Endovascular treatment for the lower extremity artery disease, a variety size of vessels is treated, and lesions include not only occlusions, but also diffuse lesions and severe calcified lesions. We explain the role and selection of guidewires in endovascular treatment.

One patient with a mixed arterial venous leg ulcer of the lower leg caused by an incomplete residual sciatic artery underwent distal sciatic artery-anterior tibial artery bypass surgery using an arteriovenous fistula and dilated upper extremity vein with excellent results. A 65-year-old male patient developed a right leg ulcer after a permanent inferior vena cava filter was placed 20 years ago for the diagnosis of deep vein thrombosis in the right lower extremity. The ulcer was diagnosed as a congestive dermatitis and the patient was treated with varicose vein therapy and compression therapy over a long period of time, but the ulcer did not improve. Considering the possibility of a mixed arterial venous leg ulcer due to incomplete residual sciatic artery and arteriosclerosis obliterans, surgery was performed. The superficial veins of the lower extremities were obliterated by treatment of varicose veins, and veins from the upper extremities were used as autologous vein grafts. An arteriovenous fistula was created in the forearm and the vein was dilated and grafted. The ulcer healed after the operation.

The authors report a case of resection of median arcuate ligament and bypass surgery for abdominal angina with celiac artery (CA) stenosis and superior mesenteric artery (SMA) occlusion, focusing on the differential diagnosis of its etiology and treatment. A 71-year-old female complained abdominal pain, vomiting, and diarrhea for 3 months. Contrast-enhanced CT scans revealed thoracoabdominal aneurysm with thick mural thrombus and severe stenosis of the proximal CA (at 3 cm distal to its origin) with “hooked appearance” (alias, “hook sign”). The SMA was occluded and its distal was patent by collateral flow from the CA. From the above, median arcuate ligament syndrome was diagnosed. Because endovascular treatment was irrelevant due to aortic calcification and mural thrombus, semi-urgent surgical revascularization (bypass surgery) was performed via laparotomy. Intestinal ischemia was not improved despite resection of the median arcuate ligament, subsequently bypass surgery to the common hepatic artery (a branch of the CA) and the ileocolic artery (a branch of the SMA) was added. Blood flow of the grafts was sufficient, and postprandial abdominal pain due to intestinal ischemia was improved.

Popliteal venous aneurysms (PVAs) often precipitate pulmonary embolism (PE). Anticoagulant therapy is insufficient to prevent PE, and surgical treatment is recommended in such cases. A 61-year-old man who underwent urologic surgery presented with sudden onset of dyspnea and hypotension on the third postoperative day. Contrast-enhanced computed tomography revealed multiple bilateral pulmonary emboli and a right PVA (saccular type, 30 mm) accompanied by a thrombus. After we treated PE, we performed PVA surgery; the patient underwent tangential aneurysmectomy with lateral venorrhaphy using a posterior approach. No PVA recurrence or complications were observed at the 18-month postoperative follow-up. Surgical treatment effectively prevents PE recurrence and is considered the first-line treatment for PVAs.

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 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 name of this database was changed from JAPAN Critical Limb Ischemia Database to JAPAN Chronic Limb Threatening Ischemia Database in 2021 because of alteration of the definition of registered patients. The abbreviation remains JCLIMB. The limbs managed conservatively are also registered in JCLIMB, together with those treated by surgery and/or EVT. In 2021, 1338 CLTI limbs (male 916 limbs: 68%) were registered by 78 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 of ASO cohort are reported.