Isolated iliac artery aneurysm-defined as aneurysmal dilatation of the common, internal, or external iliac artery without a concurrent abdominal aortic aneurysm requiring simultaneous repair-accounts for approximately 2%-7% of intra-abdominal aneurysms. This narrative review examines its natural history and the relative merits of open and endovascular treatment, with particular attention to internal iliac artery management, drawing on literature published since 2007. Two features deserve greater attention. First, much of what is cited as evidence on isolated disease derives from mixed aorto-iliac cohorts: across 7 such series, isolated aneurysms accounted for 120 of 897 patients (13.4%). Second, the frequently repeated claim that Japanese patients experience rupture at smaller diameters rests on comparisons between treated referral cohorts and Western imaging-surveillance cohorts, whose denominators are not equivalent. Reported growth rates range from 0.2 to 1.6 mm/year and accelerate with increasing diameter. Endovascular repair offers consistent perioperative advantages, whereas open repair may prove more durable when internal iliac artery sacrifice would otherwise be required. Although iliac branch devices are widely used in clinical practice, only 97 patients with truly isolated disease have been reported in dedicated series. The positions on treatment thresholds and techniques presented in this review are therefore identified as the author's opinions.
A 50-year-old man with type 2 diabetes mellitus was admitted for chronic limb-threatening ischemia (CLTI). Ulcers involved several toes on both feet. Angiography of the left lower extremity demonstrated severe below-the-ankle arterial disease with markedly compromised pedal runoff. After unsuccessful endovascular therapy of the left lower extremity, low-density lipoprotein (LDL) apheresis was initiated for limited-option CLTI. An increase in microcirculatory flow in the left foot was observed after LDL apheresis, as assessed by angiography and GOKO Bscan-ZD. Complete wound healing was achieved after a transmetatarsal amputation. GOKO Bscan-ZD may represent a novel noninvasive method with which to evaluate microcirculation.
An 85-year-old man, with a history of coronary artery bypass grafting (CABG) using bilateral internal thoracic artery (ITA) grafts, underwent zone 0 thoracic endovascular aortic repair (TEVAR) for an aortic arch aneurysm. The procedure involved axillary debranching and the combined use of conventional and fenestrated stent grafts. During deployment of the fenestrated graft, ventricular fibrillation occurred, temporally associated with a transient reduction in brachiocephalic artery blood flow that compromised ITA graft flow. He was discharged without neurological deficits. This case highlights the potentially critical risk of myocardial ischemia during zone 0 TEVAR in post-CABG patients, emphasizing the need for meticulous multidisciplinary planning.
Simple renal cysts (SRCs) have traditionally been regarded as benign, age-related incidental findings with limited clinical significance. However, accumulating evidence suggests that SRCs are associated with abdominal aortic aneurysm (AAA), thoracic aortic aneurysm (TAA), and aortic dissection (AD), indicating that they may reflect systemic extracellular matrix (ECM) degeneration rather than isolated renal aging. This narrative review summarizes the current evidence linking SRCs to aortic disease, explores the underlying biological mechanisms, and discusses their potential prognostic significance following endovascular aortic repair. Observational studies have consistently reported a 2- to 3-fold higher prevalence of SRCs in patients with aortic disease compared with controls. Shared mechanisms, including ECM remodeling, matrix metalloproteinase activation, genetic susceptibility, and arterial stiffening, provide biological plausibility for this association. Emerging evidence further suggests that SRCs are independently associated with reduced sac shrinkage after endovascular aneurysm repair (EVAR) and thoracic endovascular aortic repair (TEVAR), as well as with an increased risk of aortic-related adverse events following TEVAR for type B AD. Although the current evidence is derived predominantly from retrospective studies, SRCs represent a readily identifiable imaging marker that may enhance risk stratification and postoperative surveillance. Prospective multicenter studies are warranted to validate these findings and clarify their clinical implications.
An 85-year-old man underwent endovascular repair using the Excluder iliac branch endoprosthesis (IBE) for an abdominal aortic aneurysm with a left internal iliac artery aneurysm. He was discharged uneventfully but returned on postoperative day 16 with acute left limb occlusion. Imaging revealed complete occlusion of both the internal and external iliac limbs of the IBE, requiring emergent thrombectomy. Intraoperative assessment demonstrated mechanical compression of the external iliac limb by the internal iliac limb, causing stenosis and thrombosis. This rare complication highlights the importance of meticulous preoperative planning to prevent limb-related events, particularly in patients treated outside the device's indications.
A patient in his 40s, who had experienced acute deep vein thrombosis (DVT) of his left leg 13 years ago, developed acute DVT of his right leg due to an inferior vena cava filter (IVCF) thrombotic occlusion. A thrombus extended from just below the IVCF to the bilateral femoral veins. Given the limited availability of urokinase and the strict guidelines for the proper use of the Indigo CAT8 in Japan, we first performed catheter-directed thrombolysis with alteplase for 2 days, followed by aspiration with the CAT8 catheter after confirming the absence of an IVC thrombus. Finally, we successfully retrieved this IVCF, implanted 13 years earlier, using the bidirectional technique.
Antiphospholipid syndrome (APS) is an autoimmune prothrombotic disorder characterized by recurrent arterial and venous thrombosis, as well as pregnancy complications. Laboratory findings often show prolongation of activated partial thromboplastin time, which complicates monitoring during heparin therapy. We present the case of a 69-year-old woman with APS who developed chronic limb-threatening ischemia. She underwent successful bilateral lower-extremity open surgical revascularizations guided by a preoperatively obtained heparin-activated clotting time (ACT) titration curve to define individualized intraoperative anticoagulation targets. This method offered a straightforward and dependable strategy for personalized anticoagulation management and may enhance the safety of peripheral arterial revascularization in patients with APS.
Objectives:Although magnetic resonance imaging (MRI) is widely used to evaluate extracranial vascular anomalies (VAs), its diagnostic accuracy remains uncertain. Methods:We retrospectively assessed MRI accuracy for VAs and identified nonvascular lesions mimicking them. Patients who underwent surgical resection for suspected VAs at a tertiary referral center in Japan between April 2019 and June 2025 were analyzed. Results:A total of 172 patients met the inclusion criteria (mean age 34.9 ± 18.8 years; 62.8% female). Lesions were most commonly located in the extremities (54.1%), followed by the head and neck (32.6%) and the trunk (13.4%). Histopathology identified venous malformations (VMs) as the most frequent subtype (73.8%), followed by arteriovenous malformations (AVMs; 11.0%) and lymphatic malformations (LMs; 6.4%). MRI showed moderate sensitivity and high specificity: AVM sensitivity 0.68 and specificity 0.99; VM sensitivity 0.70 and specificity 0.98; LM sensitivity 0.80 and specificity 0.98. Seven cases (4.1%) were ultimately diagnosed as non-VA lesions despite MRI findings suggestive of VAs. Common mimickers included angioleiomyoma and myopericytoma. Conclusions:MRI demonstrates moderate sensitivity and strong specificity for VAs, although false-positive interpretations remain an important consideration.
Idiopathic iliac vein rupture (IIVR) is a rare, life-threatening condition. We report a successful case of a 66-year-old woman with hemorrhagic shock and disseminated intravascular coagulation managed with a strategic surgical approach. To prevent intraoperative pulmonary embolism from extensive deep vein thrombosis, a temporary inferior vena cava filter was placed. Distal venous control was achieved via a femoral vein clamp through a separate inguinal incision prior to pelvic exploration. Primary suture repair combined with thrombectomy successfully preserved venous outflow. This multistep strategy is effective for managing IIVR, ensuring hemodynamic stability and preventing fatal embolic complications.
Objectives:This study aimed to clarify the relationship between selection of compression stockings and grip strength in older outpatients with secondary lower limb lymphedema following gynecologic cancer surgery. Methods:This retrospective observational study involved 71 outpatients aged ≥65 years with late-stage II (International Society of Lymphology) secondary lower limb lymphedema requiring compression therapy after gynecologic cancer surgery. We investigated the patient's profile, grip strength, and the status of compression therapy. Patients were divided into early-older (65-74 years; n = 41) and late-older (75-86 years; n = 30) groups, and outcomes were compared. Additionally, patients were divided by compression stocking types: a flat-knit stocking group (n = 51) and a circular-knit stocking group (n = 20). Results:All patients continued compression therapy during the observation period between September 2022 and April 2025. Grip strength was comparable between the early-older and late-older patient groups. However, the flat-knit stocking group had significantly greater grip strength (21.1 kg) than the circular-knit stocking group (19.1 kg) (p = 0.004). Conclusions:Even late-older patients could continue to use flat-knit stockings as long as their grip strength was maintained.
A 76-year-old female Jehovah's Witness presented with an acute Stanford type A intramural hematoma. To avoid transfusion, she underwent ascending aortic replacement with a frozen elephant trunk and total fenestration. During chest closure, she developed sudden bilateral lower-limb ischemia, with regional oxygen saturation declining from 70% to 40%. Transesophageal echocardiography confirmed patency of the frozen elephant trunk and revealed rapid collapse of the distal true lumen beyond the stented segment. Emergent angiography demonstrated severe true-lumen compression. Thoracic endovascular aortic repair with distal bare-metal stent support was performed urgently, restoring flow. Stent deployment began 50 min after ischemia onset, and complete reperfusion was achieved 82 min after onset. The patient was discharged on postoperative day 17 without neurologic or ischemic sequelae.
An 82-year-old man underwent surgical repair of an infectious abdominal aortic aneurysm using a cryopreserved homograft. Twelve years later, a pseudoaneurysm at the right iliac anastomosis was treated with a stent-graft limb. Sixteen years after the initial surgery, a saccular aneurysm developed in the mid-portion of the homograft without signs of infection. Endovascular aortic repair using an AFX2 stent graft (Endologix, Irvine, CA, USA) was performed to cover the entire graft. Postoperative CT showed no endoleaks or aneurysm enlargement. Although homografts are considered infection-resistant, late degenerative complications may occur, requiring lifelong follow-up.
Postsurgical thrombotic microangiopathy (TMA) is a highly lethal complication. We report a 71-year-old woman who developed TMA following open thoracoabdominal aortic aneurysm repair. From postoperative day 2, she presented with progressive thrombocytopenia, acute kidney injury, and hemolytic anemia. Therapeutic plasma exchange (PE) and hemodialysis were promptly initiated upon clinical suspicion, without waiting for ADAMTS13 results. In conclusion, we experienced a case of postsurgical TMA triggered by profound surgical stress, in which prompt initiation of PE was effective. The patient successfully recovered from the acute phase and has remained in remission for over 3 years.
A patient who underwent endovascular abdominal aortic repair for a non-inflammatory abdominal aortic aneurysm developed asymptomatic periaortitis 2.5 years postoperatively. Conservative management resulted in aneurysm shrinkage and reduced inflammation. However, at 6 years postoperatively, tumor-like soft tissue shadows appeared around the aorta and the aneurysm diameter re-expanded. This was diagnosed as a recurrence and worsening. Prednisolone was initiated, leading to reductions in both aneurysm size and the mass-like shadow size. When the dosage was decreased, inflammation flared up again. The medication dose was then increased. Gradual dose reduction was subsequently attempted and treatment was successfully discontinued without recurrence.
A 71-year-old man was referred to our department for open surgery for complex aortoiliac aneurysms. Computed tomography angiography demonstrated aneurysms of the abdominal aorta, bilateral common iliac arteries, and the left internal iliac artery. After stent graft placement in bilateral internal iliac arteries, we planned open surgery. Before cross-clamping the aorta, regional saturation of oxygenation in the left lower limb suddenly decreased from approximately 60% to 30%, despite being stable in the right lower limb. Intraoperative angiography revealed occlusion at the popliteal artery level, for which thromboembolectomy was successfully performed. After that, the aortoiliac aneurysms were replaced. The postoperative course was uneventful.
We report a rare case of a ruptured deep femoral artery aneurysm caused by direct infiltration of diffuse large B-cell lymphoma (DLBCL). An 82-year-old man presented with acute left thigh pain and a rapidly formed aneurysm revealed by imaging. Open aneurysmectomy and bypass grafting were performed. Histopathology demonstrated destruction of the elastic laminae and media with diffuse infiltration of atypical lymphoid cells, thus confirming DLBCL. The patient received the best supportive care. Further arterial ruptures developed, and the patient died 8 months after surgery. Malignancy should be considered in the differential diagnosis of rapidly progressive, peripheral aneurysms.
An 87-year-old man with a distal aortic arch aneurysm underwent 2-debranching thoracic endovascular aortic repair (TEVAR). Five days postoperatively, he developed sudden chest pain and syncope, with severe upper-limb hypoperfusion. Contrast-enhanced computed tomography (CECT) revealed brachiocephalic artery (BCA) dissection compressing the true lumen. Although conservative management was initially selected, percutaneous transluminal angioplasty with kissing bare-metal stents from the BCA to the right subclavian and right common carotid arteries was performed for recurrent hypotension. Postprocedural CECT confirmed satisfactory stent expansion and graft patency. This case demonstrates that careful monitoring enables timely intervention for BCA dissection after TEVAR.
Onyx is a non-adhesive liquid embolic agent used for intracranial dural arteriovenous fistulas. We report delayed distal migration of residual Onyx after successful mechanical thrombectomy. An 81-year-old woman developed acute middle cerebral artery occlusion following Onyx embolization, which was recanalized with contact aspiration. Residual Onyx, not clearly visible on angiography, was later identified on computed tomography and progressively migrated distally. One week later, further migration caused embolic infarction in the superior division of the middle cerebral artery. Residual Onyx may be difficult to detect and can migrate because of its non-adhesive nature, requiring careful postoperative evaluation and follow-up.
