The author usually diagnose thoracic outlet syndrome (TOS) using ultrasonography and enhanced CT in addition to various physical examination maneuvers. In particular, stenosis between the anterior and middle scalene muscles, changes in blood flow in the subclavian artery, stenosis of the subclavian artery, or narrowing of the intercostal space are essential findings in the diagnosis of TOS. Conservative therapy, mainly rehabilitation, is effective for TOS. However, surgery is performed in young patients with apparent morphological abnormalities. If the costoclavicular space is tight, the author resect the first rib. If the costoclavicular space is vast, the author release the anterior and middle scalene muscles, leaving the first rib intact.

In recent years, endovascular treatment (EVT) for peripheral artery disease has advanced remarkably, with its indications expanding significantly, particularly in lower extremity artery disease (LEAD). This article provides an overview of the indications and treatment strategies for EVT in LEAD, focusing on the recommendations from the revised 2022 peripheral artery disease guidelines, and also discusses the usefulness and challenges of recently introduced devices.

In addition to current trend of endovascular aneurysm repair, open surgical repair for abdominal aortic aneurysm (AAA) is still essential basic skill for every vascular surgeon. In this article, basic surgical technique of open surgical repair for AAA is explained step by step method especially for young vascular surgeons.

Endovascular aneurysm repair (EVAR) has become a widely adopted invasive treatment for abdominal aortic aneurysm (AAA) and iliac artery aneurysm. In Japan, EVAR accounts for approximately 60% of treatments for these conditions, according to the latest 2016 reports, while major countries report treatment rates ranging from 50% to 80%. Meta-analyses of randomized controlled trials (RCTs) have demonstrated favorable short-term outcomes with EVAR. However, concerns remain regarding long-term complications, particularly aneurysm expansion, rupture, and aneurysm-related mortality. In clinical practice, it is crucial to acknowledge that real-world patient populations often differ from those in RCTs, which necessitates a personalized approach to treatment based on individual patient characteristics. This session will focus on strategies to improve long-term outcomes in EVAR, discuss the management of complications, and explore future directions for this evolving treatment modality.

Objectives: Although the efficacy of Viabahn stent graft (Viabahn SG) placement for refractory arteriovenous graft (AVG) outflow stenosis is well established and widely recognized, there is no clear evidence on factors affecting patency rate. In this study, we investigated the factors that affect the target lesion patency after initial Viabahn SG placement. Methods: Fifty-nine patients who underwent initial placement of Viabahn SG for AVG refractory outflow stenosis were included. The target lesion patency was calculated based on these surgical results, and factors affecting the patency rate were examined. Results: Target lesion patency after initial Viabahn SG placement was 77% at 6 months, 52% at 1 year, and 37% at 2 years. Subgroup analysis showed a trend toward better patency in the Viabahn SG diameter 7 mm group (p=0.19), the non-thrombo-occlusive group (p=0.25), and the Elephant trunk (ET) group (Viabahn SG diameter<vein diameter) (p=0.40), but the difference was not statistically significant. The presence of a venous valve within 2 cm of the downstream edge of the Viabahn SG (p=0.68) did not affect patency. Conclusion: In cases of initial Viabahn SG placement, Viabahn SG diameter, ET technique, thrombus occlusion, and venous valve within 2 cm of the downstream edge of the Viabahn SG did not affect the target lesion patency.

Dorsalis pedis artery aneurysm is an extremely rare condition among peripheral artery aneurysms. We encountered a surgical case of a dorsalis pedis artery aneurysm at our hospital and report the same herein with literature-based considerations. The patient was a 72-year-old woman who was referred to our department after a pulsatile mass was detected on the dorsum of her right foot. There was no notable history of trauma. Contrast-enhanced CT revealed a saccular aneurysm measuring 8×12 mm in the dorsalis pedis artery. The aneurysm was excised under local anesthesia, and reconstruction was performed using end-to-end anastomosis. The pathological findings diagnosed the aneurysm as a pseudoaneurysm. The postoperative course was uneventful, and no abnormalities were observed during the 1-year follow-up period.

Acute superior mesenteric artery (SMA) occlusion has a high mortality rate and requires immediate intervention. The patient was a 78-year-old man. He presented with fever, abdominal pain and vomiting, and computed tomography (CT) showed SMA occlusion. Because of his history of laparotomy, emergency laparotomy was deemed difficult, and he underwent aspiration of an embolus and stenting. On the fifth day, a blood culture on admission revealed Staphylococcus epidermidis, and an echocardiogram showed verrucous swelling at the aortic valve level. During antimicrobial therapy, aortic valve annular abscess formation and worsening aortic regurgitation were observed, and aortic valve replacement was performed semi-urgently on the 53rd day. During the course of the procedure, an aneurysm formed at the SMA stenting site, and the patient underwent artificial vessel replacement of the SMA aneurysm on the 138th day after his general condition improved. Aspiration of the embolus or stenting as bridge therapy may be an option for patients with infected SMA emboli for whom emergency laparotomy is not feasible.

Popliteal venous aneurysm (PVA) is a rare disease. Although PVA is asymptomatic, PVA can cause fatal complications such as deep vein thrombosis and pulmonary embolism (PE). And surgical treatment for PVA with PE is recommended. The 70-year-old woman was admitted her previous doctor with dyspnoea and transient loss of consciousness. The contrast-enhanced CT revealed a left PVA with a maximum diameter of 45 mm with thrombus and pulmonary embolism. After medical treatment for PE, surgical treatment was planned. However, immediately after withdrawal of anticoagulant due to surgery, PE recurred preoperatively and an inferior vena cava filter was placed and medical treatment restated. Then she underwent surgical treatment with a posterior approach on the supine position under general anaesthesia. We performed surgical aneurysmectomy and direct venous repair of a popliteal venous aneurysm using a Nelaton catheter inserted into the vein lumen to serve as a diameter guide, ensuring uniform luminal size between the proximal and distal segments. At six months postoperatively, no recurrence of the aneurysm, pulmonary embolism, or venous obstruction was observed. Although there are various methods for suturing the vein, venous suturing technique using a Nelaton catheter was effective for simple vein suturing in securing the venous luminal diameter.

The sciatic artery is the primary blood supply to the lower extremities during early embryonic development. A persistent sciatic artery (PSA) is a rare condition in which the artery fails to regress and remains functional after birth. This report describes the endovascular treatment of an 82-year-old man with a persistent sciatic artery aneurysm (PSAA), a popliteal artery aneurysm, and an abdominal aortic aneurysm (AAA). The patient had a longstanding diagnosis of a right-sided PSAA and AAA. Due to a decreased right ankle-brachial index and progressive enlargement of the AAA, abdominal stent grafting and right lower extremity stenting were performed. The procedures were successful, minimally invasive, and effective.

Uretero-arterial fistula (UAF) is a rare but highly lethal disease depending on the degree of hematuria and urinary tract infection. Anatomically, fistulas are more common at the pelvic brim, where the ureter crosses the common iliac artery. Fistula between the internal iliac artery and ureter is vanishingly rare. We describe endovascular treatment of right ureter-internal iliac artery fistula and a review of the literature. A 90-year-old female with congenital unilateral hypoplastic kidney underwent ileocecal resection for peritonitis due to appendicitis at the age of 20, and started chemotherapy for malignant lymphoma of primary cervical lymph nodes at the age of 82. At the age of 89, she underwent nephrostomy and right ureteral stenting due to right hydronephrosis. She was taken to our hospital with increased amount of hematuria after she underwent antimicrobial treatment and cystourethrostomy for three days. Based on chronic stenting, a UAF was suspected, but arterial extravasation was not identified on contrast-enhanced computed tomography (CT). However, we performed endovascular treatment judging from the closest proximity of the ureteral stent to the internal iliac artery on contrast-enhanced CT. The patient’s postoperative course was good, and her hematuria gradually improved over 3 days after the procedure. There was no recurrence of hematuria for 30 days after the treatment. It is effective to emphasize the medical history and perform intravascular imaging as early diagnostic treatment.

A man in his 60s underwent a femoropopliteal bypass and minor amputation to address necrosis of the second toe on his right foot due to lower extremity artery disease. The wound gradually healed. However, after initiating local negative-pressure wound therapy with perfusion vacuum-assisted closure, deterioration due to a methicillin-resistant Staphylococcus aureus (MRSA) infection was observed. Treatment with anti-MRSA agents was promptly initiated. During this period, the patient exhibited signs of renal function deterioration and developed purpura on the extremities. A skin biopsy confirmed a diagnosis of immunoglobulin A (IgA) vasculitis. The skin symptoms subsequently improved with appropriate management, and the toe wound showed signs of healing following infection control. Renal involvement is frequently observed in adults with IgA vasculitis, necessitating careful monitoring. Clinicians should remain vigilant for IgA vasculitis when multiple clustered purpura are observed on the extremities and assess for potential renal involvement.

Juxtacaval fat, commonly found surrounding the hepatic segment of the inferior vena cava (IVC), can mimic IVC thrombus or primary IVC tumors. We report the case of an 84-year-old male who, during a bladder cancer workup, was incidentally found to have a nodular, low-density lesion within the IVC on contrast-enhanced computed tomography (CT). The lesion was initially diagnosed as a thrombus, and anticoagulation therapy was commenced. However, a follow-up CT scan revealed no interval change, and the Hounsfield Unit (HU) values were consistent with fat attenuation. While a primary IVC tumor was considered, multiplanar reconstruction (MPR) CT imaging demonstrated continuity between the lesion and pericaval fat. This finding led to a revised diagnosis of juxtacaval fat. The juxtacaval fat in this case was likely the result of liver atrophy causing posterior displacement and narrowing of the IVC. Recognition of this characteristic imaging feature is essential for vascular surgeons as it can prevent misdiagnosis and avoid interventions.

The role of endovascular treatment for hepatic artery aneurysms has increased in recent years with the trend toward minimally invasive treatment. However, some cases will certainly require open surgery. Here we describe a case of a 55-year-old man who visited our hospital complaining of abdominal pain. A detailed contrast computed tomography scan revealed celiac artery dissection and a hepatic artery aneurysm extending from the common hepatic artery to the proper hepatic artery. Furthermore, a sac-shaped low-density area was found protruding from the hepatic artery aneurysm into the parenchyma of the pancreatic head, and the aneurysm was diagnosed as a thrombosed pseudoaneurysm. Elective surgery was performed after the spontaneous improvement of abdominal pain. During the operation, the area around the celiac artery was dissected via the lesser omentum, and the hepatic artery aneurysm was evacuated under partial aortic clamping, and revascularization was performed by an antegrade bypass using a saphenous vein graft. There were no complications after surgery, and the graft has remained patency for the past 2 years. Treatment of hepatic artery aneurysms can be broadly classified according to location. In cases where the aneurysm extends to the proper hepatic artery or where there are future concerns about collateral circulation, surgical revascularization is worth considering, and antegrade bypass can be an option.

An 82-year-old man with a history of hypertension, dyslipidemia, diabetes mellitus, and peripheral artery disease had been followed at our cardiology department. Three months earlier, he underwent transcatheter aortic valve implantation (TAVI) for severe aortic stenosis. Two weeks prior to admission, he developed a persistent fever. Laboratory tests revealed elevated inflammatory markers, and transthoracic echocardiography showed vegetations on the prosthetic valve. Blood cultures identified α-streptococcus, leading to the diagnosis of prosthetic valve endocarditis (PVE) after TAVI. Additionally, aneurysmal dilatation of the thoracoabdominal aorta, which had been normal at the time of TAVI, was detected, and the patient was diagnosed with a mycotic thoracoabdominal aortic aneurysm secondary to TAVI-PVE. Considering the patient's poor general condition, antibiotic therapy was initiated. Inflammatory markers improved, and the vegetations decreased in size. However, computed tomography performed two weeks later revealed rapid expansion of the mycotic aneurysm. After further discussion with the cardiology team, surgical intervention was planned. Graft replacement of the thoracoabdominal aortic aneurysm and omental wrapping was performed. Postoperatively, lower limb motor function was preserved, the vegetations disappeared, and infection was controlled. The patient was discharged on the 41st postoperative day.