Serious complications due to remote control often may occur during endovascular surgery. Therefore, it is necessary to know what complications are likely to occur or how to bail out those complications. Herein, we explain complications related with endovascular surgery and their bail out procedures.

Diagnosis and treatment of cardiovascular diseases often require the administration of iodinated contrast media. However, it is sometimes difficult to use such contrast media in patients with renal dysfunction because direct mechanisms of tubular cell injury and indirect mechanisms of medullary ischemia, together with the contrast medium, may cause contrast-induced nephropathy (CIN). Although the frequency of developing CIN is said to be lower than previously estimated, once it develops, there is no effective treatment, and it may affect mortality. Therefore, before using a contrast medium, it is necessary to identify the risk factors of CIN in patients—including, chronic kidney disease, advanced age, and diabetes mellitus—and understand the risk differences between intravenous and intra-arterial contrast medium administration. If there is any risk, intravenous saline or sodium bicarbonate treatments may be used to prevent CIN onset, and the use of minimum amounts of contrast media, within the corresponding range, may be recommended.

Objective: Because of the introduction of new cages that can be used for the treatment of degenerative disc disease, spondylolisthesis and other painful spinal conditions, the anterior approach has been gaining popularity as an acceptable method for exposure of the anterior spine. Due to the potential seriousness of complications of the anterior approach such as major vascular injury, vascular surgeons in Western countries collaborate to help gain access to the lumbar spine. It is not common for vascular surgeons to participate in spinal surgery in Japan. This study aimed to evaluate the complications and challenges in anterior lumbar interbody fusion (ALIF) and provide guidance on these procedures. Methods: From August 2019 to January 2023, we gained access to the anterior lumbar spine during ALIF in 21 cases. We evaluated the patients’ conditions, operating time, bleeding events, major vascular complications, and problems with these procedures. Results: The mean patient age, operating time and bleeding volume were 64.9±12.3 years (male: 13 cases), 234.8±68.7 min and 197±167 mL, respectively. In 19 of the cases (90.5%), there were no complications such as uncontrolled bleeding, arterial complication, nerve injury, or death. Bleeding from the left common iliac vein and the median sacral vein was noted in two cases (9.5%). Hemostasis with suture was very difficult to achieve, because the operative field was very deep and narrow. So we controlled the bleeding using only compression at the affected site. Since control of bleeding is often challenging in ALIF, it is important to acquire the skills necessary to control it. Conclusion: Becoming an expert in anatomical techniques and knowledge of orthopedic surgery as well as in manipulation of vessels is essential when vascular and orthopedic surgeons work together in spinal surgery.

Objective: The previous standard method for revascularization in Leriche syndrome was open surgery (OS). However, there has been a recent increase in the use of endovascular therapy (EVT), which has shown improved treatment outcomes compared with OS. We report the treatment outcomes of EVT for Leriche syndrome in our department. Methods: We examined 32 patients with 57 legs with Leriche syndrome that underwent revascularization between 2001 and 2022 (mean age 72±10 years, 27 males). The primary endpoint was the 5-year primary patency rate. The secondary endpoints were the postoperative ankle-brachial index (ABI), complications, hospital stay, and efficacy of EVT. Results: The initial technical success rate in the EVT group was 85% (18/21). The EVT group comprised 20 patients with 33 affected legs, while the OS group comprised 12 patients with 24 affected legs. There was no significant difference between the two groups in the preoperative ABI (p=0.17). The postoperative ABI was also similar in the EVT group (0.86±0.18) and the OS group (0.86±0.20) (p=0.90). There were no postoperative complications reported in the EVT group, while the OS group had one case of sepsis and one of intestinal obstruction. Excluding Fontaine IV cases, the postoperative hospital stay was significantly shorter in the EVT group (9±5 days) than the OS group (18±7 days) (p<0.002). There were no remote complications reported in the EVT group, while the OS group had one case of graft infection and one of incisional hernia. The cumulative patency rates at 1, 3, and 5 years did not significantly differ between the EVT group (100, 93, and 93%, respectively) and the OS group (100, 89, and 89%, respectively) (p=0.475). Conclusion: EVT for Leriche syndrome is a minimally invasive treatment that reduces the hospital stay without causing complications. EVT was equally effective as OS and is a valuable option.

Aortic dissection combined with aortic aneurysm is not uncommon. However, an acute aortic dissection and a ruptured aortic aneurysm rarely occur together; therefore, there is no established treatment strategy. A 90-year-old man complained of abdominal pain. Contrast-enhanced computed tomography (CT) showed a Stanford type B acute aortic dissection and ruptured abdominal aortic aneurysm. The aortic dissection had an entry in the descending thoracic aorta and a false lumen extending from the distal aortic arch to the external iliac artery, with localized extravasation of contrast medium from the false lumen of the abdominal aortic aneurysm. Emergency endovascular aortic repair was performed, and completed without any apparent endoleak. The patient was treated conservatively for Stanford type B acute aortic dissection post-surgery and discharged 34 days postoperatively. Follow-up CT demonstrated a decrease in the diameter of the abdominal aortic aneurysm and remodeling of the false lumen.

Mesenteric ischemia resulting from superior mesenteric artery (SMA) occlusion, an uncommon cause of abdominal pain, may require intervention. Superior mesenteric artery aneurysms (SMAAs) are rare. Resection is recommended because of their high risk of rupture and resultant significant mortality. Intraoperative assessment of perfusion of the involved small bowel is helpful when determining the need for vascular reconstruction or bowel resection; however, a standard means of assessing this has not yet been established. Here, we present a case of a 63-year-old man who presented with abdominal pain and who was found to have SMA occlusion caused by infective endocarditis, resulting in a non-ruptured SMAA. During resection of the SMAA, indocyanine green angiography to assess bowel perfusion indicated that neither revascularization nor small bowel resection were needed. His abdominal pain was resolved and his postoperative course uneventful. Indocyanine green fluorescence imaging is an effective means of assessing bowel perfusion during resection of an SMAA.

In thoracic endovascular aortic repair (TEVAR) for aortic arch aneurysm, preserving the neck vessels are important and many techniques are exist. In this case, the patient was 81-year-old man who had large aortic arch saccular aneurysm. The patient was very thin (BMI 15.6) and artificial vessel infection was feared when we performed 2 debranching TEVAR. Therefore, we performed zone 1 TEVAR with periscope sandwich technique for left subclavian artery reconstruction. The postoperative course was uneventful. Postoperative CT showed no endoleak and sac regression and bypass patency. Although the long term prognosis remains unclear, this method could be a feasible treatment for aortic arch aneurysm.

Isolated left vertebral artery (ILVA) is one of the common variations of the aortic arch branch. However, there are few reports of ILVA reconstruction in debranching thoracic endovascular repair (TEVAR). Case 1 was a 66-year-old woman and Case 2 was a 29-year-old woman. In both cases, the left common carotid artery (LCCA)–left subclavian artery (LSCA) bypass and ILVA were anastomosed directly onto the LCCA, and 1-debranching TEVAR was performed in Case 1 and 1-fenestrated, 1-debranching TEVAR was performed in Case 2. Case 3 was an 80-year-old man with distal arch saccular aneurysm with LCCA–LSCA bypass and 1-debrancing TEVAR. There were no obvious postoperative neurological complications in these three cases. ILVA was relatively easy to reconstruct and good results were obtained.

75-year-old man had a past medical history of endovascular aortic repair using a Talent endograft for abdominal aortic aneurysm (AAA) 11 years before at our institution. He was referred to our hospital because a 10-mm diameter enlargement of the aneurysm caused by Type II endoleak (EL) was recognized. He underwent coil embolization of the inferior mesenteric artery. However, he presented with acute lumbago 5 months later. Computed tomography revealed ruptured AAA with extravasation of the contrast medium from the right limb of the Talent endograft, suggesting Type IIIb EL. He underwent emergent laparotomy. A 10×5 mm perforation at the proximal right limb of a Talent endograft was noted. The stent graft was partially removed and a Y-graft replacement was successfully performed. He was discharged 14 postoperative day without any complications. Here, we report a rare case of AAA rupture caused by Type IIIb EL resulted from a giant fabric tear 11 years after the placement of a Talent endograft.

The patient is a 68-year-old man. He had undergone aorto-bilateral femoral artery bypass surgery 37 years ago and has undergone reoperation three times since then. This time, a non-pulsatile mass in the left inguinal region gradually enlarged, and after a close examination, a left femoral artery anastomotic aneurysm was diagnosed, and the patient was admitted to the hospital for surgery. In the operation, the deteriorated artificial vessel aneurysm, the common femoral artery, and the external iliac artery were removed as a single lump, and the previous artificial vessel and the common femoral artery were reconstructed using a new artificial vessel (HEMASHIELD). In addition, a bypass was created between the peripheral end of the external iliac artery and the HEMASHIELD using PROPATEN. Finally, an additional Excluder leg was implanted to reinforce the remaining artificial vessel in the left leg. The hybrid procedure was effective in terms of intraoperative hemorrhage control and other aspects of surgery for previously deteriorated artificial vessels.

A 79-year-old woman developed chest and abdominal pain and was rushed to the hospital. Enhanced computed tomography revealed type A acute aortic dissection with superior mesenteric artery occlusion. The patient was diagnosed with intestinal ischemia and emergency surgery was performed. Left common iliac artery-superior mesenteric artery (SMA) bypass grafting was performed using the great saphenous vein, then ascending aorta and arch replacement was performed. Intestinal blood flow was measured by using indocyanine green (ICG) fluorescence method. Although the entire small intestine looked pale, intestinal resection was not necessary on the same day. A second look operation was performed on post operative day 1, 6 cm portion of the small intestine was resected, and most of the intestinal tract could be preserved. Her progress was uneventful and she was discharged on the 29th postoperative day. SMA bypass and ICG fluorescence method may be an effective treatment for aortic dissection with intestinal ischemia.