This article provides a comprehensive overview of the treatment of chronic limb threatening ischemia (CLTI). In order to understand the optimal treatment strategy for CLTI, the following six essential aspects are discussed: (1) the PLAN concept, (2) wound treatment, (3) nutritional intervention, (4) rehabilitation, (5) drug and adjuvant therapy, and (6) major amputation. In recent years, a new comprehensive concept called CLTI has been introduced internationally, focusing not only on ischemia but also on factors such as tissue loss and infection, leading to a restructuring of treatment strategies. The goal of treatment for CLTI is not simply to save the limb, but to save the limb functionally with an emphasis on quality of life (QOL). In CLTI, which requires a multidisciplinary approach and individualized assessment and treatment strategies, clinical decisions based on the latest guidelines and evidence from Japan and overseas are important.

Based on the JCS/JSCVS/JATS/JSVS 2020 Guideline on the Diagnosis and Treatment of Aortic Aneurysm and Aortic Dissection, and also referring to the 2018 revision of The Society for Vascular Surgery practice guidelines for patients with an abdominal aortic aneurysm, as well as the 2024 revision of the European Society for Vascular Surgery (ESVS) 2024 Clinical Practice Guidelines on the Management of Abdominal Aorto-Iliac Artery Aneurysms, provide an overview of the diagnosis and treatment of abdominal aortic aneurysms and iliac artery aneurysms.

We report a case in which chimney endovascular aneurysm repair (chEVAR) was performed for a ruptured abdominal aortic aneurysm, in which the patient’s life was saved after preoperative shock vital signs. The patient was a 70-year-old man who had sudden abdominal pain and underwent a detailed examination. Contrast computed tomography (CT) revealed a ruptured abdominal aortic aneurysm. The patient was transported to our department via ambulance for surgical treatment. During transport, the patient was administered norepinephrine 0.08 γ, had a systolic blood pressure of 70 mmHg, and was in shock. Before transport, we planned to use CT images from the previous hospital and decided to perform chEVAR. It took 5 min after arrival at our hospital to enter the operating room, 16 min to start the surgery, 23 min to insert the aortic occlusion balloon, and 97 min to complete stent graft. The postoperative course was uneventful, and the patient was discharged home on postoperative day 16. After six months postoperatively, there has been no obvious endoleak, enlargement of the aneurysm diameter, or increase in retroperitoneal hematoma. Currently, the patient is undergoing outpatient follow-up.

Blunt axillo-subclavian arterial injuries are typically associated with high-energy trauma. However, we encountered two cases of such arterial injuries resulting from relatively low-energy mechanisms. Patient 1 presented occlusion and extravasation of the right subclavian artery, concomitant with a clavicular fracture sustained in a bicycle accident. Patient 2 revealed occlusion of the left axillary artery, accompanied by a humeral fracture, after falling while attempting to sit on a chair at home. Endovascular repair was performed in both cases using a VIABAHN stent graft via the ipsilateral brachial approach. The postoperative courses were uneventful. Endovascular stent grafting is probably a valuable therapeutic option in emergency settings.

Stent graft limb occlusion is considered a potential complication, and we experienced a case of successful endovascular treatment for limb occlusion caused by proximal migration of an AFX flexible limb extension. The patient was a 75-year-old man underwent endovascular aortic repair using AFX and AFX flexible limb extension in urgent for an impending rupture of a right common iliac artery aneurysm. One month after surgery, the patient complained of intermittent claudication, which was diagnosed as proximal migration of the AFX flexible limb extension and resulting limb occlusion by contrast-enhanced computed tomography scan. We planned additional endovascular treatment. We deployed a bare metal stent in left limb using the kissing balloon technique. The stent was well dilated, the bilateral limbs were well contrasted, and the patient has no symptom one year after surgery. There was rare case of using AFX flexible limb extension, we report with a literature review.

We recently experienced a rare case of superficial temporal artery (STA) true aneurysm. A 76-year-old female complained of dull pain anterior to the right auricle with a rice-grain sized tumor, which was gradually enlarged. The tumor was pulsatile and 15×15 mm without redness, hotness, spontaneous pain, or tenderness. Blood flow in the afferent and efferent STA and within the tumor on echography and 9-mm sized STA aneurysm on contrast-enhanced CT scans were recognized. No aortic, cerebral, iliac artery, or visceral artery aneurysm was identified on MRI and CT scans. Under local anesthesia, the STA aneurysm was simply resected. Histopathological examinations of the aneurysmal wall revealed intimal hyperplasia and cystic medial necrosis without inflammatory findings. Three-layered structure was preserved, and accordingly true aneurysm was diagnosed. In accordance with our comprehensive review of 28 Japanese cases including the present patient, cystic medial necrosis was found in 3 cases (10.7%). In 9 cases (32.1%), heterotopic aneurysm other than STA aneurysm (including abdominal aortic aneurysm [3 cases] and cerebral [3 cases], splenic, renal, and external carotid [each 1 case] artery aneurysm) was coexisted.

A 54-year-old woman initially presented to her previous physician with swelling of the posterior aspect of the right lower leg and pain on ambulation. She was diagnosed with venous thromboembolism (VTE), probably secondary to external compression and a hypercoagulable state induced by a giant ovarian cancer. A temporary inferior vena cava (IVC) filter was placed to prevent pulmonary thromboembolism (PTE). Anticoagulation therapy was initiated with a continuous intravenous infusion of heparin for two days, which was subsequently changed to a direct oral anticoagulant (DOAC). The patient was then transferred to our institution for management of her ovarian cancer. Post-transfer computed tomography showed extensive thrombus within the IVC filter and bilateral lower extremities. DOAC therapy was discontinued and continuous intravenous heparin infusion was resumed. The patient underwent planned surgery for ovarian cancer, followed by the addition of tissue plasminogen activator (t-PA) and warfarin for post-operative thrombolysis. Despite these measures, the thrombus remained unchanged. Percutaneous retrieval of the IVC filter was attempted but was unsuccessful due to filter adherence and thrombus organization. Consequently, open surgical removal of the IVC filter with concomitant IVC ligation was performed. This case highlights the importance of appropriate anticoagulation to prevent thrombus-related filter adhesion and that surgical intervention may be beneficial when percutaneous retrieval is not feasible.

An 83-year-old man was presented to our institution for surgery for a pulsatile mass in his right femur. He was frail and suffered from advanced dementia. A computed tomography scan revealed bilateral PFAAs (profunda femoris artery aneurysms). The right PFAA had a maximum diameter of 82 mm and the left PFAA had a maximum diameter of 51 mm. The risk of rupture was considered high due to the giant aneurysm. Right PFAA ruptured during the surgical waiting period and underwent emergency endovascular treatment; VIABAHN stent graft was implanted. The left PFAA underwent elective endovascular treatment and a VIABAHN stent graft was implanted. Postoperatively, bilateral aneurysm shrinkage was achieved without complications.