Endovascular aneurysm repair (EVAR) has become the standard treatment for abdominal aortic aneurysms. Technology has advanced and devices have improved but unresolved issues remain. Endoleak is a unique complication in EVAR, of which type II endoleak (T2EL) is the most common. No treatment is required for T2EL that occurs at the time of implantation, but there are cases in which the aneurysmal sac expands later during follow up period. Treatment of aneurysmal sac enlargement due to T2EL is challenging. Therefore, recently, efforts have been made to preventively reduce T2EL. This article reviews the current trends in the treatment and prevention of T2EL.

Blunt thoracic trauma sometimes causes great vessel injuries. However, traumatic hemiazygos vein injury is rarely reported. A 49-years-old man was injured in a traffic accident and transported to our emergency room. He was in shock; computed tomography scan showed a left massive hemothorax due to hemiazygos vein injury. We performed emergency resuscitative thoracotomy and thoracic gauze packing. After the circulatory status stabilized, the patient was moved to the operation room for a second look. We found continuous bleeding from hemiazygos vein; therefore, we ligated it and performed gauze packing again. The patients was subsequently transferred to intensive care unit for further resuscitation. 6 hours later, we performed third look surgery and chest closure. His postoperative course was uneventful, and he was transferred to a different hospital for rehabilitation on the postoperative day 17. Our observation suggest that damage control surgery is an effective strategy for case of hemiazygos vein injury with shock symptoms.

An 85-year-old female underwent lower limb revascularization for highly calcified aorto-iliac severe stenotic disease by right axillo-bifemoral bypass; however, the prosthetic graft became occluded two years later and, thus, femoro–femoral (F–F) bypass with left-sided endovascular therapy for common iliac artery stenosis was performed. Intermittent claudication with lower limb pain at rest developed four years later, and lower limb enhanced computed tomography (CT) revealed the bilateral occlusion of the superficial femoral artery. Left femoro–popliteal bypass for above the knee with a prosthetic graft was initially performed, followed by right lower limb revascularization with an in situ saphenous vein graft (ISSVG) due to the deterioration of right-sided intermittent claudication. Reversed lateral accessary saphenous vein (LASV) was introduced with ISSVG following the effective disruption of the vein valves using a hydrophilic valvulotome, and the proximal blood flow of ISSVG was successfully supplied from the prosthetic graft of F–F bypass to the distal popliteal artery below the knee. Postoperative lower limb enhanced CT indicated the excellent patency and natural features of reversed LASV and ISSVG. This surgical technique has potential as an alternative to ISSVG requiring a greater proximal inflow source of blood for the lower limb when good LASV is achieved.

We herein report a case of ascending aorta-abdominal aorta bypass for atypical coarctation caused by Takayasu’s arteritis complicated with hypertensive heart failure. The patient was a 73-year-old woman admitted for heart failure. The cause of heart failure was investigated, resulting in the detection of atypical aortic coarctation, the bilateral subclavian arteries occlusion, and the left common carotid artery occlusion, so Takayasu’s arteritis was diagnosed. As the patient was initially treated with medication but sometimes suffered from heart failure due to intractable hypertension, surgical treatment was performed. She underwent a bypass grafting with a 14 mm-diameter prosthetic graft from the ascending aorta to the infrarenal abdominal aorta using cardiopulmonary bypass. After the surgery, the pressure gradient between the upper and lower body disappeared. The postoperative course was uneventful, and she was discharged 29 days after surgery. At two years since the surgery, the patient’s antihypertensive medication has been reduced on an outpatient basis, and the left ventricular load has been markedly reduced. We confirm that this procedure is acceptable in the following respects: no need to change position, acquisition of a good surgical field of view, and being able to use a large diameter prosthetic graft for bypass grafting. In addition, it provides sufficient afterload reduction and improvement of hypertension postoperatively.

Cyanoacrylate closure for the treatment of incompetent great saphenous vein have accepted as insurance coverage in Japan. This treatment is non-thermal and non-tumescent technique. However, there are some cases develop postoperative complication. We describe allergic-like reaction caused by cyanoacrylate closure for the treatment of incompetent great saphenous vein. A 79-years-old woman had this treatment, developed swelling of diseased side leg seven days after the treatment. We suspected that there was some kind of allergic reaction. This case got a DLST, and the result was positive. We diagnosed this case as type IV hypersensitivity, administered drugs. But, the symptoms were not improved. As a result, we decannulate left saphenous vein filling CA.

Radiation arteritis (RA) is known as a late complication of radiotherapy, but it is difficult to diagnose and is often treated as a classical atherosclerotic disease. Revascularization in RA is more difficult than other atherosclerotic diseases, and it is important to keep this possibility in mind when RA is suspected. Herein, we report the successful outcome of revascularization of a critical limb ischemia due to RA using a modified bypass route. A 77-year-old man who received irradiation for right iliac lymph node area at the age of 69, presented with skin ulcers on the right heel and knee. Occlusion was found from the right external iliac to common femoral arteries, coinciding with the irradiation area. Suspecting RA, we performed right axillary-right shallow femoral artery bypass surgery. The route was devised to pass through the superior border of the iliac crest and bypass the right inguinal region. The skin ulcers healed quickly after the surgery, and the postoperative course was uneventful.

Infected aortic aneurysms are rare, accounting for 3% of all aortic aneurysms, but tuberculous aortic aneurysms are even rarer. Here in, we report a case of tuberculous abdominal aortic aneurysm (AAA), which was diagnosed after endovascular aneurysm repair, and subsequently developed aorto-duodenal fistula (ADF) after anti-tuberculosis therapy. The patient was an 84-years-old male. He had a history of Bacillus Calmette-Guérin (BCG) intravesical infusion therapy for bladder cancer. EVAR was performed for a rapidly enlarging saccular AAA. Nine months after the surgery, the aneurysm enlarged without clear etiology. Diagnosis of type V endoleak was made, and EVAR was performed once again. However, one month after the procedure, fever and aneurysm enlargement was observed. Mycobacterium bovis was detected in CT-guided biopsy culture, leading to the diagnosis of a tuberculous AAA. After starting on multiple anti-tuberculosis drugs, the inflammation subsided, and the aneurysm diameter stabilized. Seven months later, the patient developed fever again, and CT scan showed a large amount of free air in the aneurysm sac, suggesting presence of ADF. Laparotomy confirmed presence of ADF, and fistula closure, partial removal of the stent graft, and omentum coverage was performed. The patient had a good postoperative course and has been free of recurrence for more than a year. The possibility of tuberculous AAA should always be kept in mind for patients with a history of intravesical BCG therapy. Furthermore, ADF should be considered when inflammation rises during anti-tuberculosis therapy for patients with tuberculous AAA.

We experienced a case of successful endovascular open stent-graft treatment for infected right femoral pseudoaneurysm after using an arterial closure devise. A 78-year-old man. Percutaneous catheterization for left common carotid artery stenosis was performed, and an arterial closure device was used. An infected right femoral pseudoaneurysm later developed at the puncture site. So we performed emergency surgery. Revascularization using autologous vein or artificial graft was difficult because femoral vascular wall was fragile and there was a big perforation hole 1–2 cm across. Then we performed endovascular open stent-graft treatment and postoperative antibiotic therapy was given. He was discharged from the hospital after confirmation that inflammatory reaction was normalization. 6 months have passed since surgery, there is no sign of infection and keep good condition.

A 51-year-old man had suffered from numbness and pain in the right arm. These symptoms were diagnosed with thoracic outlet syndrome by an orthopedist and had been observed without any treatment for 6 years. When the symptoms exacerbated and occluded subclavian artery was detected, he was referred to our hospital. Physical examination revealed different blood pressure in bilateral upper arms, muscle weakness in the right arm, limited range of motion in the right shoulder joint and positive Roos and Morley test. CT scan showed occluded right subclavian artery 8 cm in length, anomalous first rib and no cervical rib. These symptoms were caused by arterial thoracic outlet syndrome due to anomalous first rib. Resection of right anterior and middle scalene muscle, anomalous right first rib, thromboendarterectomy and autologous vein graft interposition of right subclavian artery were performed. Bothered symptoms improved postoperatively. Arterial thoracic outlet syndrome with arterial occlusion is relatively rare. Bone and muscle resection, arterial reconstruction was effective in this case.

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 2019, 1070 CLI limbs (male 725 limbs: 68%) were registered by 83 facilities. ASO has accounted for 98% of the pathogenesis of these limbs. In this manuscript, the background data and the early prognosis of the registered limbs are reported. Although the registration format for simultaneous surgery of bilateral limbs in NCD was changed to one patient and two limbs, JCLIMB still counted two patients and two limbs in order to eliminate the discrepancy with the past annual reports.