The most important vascular lesion associated with diabetes is arteriosclerosis obliterans (ASO). Differential diagnosis from diabetic foot lesions that produce neurogenic ulcers is important, and the presence of ischemia must be diagnosed as soon as possible. It has been reported that diabetes makes ASO more severe, and often leads to lower extremity amputation. In addition to the need for appropriate early control of diabetes, vascular surgeons are required to perform immediate revascularization in cases of ulcer and necrosis, and to aggressively use surgical treatment with good long-term prognosis.

Lymphedema is caused by dysfunction of the lymphatic system. It is divided into primary edema with no apparent cause and secondary edema with an exogenous cause. The main symptoms are edema and heaviness, skin changes such as skin hardening, lymphocysts, lymphorrhoea, papillomas, and recurrent cellulitis. They are often irreversible and progressive, thus greatly reducing quality of life of the patients. Diagnosis is made by image examinations that can evaluate lymphatic flow and functions such as lymphoscintigraphy and ICG fluorescence lymphangiography. Linear pattern and dermal backflow are the main findings. Conservative treatment consists of four components: compression therapy with elastic garments, exercise therapy, manual lymphatic drainage, and skin care, which is called Complex Physical Therapy (CPT). Although CPT has become the gold standard of treatment, with evidence of efficacy reported in terms of volume reduction, maintenance, and prevention of cellulitis, it is a symptomatic treatment and does not improve impaired lymphatic flow. On the other hand, surgical treatment, such as lymphaticovenous anastomosis and vascularized lymph node transplantation, can create new lymphatic flow and improve lymphatic dysfunctions. Although these techniques are expected to be effective in volume reduction, cellulitis preventation, and improving quality of life, there is a need for more studies with a higher level of evidence in the future. In Japan, lymphedema is treated with a combination of conservative and surgical therapies, but lymphedema is intractable and few cases are completely cured. Therefore, how to improve the outcome of treatment is an important issue to be addressed in the future.

Acute aortic dissection (AAD) is a rare, but a life-threatening condition which arises from an intimal tear in the ascending aorta, resulting in separation of the intimal and medial layers of the aortic wall and subsequent entry of blood flow between the layers. The pressurization of the false lumen of the aorta can lead to coronary, brachiocephalic or branch vessel malperfusion, as well as aortic valve insufficiency, or aortic rupture. The International Registry of Acute Aortic Dissection (IRAD) reported the percentage of patients undergoing surgical treatment for type A AAD (TAAAD) increased from 70% to 90% and the overall surgical mortality improved from 25% to 18% form advances made in surgical techniques, anesthesia, and perioperative medical management. Herein, we describe diagnosis with using several modern modalities, including CT, MRI, Echo, and so on.

Varicose veins and deep vein thrombosis (DVT) of lower limbs are very frequent disorders. Duplex ultrasound (DS) is necessary for diagnosis of the varicose veins, for guiding in surgical intervention and for assessment of postoperative follow-up. DS also enable to provide appropriate treatment for deep vein thrombosis by diagnostic imaging. We should check the spread of varicose veins, vein diameters, resources and course of reflux in varicose veins. For DVT a definite diagnosis should be made by measuring thrombus extent, property and shape, and the treatment should be started as early as possible. Vascular surgeons must learn the method of DS.

Vascular trauma includes arterial and venous injury. In the paper, arterial injury, in which delay in diagnosis is often fatal, is mainly discussed with various experiences in Awaji Medical Center. As its occurrence mechanism, penetrating sharp and blunt trauma due to direct or indirect force are mentioned, and iatrogenic injury is also often experienced. Clinical findings show hemorrhage, hematoma and pseudoaneurysm, and, in blunt trauma, arterial dissection and intimal injury might induce impaired blood flow. In diagnosis, enhanced computed tomography is given as first choice because multiple organ injuries are often associated, and subsequent arteriography is often required to evaluate blood flow in detail. In treatment, direct suture, patch repair and graft replacement are employed for injured sites, and endovascular treatment such as arterial embolization and placement of stent graft are also adopted according to damaged sites and conditions. In addition in treatment strategy., emergent operation under resuscitative endovascular balloon occlusion of aorta and damage control surgery might be taken into consideration for hemorrhagic shock and multiple organ injuries with stable vital, respectively. Here, various pathologies and treatment methods are mainly discussed for vascular injury.

The incidence of axillary artery injury associated with shoulder joint dislocation is extremely rare at approximately 1–2%, and it usually occurs in people aged older than 50 years. Our patient was an 83-year-old woman. The artery in her right upper extremity could not be palpated immediately after reduction of her dislocated right shoulder joint due to a fall. Therefore, acute arterial occlusion with arterial injury was suspected, and the patient was transferred to our hospital. Emergency surgery was performed upon confirming that the axillary artery in the right shoulder joint was occluded, as observed on contrast computed tomography scans. In the right axillary artery injury site, the intima was completely severed, and the adventitia was stretched and thinned. After dissecting the injury site and removing the thrombus, the stump was trimmed and reconstructed with a direct continuous end-to-end anastomosis. Immediately after the surgery, the right radial artery became palpable. The patient showed good recovery and was discharged to her home 10 days after surgery. Herein, we report and discuss this rare case that we encountered.

Post-catheterization pseudoaneurysms are familiar to vascular surgeons. Acquired hemophilia A, on the other hand, is a very rare condition caused by autoantibodies against coagulation factor VIII, which can result in fatal hemorrhage. In the present case, a patient was diagnosed with acquired hemophilia A due to prolonged bleeding from a catheter puncture site and the formation of a pseudoaneurysm. The case was a 79-year-old man, admitted to our department with a pseudoaneurysm of the dorsal radial artery of the left hand after treatment for subacute myocardial infarction. The patient had a hematoma of the dorsal left hand and extensive subcutaneous hemorrhage of the upper limb and trunk. The laboratory date showed prolonged APTT. As the results of the examinations acquired hemophilia A was diagnosed. During the course of the treatment, he suffered acute cholecystitis and his general condition deteriorated, but the patient was successfully treated with percutaneous transhepatic gallbladder drainage and endoscopic transpapillary gallbladder drainage. In patients with severe bleeding tendency and prolonged APTT, this syndrome should be considered as a differential diagnose and an early intervention and appropriate treatment strategy for the comorbidities should be determined.

Superficial temporal artery (STA) aneurysms are rare, and in most cases, represent pseudoaneurysms due to trauma. Non-traumatic spontaneous STA aneurysms are extremely rare, and only few cases of their association with intracranial artery aneurysms have been reported. Herein, we report a case of a non-traumatic true STA aneurysm concurrent with an intracranial artery aneurysm. The patient was a 74-year-old woman who presented with a complaint of a pulsatile mass in the left anterior auricular region that had been present for several months. She had no history of head trauma. Doppler ultrasonography and magnetic resonance imaging revealed a left STA aneurysm and a 2 mm aneurysm of the right anterior cerebral artery. The left STA aneurysm was surgically treated by aneurysm resection and arterial anastomosis under local anesthesia. The patient’s postoperative course was unremarkable. Pathohistological analysis of the resected aneurysm showed preserved three-layer arterial wall, fibrous thickening of the tunica media, and partially disrupted and obscured elastic lamina. Based on these findings and the lack of trauma history, we established a diagnosis of a true spontaneous aneurysm. At the 6 month follow-up, the patient’s condition was good, and she will continue to be followed up for the right anterior cerebral artery aneurysm.

A 56-year-old man had hepercholesterolemia. A statin was prescribed by a nearby doctor. However, the oral administration was discontinued because of hypercreatine kinasemia. The patient was referred to our hospital because of continuous hepercreatine kinasemia. He had short stature, muscle weakness in both lower extremities, blepharoptosis, and left sensorineural hearing loss. As a result of detailed examination, mitochondrial encephalomyopathy was diagnosed according to the diagnostic criteria. Abdominal ultrasonography revealed a markedly mobile plaque in the abdominal aorta just above the inferior mesenteric artery (IMA). EVAR was performed because there was concern about the occurrence of embolism. In surgery, stent graft was opposed directly above the IMA bifurcation of the infrarenal abdominal aorta, and vascular echocardiography confirmed the disappearance of mobile plaque. The patient was discharged without complications such as embolism. We report a case of abdominal aortic mobile plaque complicated by mitochondrial encephalomyopathy treated with EVAR.

The persistent sciatic artery is a rare congenital disease. Owing to the weak structure of the persistent sciatic artery, it progresses into an aneurysm. The aneurysm causes embolisms or ruptures at times. Thus, timely treatment of the patient with a persistent sciatic artery is important. In this study, we report a case of an 86-year-old woman presented with fever (38°C) and pain in the right buttock. A computed tomography scanning revealed the right persistent sciatic aneurysm and inflammatory changes around the aneurysm. However, the infectious persistent sciatic artery aneurysm of the inflammatory aneurysm could not be diagnosed. Thus, the patient was treated with antibiotics, and improvement of the inflammatory reaction was noted through the results of hematological examinations. The infectious persistent sciatic aneurysm was then clinically diagnosed. Since the patient was too old for the infectious lesions to be excised, the endovascular device VIABAHN 8.0×250 mm was used for treatment. The blood culture test reported negative results and the infection was under control. VIABAHN was placed onto the aneurysm and the operation was performed successfully. The patient was discharged 9 days after the operation. 3 years after the operation, she doesn’t have any signs of infection nor obstruction of the stent. Thus, the infected persistent sciatic artery aneurysm was treated with multidisciplinary treatment. And this case can have the longest patency.

Most patients with chronic limb-threatening ischemia (CLTI) also have diabetes mellitus and are undergoing dialysis; simultaneous coronary artery lesions are often present. We report the case of a 59-year-old woman with diabetes mellitus who had been receiving dialysis treatment for 9 years. She had a severe ulcer on her right toe, for which she underwent endovascular treatment at another hospital. However, the infection continued to worsen over the next 9 months and as a result, she was transferred to our facility. The infection spread to the middle of her foot and contained necrotic tissue. A preoperative angiogram revealed occluded arteries in bilateral lower legs and bifurcated coronary artery lesions, including the left main trunk. Immediate revascularization and necrotic tissue debridement was considered to be essential to avoid major amputation. As such, we first performed right distal bypass and debridement after endovascular treatment of the right superficial femoral artery, followed by off-pump coronary artery bypass surgery involving LITA-LAD, Ao-SVG-#12. Additional debridement of the right foot was performed at 19 days post-surgery. Subsequently, vacuum-assisted closure therapy was initiated and the patient underwent split-thickness skin grafting. The condition of the foot gradually improved and the patient was able to walk unaided. The patient did not develop angina and was discharged 57 days post-surgery. Therefore, combined treatment for CLTI demonstrated satisfactory results.

Idiopathic pseudoaneurysm of the posterior tibial artery rarely occurs in the ankle. This case report describes an asymptomatic 65-year-old female patient who presented with swelling behind the right medial malleolus. Computed tomographic angiography revealed a 23 mm pseudoaneurysm with a mural thrombus in the distal posterior tibial artery and occlusion of the distal anterior tibial artery. Excision of the pseudoaneurysm and reconstruction of the posterior tibial artery, with direct end-to-end anastomosis, was performed electively since doppler and oximetry studies demonstrated that the right posterior tibial artery was the main arterial supply to the foot and it was easy to access surgically. The postoperative course was uneventful; on day 21 postoperatively, computed tomographic angiography demonstrated patency of the right posterior tibial artery. Surgical treatment should, therefore, be considered as a first choice because arterial access in the ankle is easier compared to more proximal lesions.

Intestinal malrotation refers to the impaired rotation of the intestinal tract and its fixation to the peritoneum. Pediatric patients are the most commonly affected population, while adult patients are rarely affected. Few reports exist on abdominal aortic aneurysm replacement in patients with intestinal malrotation. However, the surgical strategy remains unestablished. This study reports the case of a 69-year-old man, who was diagnosed with intestinal malrotation during gastric cancer surgery and underwent abdominal aortic aneurysm replacement via a transperitoneal approach. The intestinal malrotation was challenging to evaluate on computed tomography. Due to the patient’s age, abdominal aortic aneurysm replacement was deemed appropriate. Intraoperatively, the small intestine was located in the right abdomen, while the colon was in the left abdomen. The duodenum, mesentery, and ascending colon were not fixed to the peritoneum. The intestine was mobilized to the right upper quadrant and abdominal aortic aneurysm replacement was performed to address the infrarenal abdominal aortic aneurysm. The small intestine was placed in the right abdomen, while the colon was placed in the left abdomen to prevent postoperative midgut volvulus. Based on this case, patients with abdominal aortic aneurysm and a concomitant intestinal malrotation may nevertheless undergo surgery safely and the important procedures for the performance are how to approach the aorta and bowels’ positioning when closing abdomen.