The mainstay of revascularization for femoropopliteal artery disease is shifting from open surgery (OS) to endovascular treatment (EVT). However, the long-term results of EVT are still unsatisfactory for long and complex lesions, lesions involving common femoral artery, and lesions with severe calcification. Therefore, the clinical usefulness of OS, which provides better long-term results compare to EVT, is unquestionable. It is important to have a full understanding of guidelines and evidences for EVT and OS, and to select OS appropriately based on the anatomical characteristics and surgical risks of each patient.

Objectives: The aneurysmal sac shrinkage has been reported as the strong predictor of favorable long-term outcome after endovascular abdominal aortic aneurysm repair (EVAR). We evaluated the effects of perioperative and intraoperative factors on the aneurysm sac shrinkage. Methods: EVAR was performed for 296 patients during 2009.8–2021.12. nine patients with type Ia, Ib or III, 69 patients with sac diameter change less than 5 mm, and 5 patients with sac re-expansion after shrunk more than 5 mm were excluded. Thus, patients with sac shrinkage 5 mm or more (79 patients, shrinkage group) and with sac expansion 5 mm or more (18 patients) were included in this study. Antifibrinolytic therapy with tranexamic acid 1500 mg/day for 6 month after EVAR (TXA) was introduced in 2013 March and patent aortic side branches were coil embolized during EVAR since July 2015. Patients’ background and patent aortic side branches at the end of EVAR were evaluated. Results: Univariate analysis for comparison between patients with sac shrinkage and sac expansion revealed that male (82.3% vs. 55.6%, p=0.021), without antiplatelet therapy (40.5% vs. 66.7%, p=0.044) and TXA (79.8% vs. 38.9%, p<0.001) were significantly associated with sac shrinkage. By multivariate analysis, the odds ratio of sac shrinkage was 11.7 for male, 0.1 for the patients on antiplatelet therapy and 6.5 for the patient received TXA. The patients with patent inferior mesenteric artery (IMA) were less in shrinkage group (20.3% vs. 77.8%, p<0.001) and with 2 or less patent lumbar artery (LA) were more in shrinkage group (82.3% vs. 33.3%, p<0.001). The odd ratio of sac shrinkage was 7.8 for occluded IMA and 3.9 for 2 or less patent LA. Conclusion: The possibility of sac shrinkage would be high for the patient with occluded IMA and 2 or less patent LA at the end of EVAR, and received TXA after EVAR.

Surgical aortic fenestration is known as a treatment of type B acute aortic dissection (TBAAD) with dynamic type malperfusion. Endovascular fenestration is performed more frequently today but surgical fenestration has an advantage in regard to early diagnosis of intestinal ischemic damage and necrosis. A 70-year-old man had abdominal and back pain three days ago. He was diagnosed with TBAAD and transferred to our hospital. Contrast-enhanced CT showed dynamic obstruction of celiac artery and superior mesenteric artery. We planned operation to improve abdominal perfusion. We considered that primary entry closure by TEVAR was high risk for spinal cord ischemia because almost all his intercostal arteries were branched from false lumen. Thus we performed surgical aortic fenestration and confirmed improvement of intestinal blood perfusion by intra-operative indocyanine green fluorescence imaging (ICG-FI). We considered that ICG-FI is a useful method to evaluate intestine blood perfusion when we perform surgical fenestration for TBAAD with visceral malperfusion.

We report a successful case of adult aortic coarctation treated with thoracic endovascular aortic repair. A 47-year-old man was admitted to our hospital with uncontrollable hypertension and systolic murmur in his back. A contrast-enhanced CT scan revealed that the stenotic lesion with the saccular aneurysm at the isthmus of the descending aorta, which is diagnosed as aortic coarctation. The ABI was 0.62 on the right and 0.63 on the left. We decided to perform thoracic endovascular aortic repair for the treatment of the coarctation. The procedure was carried out under general anesthesia using the GORE TAG endovascular graft. The stent graft was implanted at zone 3 through the left femoral artery using percutaneous technique. Perioperative aortography revealed the expansion of the stenotic lesion and the no endoleaks of the aneurysm. The pressuregradient between the upper and lower limbs decreased from 80 mmHg to 30 mmHg in systole and from 30 mmHg to 7 mmHg in mean. The ABI increased up to 1.03 on the right and 1.01 on the left. The patient was discharged the day after the surgery. Postoperative contrast-enhanced CT showed no endoleaks and expansion of the stenotic lesion. No postoperative complications were occurred. Although standard treatment for aortic coarctation is an open surgery, thoracic endovascular aortic repair is safe, minimally invasive and is one of the feasible options for the treatment of adult aortic coarctation.

A 61-year-old man was admitted to our hospital with a diagnosis of deep femoral artery aneurysm (DFAA), which had expanded in diameter from 30 mm to 40 mm within one year. Considering the possibility of a ruptured DFAA, we performed aneurysm resection with DFA revascularization. We could expose the neck of the deep femoral artery by the medial approach, but could not expose the distal neck. The lateral approach was used to expose the distal outflow, and graft interposition was performed. The postoperative course was uneventful, and computed tomography revealed a fully patent graft.

Pulmonary embolism from a venous aneurysm associated with a congenital arteriovenous malformation is very rare, and no treatment strategy has been established. We report a case of pulmonary embolism from a popliteal venous aneurysm with arteriovenous malformation that was treated with venous aneurysmorrhaphy and succeeding oral anticoagulation. The patient, a 28-year-old female, was referred to our hospital for surgery after an inferior vena cava filter implantation and anticoagulation therapy at another hospital for pulmonary embolism. Congenital arteriovenous malformation in the posterior tibial artery and peroneal artery region of the right lower extremity was diagnosed by ultrasonography, contrast-enhanced CT, and lower extremity MR-angiography. We diagnosed the cause of pulmonary embolism as a thrombus from the dilated right popliteal vein, and performed plication of the right popliteal venous aneurysm without resection. No recurrence of symptoms has been observed during the 10 years follow up period.

A 6-year-old woman complained of painful mass in her left thigh. She had a history of Kawasaki disease at the age of 5. Contrast-enhanced CT scan showed a 33 mm aneurysm in the left superficial femoral artery. There was no coronary aneurysm or any other peripheral aneurysm. We resected the aneurysm and performed a vascular reconstruction procedure using the great saphenous vein. Pathological examination of the aneurysmal wall showed severe edematous and myxomatous thickening of the arterial tunica media and partial destruction of the tunica media with inflammatory cell infiltration. Kawasaki disease is well known for its coronary artery lesions, but peripheral aneurysms are uncommon, especially aneurysms of the superficial femoral artery, which have not been reported.

We report the use of ultrasound-guided thrombin injection (UGTI) in the treatment of peroneal artery pseudoaneurysm after femoro-peroneal bypass. The patient was an 86-years-old woman who was performed femoro-peroneal bypass for her right critical limb ischemia. One and a half years later, her right lower leg developed swelling. The ultrasonography revealed peroneal artery pseudoaneurysm on the peripheral side of an anastomosis. The aneurysm was successfully occluded by injection of 2,000 units of thrombin into the aneurysm sac. There were no complications and she showed disappearance of the aneurysm.

A 77-year-old man was referred to our hospital for evaluation of abdominal pain of acute onset and was diagnosed with a ruptured left common iliac artery aneurysm based on contrast-enhanced computed tomography findings. Although the distance between the inferior renal artery and the aortic bifurcation was short (55 mm) and outside the instruction for use (IFU), we performed endovascular aortic repair (EVAR) using the Double D Technique (DDT). No endoleak was observed; however, the patient developed abdominal compartment syndrome, 4 hours postoperatively and underwent open decompression. We performed retroperitoneal hematoma removal and closure on the second postoperative day. On the third postoperative day, we observed a Type Ib endoleak in the left limb of the endograft, secondary to intraoperative manipulation during retroperitoneal hematoma removal, and a stent graft was deployed. The patient did not show an endoleak thereafter. EVAR is increasingly being performed for ruptured abdominal aortic aneurysms and is considered the first-choice treatment in patients with anatomical suitability for the procedure. EVAR is less invasive than open surgery with reportedly comparable or better outcomes; therefore, utilization of EVAR is expected to increase in the future. DDT is a useful therapeutic alternative for cases of rupture outside of IFU.

Venous aneurysm (VA) is a localized dilated lesion without venous extension and meandering, and is a rare disease. VA formed in deep veins has few local symptoms and is often asymptomatic, but popliteal venous aneurysm (PVA) have been diagnosed with pulmonary embolism (PE) due to severe respiratory distress. A 46-year-old man was admitted to our hospital with chest pain and respiratory distress during exertion. He was diagnosed with PE and PVA with arteriovenous fistula (AVF) by contrast CT, and surgery was performed with the start of anticoagulant therapy. The surgery closed the AVF and sewed the PVA. He had a good postoperative course and was discharged 15 days after the operation. Although PVA is rarely associated with AVF, it has been suggested that the presence or absence of AVF should be scrutinized preoperatively.

Aberrant right subclavian artery (ARSA) is a congenital anomaly of the aortic arch. In surgery with ARSA, there are problems such as approach to ARSA and aneurysm, brain protection at circulatory arrest and reconstruction of ARSA. We present 3 cases of total arch replacement with frozen elephant trunk technique for ARSA coexisting thoracic aneurysm. In the first case, a cerebral infarction in the right vertebral artery region occurred. We considered two possible causes for this complication. One is the embolization of a thrombus in the aneurysm due to dissection and compression of the area around the aneurysm before circulation arrest. The other is hypoperfusion of the right vertebral artery due to transesophageal echocardiography compression of ARSA on the hypotension at the time of starting extracorporeal circulation. After the first case, we tried to solve this problem as follows. We closed the ARSA with a balloon to minimize dissection around the aneurysm before circulatory arrest and took care of the pressure changes in the cervical vessels specific to ARSA. With these methods, the surgery was successful without complications after the first case.

Reports on acute lower limb arterial occlusion caused by the traumatic compression of an abdominal aortic aneurysm without rupture are rare. The patient was a 62-year-old man who was injured when his abdomen was caught between a steel frame and the basket of an elevating truck. He was brought to our hospital with motor and sensory disturbance in the right lower limb and poor coloration. Contrast-enhanced CT showed a 40 mm abdominal aortic aneurysm with a mural thrombus protruding into the lumen and a peripheral contrast defect from the right common iliac artery. Emergency right lower extremity artery thrombectomy was performed, and the thrombus was removed below the femoral artery. However, the thrombus remained in the iliac artery area. As a result, abdominal aortic artery replacement surgery was subsequently performed. The patient required a postoperative fasciotomy, but he survived and his lower limb could be saved. He was transferred to a hospital for rehabilitation without myonephropathic metabolic syndrome. There was no other cause of thromboembolism other than the abdominal aortic aneurysm. Therefore, the mural thrombus in the abdominal aortic aneurysm was judged to have embolized into a peripheral artery due to traumatic abdominal compression.

Subclavian artery aneurysm is rare and sometimes seems difficult to decide an approach for surgery because it is surrounded by clavicle, ribs and apex of lung. Here, we are presenting a successfully treated case of right subclavian artery aneurysm with upper partial sternotomy. A 73-year-old man complaining of hoarseness was admitted to our hospital. CT scan revealed left subclavian artery aneurysm 5 mm distal to brachiocephalic trunk with 57×68 mm. Reversed L-shaped partial sternotomy was performed at the 2nd intercostal space, and the skin incision was extended to the superior border of clavicle. He underwent brachiocephalic-right subclavian artery bypass with an ePTFE graft excluding the aneurysm. Post-operative contrast-enhanced CT showed no blood flow in the aneurysm and good blood flow in the bypass. The upper partial sternotomy is considered useful approach for subclavian artery aneurysm.

A 52-year-old man was transported to our hospital with complaint of sudden onset of chest pain. Computed tomography showed type B aortic dissection which had a primary entry at the descending aorta near the branch of the left subclavian artery complicated by visceral malperfusion due to occlusion of the superior mesenteric artery (SMA) and impending rupture of abdominal aortic aneurysm (AAA). Thoracic endovascular aortic repair (TEVAR) was performed to seal the primary entry and expand the true lumen. Then, SMA stent was implanted, resulting in improved perfusion to the SMA. Y-graft replacement for AAA was also performed. After this operation, he suffered from prolonged diarrhea and needed to avoid oral intake for about three weeks. He was discharged on the 41st postoperative day without intestinal resection.