Objective: Persistent endoleak (EL) is a major cause of aneurysmal enlargement or rupture after endovascular aneurysm repair (EVAR). Treatment strategy for type II EL (T2EL) remains controversial. Methods: From February 2012 to August 2022, we performed 151 EVARs using Excluder (WL Gore and Associates, Flagstaff, AZ, USA). Patients with increased aneurysm diameter of ≥5 mm post-EVAR were considered for retreatment. Aortic branches artery closure and aneurysmorrhaphy (BACA) through laparotomy was performed in 11 patients (11 men, mean age 75.6±4.4 years). We retrospectively reviewed the BACA outcomes. Results: The overall retreatment rate was 8.6%. The interval from the primary EVAR was 49.7±16.2 months. The operation time was 183±37 min and postoperative hospital stay was 14.6±2.6 days. Aneurysm shrank gradually in all patients. No surgical or aneurysm-related deaths were observed during the observation period of 19.2±9.5 months. Conclusion: Early BACA results were favorable, although long-term results require further investigation. Although aneurysmal re-enlargement after BACA may occur, aneurysm-related event would be delayed because the BACA shrank sac diameter. Therefore, BACA is an acceptable procedure, considering the patients’ backgrounds.

Objective: Thromboangiitis obliterans (Buerger disease) is known as an intractable vascular disease that has been reported as thrombosis in distal arteries and occasional venous occlusion, as well as inflammatory changes in the thrombus and vascular wall. Patients often require limb amputation due to limb necrosis. Corkscrew (CS), a small arterial coiling, is an important diagnostic finding that was mainly found with angiography. Recently, however, it can also be identified using a modern ultrasonographic technique. Methods: In thease 22 cases, in 48 areas of study, we used the ultrasonographic technique to identify the CS, which allowed us to observe its relationship with the surrounding nerves and arteries. Results: In all cases, it was possible to identify the CS easily and it was confirmed that the CS and the nerve were carried down in their sheath. The sites of the CS existed in areas other than the area around the occluded main arteries and some CS that ran inside the nerve (16 areas) and some CS that accompanied the outside of the nerve (10 areas) were confirmed, suggesting the CS work as collateral blood supply vessels, with well-developed normal vessel-like anatomy. Conclusion: When we observe the CS, it is important to observe not only around the main trunk artery, but also areas where nerves mainly run, even if they do not accompany the main trunk artery.

Objective: To evaluate the mid-term outcomes following TEVAR for chronic type B aortic dissection (TBD), especially to know which re-entry closure affecting on the thoracic false lumen remodeling in the late chronic TBD. Methods: From April 2017 to April 2022, 25 patients with chronic TBD underwent TEVAR. The late chronic TBD received the re-entry closure including stent-graft deployment in renal artery, infrarenal aorta and unilateral or bilateral iliac artery. Results: Complete shrinkage of the thoracic false lumen were accomplished in 67% of the early chronic cases, but in only 13% of the late chronic cases. The thoracic false lumen shrinkage over 5 mm in diameter were obtained in 78% of the early chronic cases and in 69% of the late chronic cases. Univariate and multiple logistic regression analyses revealed the re-entry closure of common or external iliac artery affected on the thoracic false lumen remodeling. Conclusion: The re-entry closure in common or external iliac artery could affected on the thoracic false lumen remodeling following TEVAR for the late chronic TBD.

Spinal cord ischemia (SCI) is one of the serious complications in patients undergoing TEVAR (thoracic endovascular aortic repair). Although the left subclavian artery (LSA) reconstruction in patients with zone 1 and zone 2 TEVAR is controversial, LSA reconstruction has been reported to prevent peri-operative SCI. The isolated left vertebral artery (ILVA) is a common anomaly in which the left vertebral artery originates directly from the aortic arch. We report the ILVA reconstruction in addition to the left common carotid artery (LCCA)–LSA bypass in zone 2 TEVAR performed in two patients with thoracic aortic aneurysm and aortic dissection. Case 1: A 79-year-old female with hoarseness had a distal aortic arch aneurysm 50 mm in diameter with ILVA. Since the length between ILVA and the aneurysm was 19 mm, we performed ILVA end-to-side anastomosis in addition to LCCA–LSA bypass using PROPATEN graft prior TEVAR. Zone 2 TEVAR was then performed using conformable TAG. Case 2: A 70-year-old female undergoing the partial aortic arch replacement (innominate and left common carotid artery reconstruction) for type A aortic dissection had a new entry at the distal anastomosis. She had the ILVA between LCCA and LSA, we performed zone 2 TEVAR with LCCA–LSA bypass and the reconstruction of ILVA. The post-operative courses were uneventful. The ILVA reconstruction could prevent peri-operative stroke and SCI.

A 71-year-old man was found to have a saccular aneurysm of descending aorta with a concomitant vertebral erosion near the aneurysm. The aneurysmal diameter expanded from 40 mm to 43 mm during eight months, and we treated the aneurysm with TEVAR. Two thoracic endovascular grafts were released from the left subclavian artery (zone 3) to the T8 level. However, postoperative CT revealed an endoleak. We observed the patient carefully because the type of the endoleak was unknown at first. But the aneurysmal lesion occurred a residual expansion with the progression of the vertebral erosion. Accordingly, the patient complained of back pain. Thus, we reviewed CT images for an additional treatment, and pointed out a bird-beak configuration at the proximal edge of stent graft. Therefore, we concluded that a type Ia endoleak occurred after TEVAR and it caused the progressive expansion of the aneurysmal lesion. As the additional treatment, we extended the proximal edge of stent graft to zone1 by two debranching TEVAR combined with an axillary-axillary-left common carotid artery bypass. The endoleak and the progression of the vertebral erosion were terminated after the additional treatment. Also, the back pain disappeared immediately after the treatment. The CT at two years after the additional treatment showed shrinkage of the aneurysm.

We report a case of staged repair for acute aortic dissection with Kommerell’s diverticulum. A 40-year-old man with chest pain was referred to our hospital. A CT scan showed a Kommerell’s diverticulum in the descending aorta and a dissected lumen extending from the aortic root to the diverticulum. Emergency surgery was performed. Because the entry site of the diverticulum was unclear, we planned to cover the diverticulum with TEVAR (thoracic endovascular aortic repair) in the early postoperative period. The ascending aorta and aortic arch were replaced. On the fifth postoperative day, the left common carotid artery and left axillary artery were bypassed and TEVAR was performed. Postoperative enhanced CT scan revealed a type 2 endoleak from the left subclavian artery, and embolization was performed. On the 35th postoperative day, the patient was discharged from the hospital independently. We experienced a successful case of staged repair for acute aortic dissection with Kommerell’s diverticulum.

We report 3 cases of rare lesions of the lateral thoracic artery (LTA) treated with endovascular or surgical treatment. Case 1: A 31-year-old man with Marfan syndrome. He had undergone Bentall surgery for type A acute aortic dissection with annuloaortic ectasis 6 years ago and had been anticoagulated with warfarin since then. He presented to the emergency department with a complaint of bloody sputum, and a close examination revealed an intrathoracic hematoma due to spontaneous rupture of the right LTA. The patient underwent effective hemostasis by embolization of the responsible artery. Case 2: 69-year-old man presented to his local doctor with a complaint of increasing left back pain, and a pulsatile mass with thrill was palpated at the same location as the pain. CT scan revealed a pseudoaneurysm associated with a left lateral thoracic arteriovenous malformation. Endovascular treatment was performed by embolization of a pseudoaneurysm to achieve disappearance of blood flow. Case 3: A 37-year-old man with a history of surgery for left spontaneous pneumothorax. He presented hospital with hemoptysis and repeated bloody sputum and was diagnosed a left LTA-pulmonary artery fistula and hemorrhage from the same site. Thoracoscopic dissection of the neovascularization and partial resection of the lingular segment of the left lung were performed.

Although cases of superior mesenteric artery syndrome (SMAS) due to abdominal aortic aneurysm (AAA) are reported, most cases being triggered by gastrointestinal symptoms. In this report, we experienced a case of SMAS that developed during hospitalization due to large AAA. The patient was a 74-year-old man. He was seen in a referring hospital with a chief complaint of lower back pain and was diagnosed with AAA with a maximum aneurysm size of 104 mm, then referred to us. We decided to undergo semi emergency surgery and started hospitalization, but he vomited on the day after admission and was diagnosed with SMAS by contrast-enhanced computed tomography (CT) . After gastric tube placement, the gastrointestinal symptoms improved. He underwent open graft replacement on hospital day 5 and was discharged home on 13 postoperative days. Considering the CT examination before and after the onset of SMAS in this case, it was thought that SMAS could be predicted from before onset during follow up of AAA.

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 2020, 1299 CLI limbs (male 890 limbs: 69%) were registered by 85 facilities. ASO has accounted for 99% of the pathogenesis of these limbs. In this manuscript, the background data and the early prognosis of the registered limbs are reported.