcelain aorta with extensive heavy calcification. Upon examination of her CT scan, mild calcification was found in a part of the abdominal aorta. Thus, to save her life, a laparotomy was done, and TEVAR was performed from that point of the abdominal aorta. Subsequently, intravenous antibiotics were administered for 6 weeks postoperatively, after which her medications were changed to oral antibiotics, and she was managed as an outpatient. She has had no infections 1-year post-surgery, and good results have been obtained.

We report an extremely rare case of forearm compartment syndrome that occurred after thrombectomy for acute upper limb artery occlusion. The patient was a 76-year-old man who developed pain and motor paresthesia in his right hand and was brought to our hospital by ambulance. The patient was diagnosed with acute arterial occlusion of the right upper limb, for which we initially performed thrombectomy. Blood flow recovered 6 hours after onset. However, he complained of severe pain in his right upper extremity immediately after surgery; his right upper extremity showed rapid swelling. Contrast-enhanced computed tomography revealed swelling of the volar flexor muscles of the forearm and decreased contrast efficacy of these muscles, leading to the diagnosis of compartment syndrome. We performed fasciotomy of the superficial and deep volar compartments for decompression. We subsequently performed skin grafting at a later date. The patient was discharged 37 days after the first operation. One year postoperatively, he reported no adverse sequelae. Thus, enhanced CT was useful for diagnosing forearm compartment syndrome in this case.

In the treatment of aortic emergencies, it is important to shorten the interval from initial hospital arrival to treatment. However, patients often need to be transferred to another hospital to undergo surgery, since the number of hospitals equipped to perform surgery to treat aortic pathologies is limited. In this report, we present the case of an aortic emergency managed using a cloud-based mobile network which enabled us to seamlessly share patient information in order to utilize the time required for transfer to prepare for surgery. An 85-year-old man presented with sudden back pain and was transferred to the first hospital. After computed tomography images were obtained, the patient’s information was shared with our hospital thorough a cloud-based mobile network. The patient was diagnosed with a ruptured descending thoracic aortic aneurysm, and preparation for thoracic endovascular aortic repair was started immediately. Although the patient was in the state of a shock at the time of arrival at our hospital, he was immediately transferred to the operating room and underwent emergency thoracic endovascular aortic repair with excellent outcomes. The cloud-based mobile network would be indispensable techniques in the treatment of aortic emergencies.