Endovascular therapy for femoropopliteal lesions has been accepted in the real world clinical settings, due to development of devices and establishment of procedures. The author herein described the current situation focusing on the latest devices. Selecting an appropriate finalizing device according to patient background and lesion anatomy is an important factor in long-term clinical results, but currently there are no uniform selection criteria. This article outlines the clinical results in Japan of the main finalizing devices for femoropopliteal EVT available in Japan, and describes the advantages and disadvantages of each device (stent graft, drug eluting stent, drug coated balloon, and interwoven nitinol stent).

Acute limb ischemia (ALI) is a sudden decrease in lower limb arterial perfusion with a potential threat to not only the survival of the limb but also the life, requiring urgent evaluation and management. The etiology of ALI is broadly divided into embolism and thrombosis with various comorbidities. Severity and treatment strategy should be determined based on physical findings and image findings. Revascularization can be performed surgically (thromboembolectomy or bypass), endovascularly, or as a hybrid procedure. In all cases, it is important to perform intraoperative angiography and perform appropriate additional procedures. Prompt response to myonephric metabolic syndrome or compartment syndrome during or after revascularization is also essential. ALI is a serious condition requiring emergency treatment, and it is important to be familiar with all treatment options, including surgical and endovascular treatments, fasciotomy, and primary limb amputation, and to promptly provide the best initial treatment available at each facility.

Aberrant radial arteries, also called superficial radial arteries, have been described to lie close to the cephalic vein of the forearm that is frequently cannulated for venous access. Certain medications cause serious sequelae, such as gangrene and limb loss, if accidentally injected into the artery. An 81-year-old-woman was injected with diazepam near her left wrist joint prior to upper gastrointestinal endoscopy at a local clinic. Swelling, pain, and a cold sensation immediately appeared from the wrist joint to the first to third fingers. The patient was referred to our hospital for further investigation and treatment on the seventh day. Ultrasonic examination and contrast-enhanced computed tomography images showed that her radial artery ran superficial to the anatomical snuffbox and was confirmed to be a superficial radial artery. We surmised that diazepam was injected into the artery, misidentifying it as the cephalic vein, and causing ischemia. Lipo-prostaglandin E1 was administered intravenously every day; however, ulceration was suspected on the 18th day. We determined that she was a candidate for hyperbaric oxygen therapy, and a total of 16 sessions were administered. Epithelialization was achieved one month later, and no sequelae were observed.

We experienced a rare case of retrograde type-A acute aortic dissection with patent false lumen complicated with multiple simple hepatic and renal cysts. The patients suffered stroke at the onset of aortic dissection and cardiopulmonary bypass was contraindication. Thoracic endovascular aortic repair was performed to exclude the primary entry in the distal aortic arch. For 2 years from January in 2022 to December in 2023, 45 patients underwent surgery (including endovascular repair) for type-A acute aortic dissection in our hospital. Among them, there were 14 cases (31.1%) with simple renal cyst, 11 cases (24.4%) with simple hepatic cyst, 20 cases (44.4%) with either cyst, 5 cases (11.1%) with both cysts, and one case (2.2%) with both multiple simple hepatic and renal cysts. Although matrix metalloproteinases have been suggested to play a role in common etiology of simple hepatic and renal cysts and aortic dissection, further investigations would be required.

Endovascular treatment for renal artery aneurysms has been reported with good results. A large saccular aneurysm (25 mm×30 mm×30 mm) in the anterior branch of the left renal artery in a healthy 34-year-old man had a broad-base neck of 11 mm with a neck-to-dome ratio of 2.3. The aneurysm was considered unsuitable for coil embolization, and a covered stent would have occluded the other segmental artery. A stent for coronary artery (Xience Skypoint) was placed in the target vessel to cover the aneurysmal neck, and the aneurysm was adequately filled with coils. This procedure was considered to provide sufficient filling of coils even for aneurysms unsuitable for coil embolization. The patient was discharged on the second postoperative day without any complications. On the other hand, we initially selected a stent so that it was landed approximately 4 mm proximal and distal of the aneurysm, but it fell into the aneurysm because its length was shorter than expected to need stent-landing sufficiently. Thus, we delivered an additional stent long enough. Endovascular treatment for renal artery aneurysms with good short-term results has been established, and experiences of device selection and mid- to long-term outcomes would like to be accumulated.

A 78-year-old woman was presented with an 80-mm infrarenal abdominal aortic aneurysm. The inferior mesenteric artery was occluded. The bilateral internal iliac arteries, 5 pairs of the intercostal arteries, and 3 pairs of the lumbar arteries were patent. The Adamkiewicz artery was unidentified. Endovascular aneurysm repair (EVAR) under general anesthesia was performed. The limbs of the stent graft were landed on the bilateral common iliac arteries. Since admission to the intensive care unit, numbness in bilateral lower extremities had continued. Four hours after the operation, thermoanesthesia and analgesia below the L1 level and motor paralysis of the bilateral lower extremities were observed. Steroid pulse therapy, continuous intravenous infusion of naloxone, and cerebrospinal drainage (CSFD) were commenced for paraplegia. These treatments, however, were ineffective. Magnetic resonance imaging (T2WI) revealed swelling and raised signal in the spinal cord from the Th11 to L1 level, and spinal cord infarction was diagnosed. There is no valid prophylaxis for postoperative SCI. Although CSFD might be effective to treat SCI to some extent, explaining the risk of post-EVAR SCI (despite extremely low) is important in obtaining informed consent.

Syphilis has been on the rise in recent years, but syphilitic aortic aneurysm remains a rare disease. In this report, we describe a case of syphilitic thoracic aortic aneurysm treated with antimicrobial agents followed by surgical treatment. The patient is a 76-year-old woman. A brachiocephalic aneurysm and left common carotid artery origin stenosis were treated at another hospital 28 years ago with brachiocephalic aneurysm resection, resection opening patch closure, and aorta-left common carotid artery bypass surgery. She was positive for syphilis in the preoperative examination at that time, but was not routinely tested for syphilis after the surgery. This time, she was admitted to the department of internal medicine for congestive heart failure due to aortic valve regurgitation. The patient was positive for syphilis serology, and CT scan showed an ascending arch aortic aneurysm with a maximum short diameter of 57 mm, which was judged to be a probable syphilitic thoracic aortic aneurysm. There was no significant stenosis in the coronary arteries, but the left common carotid artery was occluded. The patient was treated for heart failure and received amoxicillin 1500 mg/day for 6 weeks, followed by ascending arch aortic prosthesis and aortic valve replacement.

Uretero-arterial fistula is a rare but highly lethal disease depending on the degree of hematuria and infection. In this study, we report a case of ureter-common iliac artery fistula with urinary tract infection after total bladder resection with ureterocutaneous fistula. We treated ureter-common iliac artery fistula with the covered stent graft. The patient had a urinary tract infection at the time of the initial visit to our department, and the covered stent was placed in the left common iliac artery when the signs of infection had resolved after about two weeks of antibiotic treatment. The patient’s postoperative course was good, and his hematuria improved immediately after the procedure. Twelve months after surgery, the patient has no signs of hematuria recurrence or stent infection. The patient should be closely monitored for hematuria recurrence, device infection, and graft occlusion.

In rare cases, neurofibromatosis type 1 (NF1) follows a fatal course due to spontaneous artery ruptures because of vascular fragility. We report a case of successful stent graft treatment for spontaneous rupture of the subclavian artery, in a patient with NF1. A 72-year-old woman with a history of NF1 suddenly lost consciousness seven days after surgery for a strangulated ileus. She suffered a massive hemothorax due to spontaneous rupture of the left subclavian artery, leading to cardiac arrest. After resuscitation, emergency evasive stent graft treatment for hemostasis was successfully performed in 8 min, through a left brachial percutaneous approach, by introducing and deploying a Viabahn VBX stent graft into the left subclavian artery from just below the vertebral artery bifurcation. On the 43rd postoperative day, she was transferred, with a walker, to a rehabilitation hospital. We have successfully performed a stent graft treatment for rapid hemostasis with a minimally invasive technique, even in this case of spontaneous artery rupture of NF1. However, since it is difficult to accurately detect fragile vessels in NF1, the safety of stent graft treatment requires further case studies.