Aorto-iliac occlusive disease (AIOD) is a clinically significant manifestation of systemic atherosclerosis that substantially affects patient quality of life and long-term prognosis. While open surgical revascularization has historically been the primary treatment modality, technological advancements have positioned endovascular therapy (EVT) as the preferred first-line option for most lesions. This review provides a comprehensive overview of the evolution of major international and domestic clinical guidelines, including TASC II, AHA/ACC, ESC, ESVS, and JCS/JSVS, with a focus on the shift from anatomical lesion classification to integrated disease assessment incorporating the WIfI and GLASS classification systems, as well as the increasing importance of personalized medicine. Additionally, we discuss key future perspectives in AIOD management, such as optimal device selection, hybrid revascularization strategies that combine open surgery and EVT, the expanding role of the transradial approach (TRA), optimization of pharmacological therapy (including antiplatelet agents, anticoagulants, and low-dose rivaroxaban combination therapy), and the implementation of shared decision-making (SDM) as a crucial component of contemporary individualized vascular care.

Objective: In superior mesenteric artery (SMA) bypass surgery, no definitive superiority in patency has been established regarding graft route or conduit material, and procedural selection varies among institutions. Conventional loop-C retrograde bypass is associated with graft kinking and excessive graft length. We evaluated the surgical outcomes of our retroperitoneal linear retrograde bypass technique using a prosthetic graft. Methods: We retrospectively analyzed 16 patients who underwent this procedure at our institution between 2013 and 2025. Patient characteristics, perioperative outcomes, and primary graft patency were assessed. Results: The median age was 69 years, and 12 patients were male. The underlying diseases were mesenteric ischemia (n=9) and aortic aneurysm (n=7). The median follow-up period was 528 days. The primary patency rates at 1 and 3 years were 93.8% and 78.1%, respectively. Conclusion: The retroperitoneal linear retrograde approach using a prosthetic graft simplifies graft configuration and avoids kinking, demonstrating favorable patency outcomes. This technique may represent a useful option for SMA revascularization.

Objective: Incisional hernia is a common late complication after open abdominal aortic aneurysm (AAA) repair. This study aimed to evaluate the association between abdominal wall closure techniques and the incidence of incisional hernia following open AAA surgery. Methods: We retrospectively analyzed 117 consecutive patients who underwent open AAA repair through a midline laparotomy between April 2021 and August 2024. Patients were classified according to the abdominal wall closure technique into a layered continuous closure group using barbed sutures (n=60) and a conventional interrupted closure group (n=57). The primary outcome was the occurrence of incisional hernia, assessed by follow-up computed tomography. Cumulative incidence was evaluated using Kaplan–Meier analysis, and risk factors for incisional hernia were analyzed using Cox proportional hazards models. Results: The mean follow-up duration was 31 months in the continuous closure group and 15 months in the interrupted closure group. Incisional hernia occurred in 7 patients (11.7%) in the continuous closure group and in 17 patients (29.8%) in the interrupted closure group. Kaplan–Meier analysis demonstrated a significantly lower cumulative incidence of incisional hernia in the continuous closure group (log-rank p=0.0069). In multivariable Cox regression analysis, the abdominal wall closure technique was independently associated with incisional hernia occurrence (hazard ratio 0.37, p=0.018). Conclusion: In patients undergoing open AAA repair, differences in abdominal wall closure techniques were associated with the occurrence of incisional hernia. A layered continuous closure strategy using barbed sutures may represent a feasible abdominal wall closure approach, although the independent contribution of each technical component could not be determined in this study.

A 76-year-old patient with an aortic arch aneurysm initially underwent total aortic arch replacement combined with a frozen elephant trunk (FET) procedure using the FROZENIX device at another institution. Subsequently, thoracic endovascular aortic repair (TEVAR) was performed using a Relay Plus stent graft, with the non-stented portion of the frozen elephant trunk serving as the proximal landing zone. During a 10-year follow-up period after the initial treatment, the aneurysm diameter gradually decreased and remained stable. However, 11 years after the primary intervention, the patient developed rapid aneurysmal expansion due to damage to the non-stented prosthetic graft, resulting in a type III endoleak. The presumed mechanism was localized stress concentration caused by long-term mechanical interaction between the prosthetic graft and the proximal edge of the bare stent. To address this complication, additional TEVAR was successfully performed using a Relay Pro NBS, achieving favorable clinical and radiological outcomes. Late aortic events following stent graft treatment, such as neck dilatation and stent graft-induced new entry, have been well documented. This case highlights that delayed complications involving prosthetic graft injury and type III endoleak can also occur long after FET and TEVAR, even when early and mid-term outcomes appear satisfactory. The present findings underscore the importance of meticulous, long-term imaging surveillance, as late adverse events may arise from prolonged mechanical interactions between implanted devices.

We report the successful staged management of an acute Stanford type B aortic dissection (TBAD) complicated by a completely thrombosed abdominal aortic aneurysm (AAA) causing acute bilateral lower limb ischemia. A 77-year-old man presented with severe chest, back, and bilateral lower extremity pain. Contrast-enhanced CT revealed an acute aortic dissection with a patent false lumen extending distally from the left subclavian artery, and a 68-mm completely thrombosed AAA causing limb ischemia. With limb salvage as the priority, an emergency right subclavian-to-bilateral common femoral artery bypass was performed. The patient developed postoperative myonephropathic metabolic syndrome (MNMS) but recovered, and underwent prosthetic graft replacement for the AAA on postoperative day 45. Subsequently, due to true lumen narrowing in the abdominal aorta, thoracic endovascular aortic repair (TEVAR) was performed on day 88 to close the entry tear. Postoperative CT confirmed thrombosis and shrinkage of the false lumen. In cases of acute type B aortic dissection involving an abdominal aortic aneurysm, staged management is crucial for mitigating complication risks.

A 62-year-old man presented with dysphagia. Computed tomography revealed Kommerell’s diverticulum (KD) with right-sided aortic arch. The subclavian arteries branched independently, and all 4-arch branches were thin. Total aortic arch replacement with frozen elephant trunk (FET) was planned. To reconstruct thin branches and avoid anastomotic mismatch, the first 12-mm side branch of thoraflex hybrid (TH) was modified into two 8-mm side branches. The subclavian arteries were reconstructed using additional side branches. To prevent kinking and stenosis, the TH collar was placed outside the aortic stump and secured with circumferential mattress sutures (outer collar technique). Postoperative computed tomography revealed no FET stenosis and complete KD thrombosis.

Aneurysm sac enlargement after endovascular aneurysm repair (EVAR) is most commonly caused by endoleak; however, sac enlargement without an apparent endoleak can also occur. A 75-year-old man underwent EVAR using an Endurant stent graft for an abdominal aortic aneurysm and subsequently developed progressive sac enlargement. Contrast-enhanced computed tomography in both the early and delayed phases demonstrated no evident endoleak. Therefore, open surgical conversion was performed for definitive diagnosis and reliable treatment. Upon opening the aneurysm sac, a large amount of whitish, viscous serous fluid without blood components was found filling the sac, leading to the diagnosis of perigraft seroma. This case suggests that perigraft seroma can be a cause of aneurysm sac enlargement even after EVAR, and it should be considered in the differential diagnosis of post-EVAR sac enlargement in the absence of an apparent endoleak.

A 79-year-old man had undergone endovascular aneurysm repair (EVAR) with an AFX/AFX2 stent graft for an abdominal aortic aneurysm five years prior and thoracic endovascular aortic repair (TEVAR) for a saccular aortic arch aneurysm two years prior at another institution. He presented with left thigh swelling and difficulty ambulating. Contrast-enhanced computed tomography revealed a left thigh hematoma and contrast enhancement within the abdominal aortic aneurysm sac, consistent with a Type IIIa endoleak. The Type IIIa endoleak was considered to have triggered disseminated intravascular coagulation (DIC), resulting in a hemorrhagic tendency and subsequent hematoma formation. Following pharmacological DIC management with nafamostat mesilate, relining with a GORE Excluder was performed. Postoperatively, the endoleak was no longer demonstrated, and DIC resolved.

External iliac venous aneurysm is a rare condition. There is no standard therapy or established guideline for the management of primary pelvic venous aneurysm. We herein report a case of a primary aneurysm of the left external iliac vein successfully reconstructed using the great saphenous vein. A 76-year-old man was referred to our department after a computed tomography scan for bladder cancer evaluation revealed a 4-cm saccular aneurysm of the left external iliac vein. Contrast-enhanced imaging showed no arteriovenous communication, and the patient had no history of trauma or abdominal surgery. These findings were consistent with a primary venous aneurysm of the left external iliac vein, and surgical repair was indicated. Intraoperatively, after performing a longitudinal incision of the external iliac vein, we found that the aneurysmal wall was diffusely thinned and that the border between the normal venous wall and the aneurysm was clearly demarcated. The aneurysm was resected, and the vessel was reconstructed using the ipsilateral great saphenous vein. The harvested vein was divided into three longitudinal segments, sutured together to create a large venous patch, and then fashioned into a tubular graft, which was anastomosed to the defect. The postoperative course was uneventful, and follow-up imaging showed no graft occlusion or thrombosis. External iliac venous aneurysms carry the risk of rupture and thrombosis; therefore, careful evaluation and individualized surgical planning are essential for their management.

A 66-year-old man with a history of Stanford type A acute aortic dissection underwent ascending and total arch replacement with elephant trunk insertion six years earlier. During follow-up, he required two surgical repairs for proximal anastomotic pseudoaneurysms. In addition, thoracic endovascular aortic repair was performed for insufficient expansion of the elephant trunk. Three years and ten months after the last operation, he presented with fatigue and dark-colored urine. Laboratory findings revealed severe hemolytic anemia with markedly elevated lactate dehydrogenase levels, hyperbilirubinemia, and acute kidney injury requiring hospitalization. Although thrombotic microangiopathy was initially suspected, the absence of thrombocytopenia and low PLASMIC and French scores made hematologic disease unlikely. Contrast-enhanced computed tomography demonstrated a proximal anastomotic pseudoaneurysm causing significant extrinsic compression of the prosthetic graft and stent graft. Based on these findings, mechanical hemolysis due to graft compression was diagnosed, and urgent surgical intervention was indicated. The patient underwent valve-sparing aortic root replacement and redo total arch replacement under cardiopulmonary bypass. Postoperatively, hemolytic parameters rapidly normalized, and renal replacement therapy was successfully discontinued.

We report a case of successful emergency EVAR for bilateral internal iliac artery aneurysms with an unclear rupture site. An 80-year-old man suddenly developed lower abdominal pain and was taken to another hospital. A CT scan showed ruptured internal iliac artery aneurysms, and he was transferred to our hospital for emergency treatment. A retroperitoneal hematoma was found from the renal artery level to the pelvic cavity, but the exact rupture site was unclear. The aneurysms on both sides extended from their origins to the bifurcations of the superior and inferior gluteal arteries. We decided to perform emergency embolization of the superior and inferior gluteal arteries on both sides, followed by EVAR. First, we embolized the left superior and inferior gluteal arteries from the right side. Then, we placed an Excluder leg from the left common iliac artery to the left external iliac artery from the left side. We embolized the aneurysm with NBCA through a catheter left inside from the right side. We did the same procedure for the right internal iliac artery aneurysm. Postoperative course was good. He was discharged 9 days after surgery. At 6 months, the aneurysms were not enlarged, and no gluteal claudication was seen.

Persistent sciatic artery is a remnant of the sciatic artery from early fetal development and is an extremely rare anomaly. An aneurysm of the sciatic artery is prone to thrombotic occlusion and is considered to be an indication for treatment. A 71-year-old woman presented with an incidental residual sciatic artery aneurysm. Thrombus formation was observed in part of the aneurysm, so we decided to perform stent graft placement. A VIABAHN stent graft was placed distal to the aneurysm, followed by placement of a VIABAHN of the same size overlapping the first one. As the overlapped area was 1 cm, an additional VIABAHN was placed in the same area. Postoperatively, the patient was treated with antiplatelet therapy of aspirin and clopidogrel, and no thrombus formation or stenosis was observed in the stented vessel at 2 years after the surgery. Endovascular treatment is one treatment for residual sciatic artery aneurysms, and it has been considered as the main form of treatment in recent years because it is less invasive than conventional open treatment that involves revascularization. However, there are few reports on the patency rate of stent grafts for residual sciatic artery aneurysms due to their susceptibility to external forces from the surrounding tissues, and further investigation of treatment results is needed.