In recent years, EVT has come to play an important role in revascularization of the femoropopliteal artery region, however the number of cases that cannot be treated with EVT is increasing, and the importance of bypass surgery has been reaffirmed. We will provide an overview of revascularization of the femoropopliteal artery region in accordance with JCS/JSVS 2022 Guideline on the Management of Peripheral Arterial Disease.

Infrapopliteal revascularization is generally performed for patients with chronic limb-threatening ischemia. As with revascularization in other fields, the indications for endovascular treatment have expanded in recent years due to advances in endovascular devices and techniques. However, the optimal revascularization method must be selected based on (1) patient risk, (2) limb severity, and (3) anatomical pattern of disease. Therefore, vascular surgeons need to understand the characteristics of endovascular treatment and surgical treatment and improve the technical skills of both procedures. Here is an overview of the current methods of revascularization.

It is a clear fact that many complications in surgical treatment, not just in cardiovascular surgery, are caused by things related to surgical techniques. In other words, post-operative problems are already determined by the pre-operative surgical managements and intra-operative surgical operations. This describes strategies to avoid the surgical complications of distal bypass using the autogenous veins for each item.

The patient was a 45-year-old woman with diabetes mellitus and chronic kidney disease requiring dialysis. She was referred to our hospital with a chief complaint of an ulcer in the center of the left lower leg. The ulcer worsened despite critical limb ischemia revascularization. The femoral amputation wound was considered to have sufficient blood flow. However, the cut stump and inguinal wound opened, thereby requiring debridement and negative pressure wound therapy. The first ulcer in this case was not a toe ulcer, which is a characteristic of arteriosclerosis obliterans. However, the ulcer was located in the middle of the lower leg. Moreover, the ulcer occurred at the cut stump of the thigh and groin area that had no ischemic damage. As the painful ulcer progressed, we diagnosed the patient with calciphylaxis. We decided to discontinue oral warfarin and corrected serum calcium and phosphorus levels. Finally, these treatments healed the wounds.

Pulmonary artery intimal sarcoma is a rare disease associated with poor prognosis. The incidence of orphan disease is 0.001–0.03%, but it must be underestimated because pulmonary sarcoma frequently mimics pulmonary vascular disease, such as acute pulmonary embolism, chronic thromboembolic pulmonary hypertension. Clinical presentations are unusually with symptoms of cardiorespiratory dysfunction, and although early diagnosis is always difficult. We reported the case of male who was admitted to our hospital with abnormal chest shadow. A computed tomography (CT) scan showed a tumor invaded the main pulmonary artery from the left pulmonary artery. The tumor was aggressively resected with left pneumonectomy and reconstruction of the main pulmonary artery to right pulmonary artery using an artificial blood vessel under cardiopulmonary bypass. Although surgical resection is the standard of care, radical complete resection is rarely reported for tumors involving the main PA. We introduced a heart-lung machine under local anesthesia before introducing general anesthesia, and started the heart-lung machine at the same time as the start of surgery. Hemodynamics were stable and surgery could be performed safely. Complete tumor resection was possible by revascularization using artificial blood vessels. As a result, no local recurrence was observed 6 months after the operation, and a prognosis of 9 months was obtained.

A 39-year-old man complained of repeated nausea and vomiting after eating. Computed tomography showed that the esophagus was compressed between the trachea and the aberrant right subclavian artery and Kommerell’s diverticulum. Additionally, upper gastrointestinal endoscopy showed membranous stenosis in the mid-esophagus. Surgical intervention was carried out through a median sternotomy approach, involving the excision of Kommerell’s diverticulum and reconstruction of the right subclavian artery. Approximately 3 months later, esophageal dilation was performed for the remaining membranous stenosis using an esophageal bougie in three sessions with the bougie size gradually increasing at 1.5 month intervals. This procedure resulted in expansion of the stenotic area and improvement of the esophageal passage obstruction.

Spinal cord ischemia is an extremely rare but severe complication following infrarenal abdominal aortic aneurysm repair and occurs in approximately 0.1 to 0.2% of elective cases. We present a case of a 79-year-old man who developed paraplegia due to spinal cord ischemia after an elective repair for a 50 mm infrarenal aortic aneurysm. The procedure involved infrarenal aortic clamping and aorto-bilateral external and internal iliac reconstruction. Three pairs of lumbar arteries were suture ligated. Postoperative paraplegia was neurologically recognized, and spinal cord infarction was confirmed by magnetic resonance imaging. Despite the steroid administration and rehabilitation efforts, there was no discernible improvement in paraplegia, sensory disturbance, or urinary and bowel excretory dysfunction. Currently, no reliable method exists to prevent paraplegia following abdominal aortic aneurysm repair. Although it is an extremely rare, the possibility of this serious complication should be included in preoperative informed consent documents.

Budd-Chiari syndrome is a disease of impaired hepatic venous outflow that can progress to cirrhosis, portal hypertension, and other progressive liver disorders. To improve the long-term prognosis of Budd-Chiari syndrome, it is important to drainage the hepatic venous outflow, which is the essence of the disease. We herein report a case in which the occluded hepatic veins were successfully drained by direct surgery through a median sternotomy and upper partial laparotomy. A 64-year-old woman was hospitalized for a Budd-Chiari syndrome due to obstruction of the middle and left hepatic veins. She was approached by an upper approach through a median sternotomy and upper partial laparotomy. The inferior vena cava (IVC) was incised through the right atrium under cardiopulmonary bypass. The occluded hepatic veins were buried in liver parenchyma, they could be reopened by excising some volume of liver tissue between IVC and hepatic veins. Then, hepatic veins perfusion was improved.In patients with Budd-Chiari syndrome, which occurred on occlusion of hepatic veins, an upper approach with cardiopulmonary bypass is a valuable technique to improve hepatic veins perfusion.

Venous aneurysm (VA) is a relatively rare disease defined as a localized dilating lesion of vein without elongation. VA can develop anywhere in the venous system. We report a rare case of peripheral neuropathy caused by a VA in the upper extremity. A 44-year-old male carpenter, present with numbness and pain in the entire left upper extremity while using the left arm. Magnetic resonance image and computed tomography revealed a 42×26 mm VA of the median cubital vein. The VA was surgically resected and the symptoms completely disappeared. The resected specimen was histopathologically consistent with VA.

Arterial injury associated with central venous catheterization may be fatal and warrants appropriate management. We report a case of successful endovascular treatment for right subclavian artery injury secondary to central venous catheterization in a 49-year-old man with end-stage renal failure. We attempted insertion of a cuffed hemodialysis catheter through the right internal jugular vein; however, the catheter accidentally entered the right thoracic cavity and led to hemothorax. Contrast-enhanced computed tomography showed that the catheter crossed the right subclavian artery, and although we suspected arterial injury, we did not detect apparent extravasation. Therefore, we performed endovascular treatment for catheter removal. We observed a large amount of bleeding into the thoracic cavity after removal of the catheter and immediately deployed a stent graft into the right subclavian artery. Currently, guidelines are unavailable for treatment of vascular injuries caused by central venous catheters. Endovascular treatment may be a useful minimally invasive therapeutic option in such cases.

We report a rare case of a right subclavian artery aneurysm with recurrent laryngeal nerve paralysis. A 67-year-old male who complained of hoarseness was diagnosed with recurrent laryngeal nerve paralysis and a right subclavian artery aneurysm. Contrast-enhanced computed tomography revealed that the recurrent laryngeal nerve passed through a tortuous aneurysm. To avoid direct surgical damage to the laryngeal nerve, a hybrid treatment with stent grafting was chosen. Stent grafting (Viabahn VBX, W.L.Gore & Associates, Flagstaff, AZ, USA) from the brachiocephalic artery to the right common carotid artery, measuring 7×39 mm, was performed followed by the embolization of the distal aneurysm (Target (Stryker Neurovascular, Fremont, CA) 10 mm–40 cm) using Interlock (Boston Scientific, Marlborough, MA, USA) measuring 8 mm–20 cm. A bypass from the right common carotid artery to the right subclavian artery (Propaten 7 mm, W.L.Gore & Associates, Flagstaff, AZ, USA) was performed. Six months later, the patient’s hoarseness disappeared, and the aneurysm reduced in size. Three years and six months have passed without recurrence of hoarseness, enlargement of the aneurysm, or bypass occlusion.

In the treatment of CLTI with foot deformity, there are many cases where ulcers recur due to poor compliance with the orthosis, even though the ulcers have been healed by revascularization. For foot deformities that are difficult to manage even with conservative offloading such as an orthosis, surgical offloading is recommended, which surgically corrects foot deformities and aims to distribute pressure. In this study, we performed surgical offloading (Achilles tendon lengthening and tibialis posterior tendon transfer) after revascularization for CLTI with equinovarus foot. Four years after surgery, the patient is able to walk barefoot and has no recurrence of ulceration. In cases of CLTI with foot deformity that is difficult to manage even with conservative offloading, surgical offloading should be considered in addition to revascularization.

Popliteal venous aneurysms are relatively rare and may cause pulmonary embolism. Anticoagulation alone may not prevent recurrent pulmonary embolism, and surgery should be performed. Case 1: A 76-year-old male presented with palpitations and dyspnea, and CT showed bilateral pulmonary embolism and deep venous thrombus in the left external iliac vein. At the same time, it showed a right popliteal venous aneurysm with a diameter of 30 mm. He was treated with anticoagulant therapy, and the pulmonary embolism improved. An elective tangential aneurysmectomy for the right popliteal venous aneurysm was performed. Case 2: A 77-year-old female presented with palpitations and dyspnea. CT revealed a pulmonary embolism and a left popliteal venous aneurysm with the thrombus. She was anticoagulated for the preoperative period. After pulmonary embolism improved, an elective tangential aneurysmectomy was performed to prevent a recurrence of pulmonary embolism. Both patients have had no recurrence of pulmonary embolism.

Posterior tibial artery aneurysms are extremely rare, and most of them are iatrogenic or traumatic pseudoaneurysms. I have experienced a case in which revascularization was performed using the great saphenous vein for an idiopathic posterior tibial artery pseudoaneurysm for which the extrinsic cause was not clear, and we report this including a review of the literature. The patient was a 74-year-old man. He had been aware of swelling in his left lower leg for three months before coming to the hospital. He was diagnosed with a left posterior tibial artery aneurysm and was referred to our department. The left posterior tibial artery aneurysm was approximately 41×70 mm in size and extremely large. Due to the large size of the aneurysm, it was difficult to reconstruct the aneurysm with direct anastomosis, and a great saphenous vein graft was used to reconstruct the blood circulation. Postoperative echocardiograms of the lower limbs showed the blood flow in the reconstructed graft, and ankle brachial index and skin perfusion pressure did not change before and after the surgery. In this case, revascularization with the great saphenous vein was required due to the huge posterior tibial artery aneurysm, but revascularization can be performed with relatively minimal incisions, and the postoperative course progressed without any symptoms of lower extremity artery occlusion and any trouble of wound. The blood flow to the distal side of the posterior tibial artery was patent before surgery, and aggressive surgical revascularization should be considered to maintain long-term blood flow in the peripheral blood vessels of the lower extremities.