Abdominal aortic aneurysm (AAA) remains a major vascular disease in aging societies, including Japan, where the number of affected patients is expected to increase. Over the past two decades, endovascular aneurysm repair (EVAR) has dramatically changed the management of AAA and has become a standard minimally invasive treatment option. Despite these advances, optimal patient selection, preoperative anatomical assessment, device selection, procedural planning, and long-term surveillance still require advanced clinical judgment. This lecture reviews contemporary strategies for the management of abdominal aortic aneurysms, with a particular focus on EVAR. Key topics include indications for intervention, essential elements of preoperative imaging assessment, evaluation of proximal and distal landing zones, practical considerations in device selection, and management of complex anatomies such as iliac artery involvement and juxtarenal or pararenal aneurysms. Current evidence and practical decision-making processes in daily clinical practice are emphasized. This article aims to provide vascular surgeons with a structured framework to support optimal treatment planning for patients with abdominal aortic aneurysms.

Deep femoral artery aneurysm is rare, and no standard treatment protocol has been established. We encountered a surgical case involving an incidentally diagnosed deep femoral artery aneurysm. The patient was an 83-year-old man who was referred to our hospital for further evaluation of urinary protein. Computed tomography revealed a right deep femoral artery aneurysm with a maximum short-axis diameter of 51 mm. Surgical intervention was indicated, and the patient underwent prosthetic vascular graft replacement. Despite delayed wound healing, he was discharged walking independently on postoperative day 22. Given the scarcity of published cases, this case is reported along with a literature-based discussion.

Kommerell’s diverticulum is a rare congenital condition often associated with aortic dissection. This case involves a 67-year-old male who suffered from an aortic dissection (Stanford type B) 14 years ago and has since been managed conservatively. The aortic diameter has gradually increased over time. The true lumen of the aorta was nearly obstructed at the level of the diaphragm and completely obstructed at the terminal aorta. Although a two-stage operation was considered, a primary operation was chosen due to the technical difficulties of Thoracic Endovascular Aortic Repair (TEVAR) and the risk of organ ischemia from false lumen obstruction. The operation was performed via median sternotomy and a separate 6th left thoracotomy. The aorta was transected at the proximal arch and descending aorta. An inverted vascular graft was inserted into the aorta and sutured using a stepwise distal anastomosis technique, which was also applied at the proximal arch anastomosis. The graft-graft anastomosis was completed medially, and the carotid arteries were anastomosed as usual. The bilateral stepwise technique is a viable option for extended arch repair.

An 82-year-old woman was referred to our hospital for evaluation and treatment of worsening numbness in the right lower limb and a pulsatile mass in the right buttock. Contrast-enhanced computed tomography revealed a right persistent sciatic artery aneurysm with a maximum short-axis diameter of 34 mm. Because neurological symptoms were predominant, a hybrid approach was selected to minimize the risk of sciatic nerve injury. Under general anesthesia with the patient in the supine position, a right femoropopliteal bypass was first constructed using an 8 mm ringed prosthetic graft. Subsequently, the inflow and outflow vessels of the persistent sciatic artery aneurysm were embolized. Completion angiography confirmed complete aneurysm exclusion and good graft patency. Both numbness in the right lower extremity and pulsation of the right buttock mass resolved immediately after surgery. Postoperative CT demonstrated aneurysm exclusion and a patent bypass graft. Follow-up CT at 1 and 2 years postoperatively confirmed sustained aneurysm exclusion with a reduction in aneurysm size. These findings indicate that hybrid surgery may be a useful treatment option for persistent sciatic artery aneurysms associated with neurological symptoms.

Perigraft seroma is a known complication following open abdominal aortic aneurysm repair. We experienced an infected perigraft seroma after expanded polytetrafluoroethylene (ePTFE) aortobiiliac graft replacement. An 85-year-old man with the history of transperitoneal open aortobiiliac replacement using an ePTFE graft 11 years ago presented with abdominal distention and discomfort. A computed tomography (CT) scan revealed a large perigraft fluid collection measuring 12 cm in maximal diameter. This was diagnosed as a perigraft seroma after surgical procedure. Since the patient preferred to avoid surgery, conservative management with observation was chosen. Two years later, he was febrile and referred to our hospital. Blood tests showed elevated inflammatory markers, and a CT scan showed an air-density area within the fluid collection around the graft. This led to the diagnosis of infected perigraft seroma. We proceeded with urgent surgery, replacing the infected ePTFE graft with a rifampicin-soaked woven Dacron graft and wrapping it with omentum. Thirty-five days postoperatively, a CT scan demonstrated an air-density area within the fluid collection again. We diagnosed reinfection after replacement and open laparotomy was performed through a midline incision. Intraoperative findings revealed that the graft was completely encapsulated by the omentum. We performed thorough irrigation with normal saline and temporarily placed a drainage tube. Aside from that, his postoperative course was uneventful. The inflammatory response resolved completely with oral antibiotics, and the patient was discharged from the hospital. This case demonstrates that replacing the graft with a different type of material covered by omentum can be an effective surgical option for this rare complication.

Since 2013, the Japanese Society for Vascular Surgery has operated a nationwide registration and follow-up database project on critical limb ischemia (CLI), known as the Japan Critical Limb Ischemia Database (JCLIMB), to clarify the real-world clinical practice of CLI in Japan and contribute to improvements in the quality of care by returning the results to clinical practice. This database registers patient background, treatment details, early postoperative outcomes, and five-year long-term results for CLI cases—including non-surgical cases—and is constructed on the National Clinical Database (NCD) platform. Until 2020, the registry had been operated under the name Japan Critical Limb Ischemia Database (JCLIMB); however, based on the Global Vascular Guidelines (GVG) published in 2019, the target disease for registration was changed to chronic limb-threatening ischemia (CLTI) beginning in 2022, and consequently, the name of the database was revised to the Japan Chronic Limb-Threatening Ischemia Database (JCLIMB). In 2022, a total of 1337 limbs were registered from 116 institutions, of which 1317 limbs (99%) were attributed to CLTI caused by arteriosclerosis obliterans (ASO). This annual report summarizes, exclusively for ASO cases, aggregated findings on patient background, ischemic limb status, treatment profiles, and early outcomes at 1 month after treatment.