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.

Endovascular treatment for patients with lower extremity artery disease (LEAD) has expanded its indications owing to the evolution of devices, improvements in techniques, and the establishment of clinical evidences. In particular, improvements in balloon and stent performance have significantly contributed to improved treatment outcomes. Herein, we describe the current status of basic balloon and stent related topics for the treatment of LEAD.

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.

An 84-year-old woman had a distal arch aortic aneurysm 55 mm in diameter, a descending thoracic aortic aneurysm at the level of the diaphragm 60 mm in diameter, and an abdominal aortic aneurysm 46 mm in diameter. 18 days later, the distal arch aortic aneurysm rapidly expanded to 65 mm, and the descending thoracic aortic aneurysm to 65 mm. In addition, the abdominal aortic aneurysm seemed to cause DIC. Since it was difficult to perform surgery with the same view, we decided to perform an early two-stage operation: total arch replacement+open stent graft insertion on the first day, and Y-graft replacement+thoracic endovascular aortic repair (TEVAR) on the second day. Because of bilateral external iliac artery stenosis, TEVAR was performed using the Y-graft leg as the access route. We report a case of an early two-stage operation for an elderly patient with a multiple aortic aneurysm and the postoperative course was uneventful. TEVAR using the Y-graft leg as the access route was effective in the patient with the stenosis of iliac arteries.

In recent years, the use of extracorporeal membrane oxygenation (ECMO) and other percutaneous circulatory support devices has become widespread due to dramatic advances in medical technology. However, reports of vascular injury associated with their use are rare. This case involves a 50-year-old man who, while being treated in the hospital for acute lymphoblastic leukemia, developed acute respiratory distress syndrome due to an acute deterioration in his condition and was placed on a ventilator. Despite this, his oxygenation did not improve, prompting the introduction of ECMO. Subsequently, veno-venous ECMO (VV-ECMO) was discontinued, but the patient complained of pain in the right neck. A neck vascular ultrasound revealed a right common carotid-venous fistula and a pseudoaneurysm. The puncture site exhibited a clear shunt sound, and the patient complained of neck pain, leading to a diagnosis of imminent rupture. Given the patient's overall poor condition, surgical intervention was deemed risky. Therefore, under general anesthesia, a VIABAHN stent-graft (W.L. Gore, Flagstaff, AZ, USA) was implanted. Contrast-enhanced computed tomography (CT) confirmed that the fistula was occluded and that there was no blood flow within the aneurysm. Hence, endovascular treatment using a VIABAHN stent-graft yielded favorable outcomes for the vascular injury sustained during VV-ECMO insertion.

Although infected abdominal aortic aneurysms is known to be associated with pyogenic spondylitis, reports of stent graft infection complicated by pyogenic spondylitis are rare and the primary cause is often unclear. We report a successfully treated case of abdominal stent graft infection attributed to pyogenic spondylitis. The patient was a 75-year-old man who underwent stent graft insertion for abdominal aortic aneurysm 10 years earlier and the aneurysm remained reduced in size. At this presentation, he complained of fever and lower back pain and was admitted with diagnoses of pyogenic spondylitis, iliopsoas abscess, and subcutaneous abscess of the right lower leg. Treatment with antibiotics led to improvement and he was discharged, but back pain recurred a month later. Because some images revealed signs of abdominal stent graft infection, we performed stent graft removal and in situ replacement using rifampicin-bonded grafting and omental pedicle grafting. He was discharged home on post-operative day 22, and the infection has not recurred since completing the course of antibiotics. Development of pyogenic spondylitis in the presence of a stent graft poses a risk of infection spreading to the stent graft, so prompt intervention is imperative. If infection spreads to the stent graft, early radical surgery is desirable if feasible.

A 72-year-old man was brought to the emergency room one day after undergoing esophagogastroduodenoscopy at a different hospital, complaining of orbital pain. Computed tomography (CT) revealed a mediastinal hematoma, which was suspected to be an iatrogenic perforation of the esophagus; however, this had not been detected by esophagogastroduodenoscopy. The patient was transferred to the emergency room of our hospital, and underwent conservative treatment. However, follow-up chest CT after 1 week revealed an aneurysmal change of the bronchial artery that had expanded. Therefore, we performed urgent thoracic endovascular aortic repair (TEVAR). Postoperative CT showed that the aneurysm had disappeared. The patient was discharged 14 days after the procedure. Herein, we report a case of spontaneous bronchial artery rupture treated with urgent TEVAR with satisfactory outcome. Though there have been many reports of coil embolization as a treatment for ruptured bronchial arteries, the present report demonstrates TEVAR to be an effective option.

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.