Misdiagnosis of Primary Iliac Aneurysmo-Colonic Fistula as a Submucosal Tumor Leading to Delayed Treatment: A Case Report.

An aortoenteric fistula (AEF) is an uncommon cause of gastrointestinal bleeding that requires prompt diagnosis and intervention owing to its high mortality rate. Moreover, iliac aneurysmo-colonic fistula is an exceptionally infrequent presentation. We report a unique case of a 71-year-old male presenting with hematochezia, later diagnosed with a primary fistula between a common iliac artery aneurysm and the sigmoid colon. Initially, the patient was misdiagnosed as having a gastrointestinal stromal tumor, leading to delayed and emergent surgical intervention due to massive bleeding 2 days later. This case is particularly notable for its rarity, misinterpretation of the initial diagnosis, complicated surgical procedures, and development of complications including ischemic myopathy. This case highlights the criticality of accurate diagnosis with a high index of suspicion, significance of consultation with a vascular surgeon for vascular abnormalities, and importance of considering ischemic time in the sequence of surgical treatments to ensure timely and appropriate management.

Comparing clinical outcomes of vitamin K antagonists vs non-vitamin K antagonists in anticoagulant therapy for mesenteric venous thrombosis.

OBJECTIVE: Non-vitamin K antagonist oral anticoagulants have shown similar efficacy and lower bleeding rates than vitamin K antagonists for venous thromboembolism. However, this has not been proven in mesenteric vein thrombosis. This study aimed to compare the clinical outcomes of vitamin K antagonists and non-vitamin K antagonist oral anticoagulants. METHODS: Between January 2014 and July 2022, mesenteric vein thrombosis was diagnosed on computed tomography in 225 patients in a tertiary hospital. Among them, a total of 44 patients who underwent long-term anticoagulation therapy over 3 months were enrolled in this study. Patients were divided into two groups based on the anticoagulant used: vitamin K antagonists (Group 1, n = 21) and non-vitamin K antagonist oral anticoagulants (Group 2, n = 23). The efficacy outcomes were symptom recurrence and thrombus resolution on follow-up computed tomography, and the safety outcome was bleeding complications. RESULTS: The median age of the patients was 56 years (range, 46-68 years), and 52% were men. The most common risk factors were unprovoked intra-abdominal infections (30%). The median duration of anticoagulation therapy was 13 months (20 months in Group 1 vs 6 months in Group 2; P = .076). Of the 44 patients, 17 (39%) received the standard treatment. The median follow-up period was longer in Group 1 than in Group 2 (57 vs 28 months; P = .048). No recurrence of mesenteric vein thrombosis-related symptoms were observed in either group. The median duration of follow-up computed tomography was 31 months (42 months in Group 1 vs 18 months in Group 2; P = .064). Computed tomography revealed complete thrombus resolution, partial resolution, and no changes in 71%, 19%, and 10%, respectively (P = .075). Regarding bleeding complications, varix bleeding and melena developed in two patients in Group 2, and anticoagulation treatment thereafter ceased. CONCLUSIONS: Despite the short follow-up duration in the non-vitamin K antagonist oral anticoagulants group, there was no clinically significant difference in the thrombus resolution rate or bleeding complications when compared with the vitamin K antagonists group. Although research on the long-term effects of non-vitamin K antagonist oral anticoagulants in patients is limited, non-vitamin K antagonist oral anticoagulants can be considered an alternative to conventional treatments.

Case Report: Popliteal artery entrapment syndrome as a cause of deep vein thrombosis and subsequent popliteal artery occlusion.

Background: Popliteal artery entrapment syndrome (PAES) is a relatively rare cause of arterial insufficiency in young and physically active individuals; however, deep vein thrombosis (DVT) can develop in association with PAES. Case report: A 47-year-old man presented with a 6-day history of left leg swelling and discomfort which was diagnosed as DVT extending to the distal femoral vein and pulmonary embolism on computed tomography (CT). PAES was not suspected at this time, and the patient was administered anticoagulants for 1 year. Two years after the DVT diagnosis, the patient developed sudden-onset left calf claudication for 1 week. Repeat CT angiography showed popliteal artery (PA) occlusion caused by PA displacement from an abnormally lateral insertion of the medial gastrocnemius head. A retrospective review of the initial CT scan confirmed this, as well as compression of the popliteal vein between the displaced medial head and the normal lateral head of the gastrocnemius. The patient eventually underwent myotomy and resection of the PA with an interposition graft. Conclusion: This case underscores the potential of PAES as a rare etiology of DVT, emphasizing the importance of considering it in the differential diagnosis of DVT in younger patients lacking common predisposing factors.

Outcomes of Surgical and Endovascular Treatment for Cephalic Arch Stenosis in Proximal Arteriovenous Fistula.

Purpose: The cephalic arch is a significant site of stenosis in proximal arteriovenous fistulas (AVFs) that contributes to access dysfunction and thrombosis. This study aimed to evaluate the outcomes of surgical treatment (ST) and endovascular treatment (ET) for cephalic arch stenosis (CAS). Materials and Methods: A total of 62 patients with proximal AVF who underwent CAS revision using either ST or ET were enrolled between January 2018 and March 2023. In the ET group, only the initial ET following AVF formation was considered, to mitigate bias. In the ST group, central transposition of the native AVF (transposition group) or interposition of the prosthetic graft into the proximal basilic or axillary vein (interposition group) was performed. We evaluated primary and functional patency based on these groups and calculated the number of patency loss events after CAS treatment. Results: Of the 62 patients, 38 (61%) were male, with a mean age of 66.4 years. ST was performed in 26 (42%) patients, including transposition in 16 and interposition in 10, whereas ET was administered to 36 patients during the study period. Among the ST recipients, 42% had a history of ET for CAS. The incidence of AVF thrombosis was marginally higher in the ST group than in the ET group (39% vs. 19%, P=0.098). The primary patency rates at 6 months, 1 year, and 3 years were 87%, 87%, and 66% in the transposition group; 45%, 23%, and 11% in the interposition group; and 66%, 49%, and 17% in the ET group, respectively. Notably, the primary patency of the transposition group was significantly higher than that of the interposition (P=0.001) and ET groups (P=0.016). The frequency of patency loss events per person-year after the initial revision was 0.40, 0.52, and 1.42 in the transposition, interposition, and ET groups, respectively. Conclusion: Transposition exhibited the most favorable primary patency rate and the lowest number of subsequent patency loss events during follow-up despite the higher rates of AVF thrombosis and previous ET at presentation. Consequently, transposition should be actively considered in eligible patients with CAS.

Surgical Strategies and Long-Term Outcomes for Complex Coral Reef Aorta with Multisegmental Involvement: A Case Report.

Coral reef aorta (CRA) is a rare condition characterized by the distribution of rock-hard calcifications in the visceral part of the aorta, leading to potentially life-threatening symptoms, such as hypertension, congestive heart failure, and limb and visceral ischemia. The patient was a 54-year-old female who presented with leg claudication and was diagnosed with CRA using computed tomography. CRA affected the descending thoracic and abdominal aortas, including the visceral portion, leading to reduced perfusion of both limbs and the left kidney. The surgical intervention involved bypass surgery from the descending thoracic aorta proximal to the CRA to the aortic bifurcation, including reimplantation of the left renal artery. Postoperative recovery was successful and the symptoms resolved. However, the patient experienced decreased right renal function due to CRA progression three years postoperatively. Given the uncertainty regarding the optimal surgical approach for CRA, long-term considerations are crucial for its management.

Case Report: Hybrid approach as a Rescue Treatment in a patient with vascular Ehlers-Danlos Syndrome.

Vascular Ehlers-Danlos Syndrome (vEDS) is a rare connective tissue disorder associated with COL3A1 gene mutation encoding type III collagen. Given the possible fatal prognosis if not treated timely, it is important to suspect and diagnose as soon as possible. Despite advances in endovascular technique, access point complications remain a serious challenge in patients with vEDS. Here, we describe a 30-year-old male patient who was diagnosed with vEDS after consecutive events of bilateral iliac vessels at an interval of 3 months: (1) spontaneous dissecting aneurysm of right iliac artery and (2) arteriovenous fistula between left internal iliac artery (IIA) and left common iliac vein. This patient was treated with iliac stent-grafts and overlapping femoral interposition graft (Dacron) in the 1st operation and access artery repair with surgical dissection after coil embolization of IIA and stent-graft insertion into left common to external iliac arteries in the 2nd operation. The patient has been treated with beta-blockers and anticoagulants for the management of vEDS and postoperative deep vein thrombosis, respectively. The stent-grafts in both iliac arteries and the access sites have been well-tolerated without any adverse effects for 14 months following the 2nd operation. In conclusion, given the vascular fragility and the potential for future events, additional vascular manipulation should be avoided unless it is in a life-threatening condition. In particular, meticulous hybrid interventions can be effective treatments.

Lethal abdominal compartment syndrome after extracorporeal cardiopulmonary resuscitation in a patient with out-of-hospital cardiac arrest: a case report.

BACKGROUND: Clinical attempts of extracorporeal cardiopulmonary resuscitation (ECPR) in patients with out-of-hospital cardiac arrest (OHCA) have increased in recent years; however, it also has life-threatening complications. Massive fluid and transfusion resuscitation, shock status, or low cardiac output status during ECPR may lead to ascites and interstitial edema, resulting in secondary abdominal compartment syndrome (ACS). CASE PRESENTATION: A 43-year-old male patient was admitted to the emergency department due to cardiac arrest. Due to refractory ventricular fibrillation, ECPR was initiated. Approximately, 3 h after extracorporeal membrane oxygenation support, abdominal distension and rigidity developed. Therefore, ACS was suspected. Decompression laparotomy was required to relieve elevated intra-abdominal pressure. CONCLUSIONS: We report a case of a patient with OHCA who developed lethal ACS after ECPR. Despite this, the patient was able to recover from several major crises. Regardless of how lethal the patient is, if compartment syndrome develops in any part of the body, we should aggressively consider surgical decompression.

Clinical Outcomes of Internal Iliac Artery Interruption during Endovascular Aneurysm Repair.

Purpose: This study aimed to investigate the clinical outcomes of internal iliac artery (IIA) interruption during endovascular aneurysm repair (EVAR) and to identify the risk factors for ischemic complications. Materials and Methods: Endovascular treatment was performed in 316 patients with aneurysms or pseudoaneurysms of the abdominal aorta or iliac arteries between March 2006 and January 2022. Medical records and radiological imaging studies were retrospectively reviewed. The incidences of buttock claudication, ischemic colitis, and spinal cord ischemia after IIA interruption were investigated as clinical outcomes. Binary logistic regression analysis were performed to identify the risk factors. Results: IIA embolization was performed in 78 patients. Among the 42 patients who underwent IIA flow preservation procedures, the one-month computed tomography detected early failure in five patients. The origin of the IIA was covered with an endograft in ten patients who did not undergo embolization. Eventually, interruption of the IIA by EVAR was observed in 93 patients. Considering preoperative IIA occlusion, there was a total of six patients who did not have at least one IIA patency. Buttock claudication occurred in 32.6% of the patients, and none of the patients had ischemic colitis or spinal cord ischemia. In multivariable analysis, age ≤80 years and isolated iliac artery aneurysm were associated with the development of postoperative buttock claudication. Conclusion: The most common complication after IIA interruption is buttock claudication; however, critical complications such as ischemic colitis or spinal cord ischemia are rare, even in bilateral IIA occlusion. Adjunctive procedures to preserve bilateral IIA perfusion should be adopted selectively.

Recurrent C3 Glomerulonephritis along with BK-Virus-Associated Nephropathy after Kidney Transplantation: A Case Report.

C3 glomerulonephritis (C3GN) is a rare cause of end-stage kidney disease and frequently recurrent in allografts following kidney transplantation (KT). Herein, we describe the case of a kidney transplant recipient who developed recurrent C3GN along with BK-virus-associated nephropathy (BKVAN) following KT. A 33-year-old man diagnosed with membranoproliferative glomerulonephritis 17 years ago underwent preemptive KT with a donor kidney from his aunt. Proteinuria gradually increased after 3 months following KT, and graft biopsy was performed 30 months after KT. Histopathological examination revealed recurrent C3GN. The dosages of triple immunosuppressive maintenance therapy agents were increased. Subsequently, serum C3 levels recovered to normal levels. However, at 33 months following KT, the BK viral load increased and graft function gradually deteriorated; a second graft biopsy was performed at 46 months following KT, which revealed BKVAN and decreased C3GN activity. The dosages of immunosuppressive agents were decreased; subsequently, BKVAN improved and graft function was maintained with normal serum C3 levels at 49 months following KT. This case indicates that C3GN is highly prone to recurrence following KT and that immunosuppressive therapy for C3GN increases the risk of BKVAN.

Below-Knee Prosthetic Bypass Is a Viable Option for Limb Salvage in Patients with Extensive Femoropopliteal Occlusive Disease.

Purpose: This study aimed to (1) evaluate the outcomes of below-knee prosthetic bypass (BKPB) in the absence of the great saphenous vein, and (2) identify risk factors associated with these outcomes. Materials and Methods: This study included 37 consecutive patients who underwent BKPB with or without distal modification between 2010 and 2022. We further assessed the following treatment outcomes: primary patency (PP), secondary patency (SP), limb salvage (LS), and amputation-free survival (AFS) rates. The risk factors for PP were also examined. Results: Most patients (n=31) were male. In 32 (86.5%) patients, BKPBs were performed for chronic limb-threatening ischemia. At the time of initial admission, two (5.4%) early deaths and three (8.1%) major amputations were noted. At 1 year after BKPB, the overall PP, SP, LS, and AFS rates were 78%, 85%, 85%, and 70%, respectively; at 3 years, they were 58%, 70%, 80%, and 52%, respectively; and at 5 years, they were 35%, 58%, 62%, and 29%, respectively. Notably, PP was significantly lower in limbs with ≤1 patent tibial arteries than in limbs with ≥2 patent artery (hazard ratio [HR], 3.80; 95% confidence interval [CI], 1.14-12.69 for overall; and HR, 12.97; 95% CI, 2.15-78.08 for distal anastomosis to below-knee popliteal artery). However, the PP was unaffected by the distal modification. Conclusion: BKPB is a viable option for LS in patients with extensive femoropopliteal disease. Tibial runoff was significantly correlated with patency; therefore, decision-making for BKPB and follow-up must involve careful evaluation of the outflow arteries.

Significance of collateral circulation in managing persistent sciatic artery: Two case reports.

Persistent sciatic artery (PSA) is a rare congenital anomaly considered an embryologic remnant of the internal iliac artery. Traditionally, the classification systems categorized PSA based on the completeness of PSA and superficial femoral artery (SFA) alongside the origin of PSA. The most common class has been known as type 2a in Pillet-Gauffre classification, meaning complete PSA with incomplete SFA. The mainstay of these patients with limb ischemia has been surgical bypass alongside excision or ligation of PSA aneurysm if present. However, the current PSA classification system does not account for collateral blood flow. Herein, we described two cases of type 2a PSA with distal embolization and explored therapeutic choices for PSA based on collateral presence. The first patient was treated with thromboembolectomy and patch angioplasty, and the second with conservative management. Despite distal embolization in both patients, bypass surgery was avoided, and distal circulation was maintained via collaterals from deep and superficial femoral arteries without increased risk of recurrent embolization. Thus, carefully examining collateral circulation and customized strategy is essential for managing PSA.

Pretransplant C-reactive protein-to-albumin ratio predicts mortality in kidney transplant recipients: a retrospective cohort study.

Background: The C-reactive protein (CRP)-to-albumin ratio (CAR) is a more effective prognostic indicator than CRP or albumin alone in various diseases. This study aimed to evaluate the predictive value of the CAR for mortality in kidney transplant recipients (KTRs). Methods: A total of 924 patients who underwent their first kidney transplantation at Kyungpook National University Hospital during 2006-2020 were enrolled and classified into quartile (Q) groups according to their pretransplant CAR values. A Cox regression analysis was conducted to analyze the hazard ratios (HRs) of mortality. Results: Fifty-nine patients died during the posttransplant period (mean, 85.2±44.2 months). All-cause mortality (Q1, 3.0%; Q2, 4.8%; Q3, 7.8%; Q4, 10.0%; P for trend <0.001) and infection-related mortality increased linearly with an increase in CAR (P for trend=0.004). The Q3 and Q4 had higher risks of all-cause mortality than Q1 after adjusting for confounding factors (Q3 adjusted HR [aHR] 2.49, 95% confidence interval [CI] 1.04-5.99, P=0.041; Q4 aHR 3.09, 95% CI 1.31-7.27, P=0.010). Q4 was also independently associated with infection-related mortality (aHR 5.83, 95% CI 1.27-26.8, P=0.023). The area under the curve of the CAR for all-cause and infection-related mortality was higher than that of CRP or albumin alone. There was no association between CAR and death-censored graft failure or acute rejection. Conclusions: A higher pretransplant CAR increases the risk of posttransplant mortality, particularly infection-related, in KTRs. Pretransplant CAR can be an effective and easily accessible predictor of posttransplant mortality.

Right Gastroepiploic Artery Transposition for a Common Hepatic Artery and Proper Hepatic Artery Aneurysm Repair.

Although hepatic artery aneurysms (HAAs) are uncommon, they are associated with risk of rupture. HAAs >2 cm in diameter require endovascular or open surgical repairs. For HAAs involving the proper hepatic artery or gastroduodenal artery, which is a collateral artery from the superior mesenteric artery, hepatic arterial reconstruction is especially important to avoid ischemic liver injury. In this study, right gastroepiploic artery transposition was performed in a 53-year-old man after a 4 cm common hepatic artery and proper hepatic artery aneurysm was identified. The patient was discharged without any complications on postoperative day 8.

Off-label use of an iliac branch device and a reversed iliac limb for a patient with a unilateral common iliac artery aneurysm and a narrow distal aorta: A case report.

INTRODUCTION: Current bifurcated aortic endografts are unsuitable for patients with a narrow distal aorta except AFX2, which is unavailable in South Korea. An iliac branch device (IBD) was introduced to exclude iliac aneurysms while preserving the pelvic circulation. With advancements in endovascular techniques, various attempts for outside instructions for use have been reported to be practicable in certain patients. PATIENT CONCERNS: A 58-year-old man was referred to our emergency room with an incidentally found left common iliac artery aneurysm (CIAA) in a general checkup. DIAGNOSES: Computed tomography angiogram showed a narrow distal aorta that tapered from 20 mm just below the renal artery to 13 mm at aortic bifurcation and a left isolated CIAA with a maximal diameter of 40 mm and 70 mm in length. INTERVENTIONS: After left hypogastric artery embolization, the Cook IBD was placed at the aortic bifurcation, and the Bard Covera Plus stent-graft was deployed from the IBD cuff to the left external iliac artery. Then, a reversed Medtronic Endurant iliac limb was implanted into the infrarenal aorta down to the proximal IBD. OUTCOMES: The stent grafts were patent without endoleak at the 6-month follow-up. LESSONS: In selected patients with an isolated CIAA with a narrow distal aorta, IBD can be used as a main body at the aortic bifurcation for successful aneurysm exclusion. However, considering the application of outside instructions for use, special attention and careful planning must be taken before the procedure.

Outcomes of Isolated Endarterectomy and Patch Angioplasty of the Common Femoral Artery According to Current Inclusion Criteria for Endovascular Treatment.

Purpose: This study aimed to evaluate the outcomes of isolated common femoral endarterectomy with patch angioplasty (IFEA) in the endovascular era. Materials and Methods: In 2012-2022, 189 limbs underwent femoral endarterectomy with patch angioplasty. Of them, 45 IFEAs were included. We evaluated safety based on early complications; efficacy with primary patency (PP) and reintervention, above-ankle amputation, or stenosis (RAS)-free survival. We also evaluated lesion characteristics and outcomes according to the inclusion criteria (IC) of vascular mimetic implant-common femoral artery (VMI-CFA) stenting trial. Results: Forty-one patients were male, and 30 IFEAs were required for claudication. No cases of early mortality occurred. Ten limbs (22%) developed local/nonvascular complications (hematoma, 3; lymphocele, 5; wound infection, 2), of which 8 resolved spontaneously. The overall PP and secondary patency rates were 100% at 1 year and 87% and 97% at 3 years, respectively. Twenty-one lesions (47%) did not meet the IC. The PP within the IC was 100% at 1 and 3 years, and the PP outside the IC was 100% at 1 year and 73% at 3 years (P=0.068). The overall RAS-free survival rates were 91% at 1 year and 81% at 3 years. All cases of RAS occurred in lesions outside the IC. The multivariate analysis showed that dialysis was associated with poor RAS-free survival (adjusted odds ratio, 8.56; 95% confidence interval, 1.9-35.5; P=0.005). Conclusion: The recent VMI-CFA trial results should be interpreted with caution. IFEA is a low-risk and durable procedure; however, careful follow-up is warranted in patients undergoing dialysis.

In Situ Bypass from the Brachial to Radial Artery in the Anatomical Snuffbox for Limb Salvage in End-Stage Renal Disease.

Diabetes and renal failure frequently involved in small vessel arteriopathy. With medical advancements, those patients survive longer with an increasing incidence of resultant arterial occlusive disease affecting the distal upper extremity (UE). In patients with ulcers or gangrene in the distal UE, bypass surgery is often complicated by severe atherosclerosis with calcification, resulting in poor distal anastomosis quality. Here we report a patient with a fingertip gangrene who were successfully treated with in situ bypass from the brachial artery below the elbow to the radial artery in the anatomical snuffbox under local anesthesia. Bypass graft patency was maintained during the 18-month follow-up. If the forearm cephalic vein and radial artery in the anatomical snuffbox are of adequate quality, in situ bypass to radial artery in the anatomical snuffbox may be a useful option for limb salvage in selected patients.

Incidence and Risk Factors for Sac Expansion after Endovascular Aneurysm Repair of Abdominal Aortic Aneurysms.

PURPOSE: This study aimed to examine the sac changes after endovascular aneurysm repair (EVAR) in patients with abdominal aortic aneurysms. MATERIALS AND METHODS: We examined the aneurysm sac size initially and regularly after surgery in 157 consecutive patients who underwent EVAR in 2009-2019. Contrast-enhanced computed tomography (CT) scans were used as well as ultrasound images with non-enhanced CT scans in the patients with renal insufficiency. Sac expansion (SE) at 3 years was divided into two categories: progressive SE (PSE) defined as continuous sac enlargement of ≥5 mm on serial follow-up images at 1 and 3 years compared with the initial sac and delayed SE (DSE) defined as re-expansion of ≥5 mm compared with the regressed or stable sac at 1 year. The SE rate at 1 and 3 years and the risk factors for SE at 3 years were analyzed using logistic regression. RESULTS: During a median follow-up of 32.5 months, nine reinterventions in six patients were performed with open conversion (n=5) and endovascular repair (n=4). At 1 year, 112 patients underwent follow-up imaging. SE and sac regression were noted in 4 (3.6%) and 57 (50.9%) patients, respectively. Of the 64 patients with 3-year follow-up images, 16 (25%) exhibited SE (PSE [n=6] and DSE [n=10]). In the multivariable analysis, the risk factors for overall SE at 3 years were endoleaks at 1 year (P=0.006) and renal insufficiency (P=0.003). CONCLUSION: During post-EVAR follow-up, patients with any endoleak at 1 year or renal insufficiency must be strictly monitored for SE development.

Endovascular Repair of an Ilio-Iliac Arteriovenous Fistula with Pseudoaneurysm after Lumbar Disc Surgery: A Case Report.

Aortoiliac vascular injury during lumbar disc surgery is potentially life-threatening, but occasionally presents with delayed-onset symptoms. This is a case report of a fistulized pseudoaneurysm presenting with claudication. A 73-year-old female presented with swelling of the left leg and short-distance claudication. Two months prior, she had undergone discectomy for the management of right foot drop caused by an L4-L5 herniated lumbar disc. The left ankle-brachial index was 0.71. Computed tomography angiography revealed a 31 mm×20 mm pseudoaneurysm of the left common iliac artery fistulized to the left common iliac vein. The patient was successfully treated with stent graft placement.

Long-Term Result of Tibioperoneal Trunk Bypass with an Autogenous Graft Using the Varicose Great Saphenous Vein for Acute Limb Ischemia.

For the management of acute limb ischemia (ALI) and multilevel arterial occlusive disease, tibial bypass using the saphenous vein has been considered a mainstay due to the long-term durability in selected patients with acceptable saphenous veins and comorbid conditions. Traditionally, bypass using a varicose autogenous graft has been contraindicated due to the risk of late aneurysmal dilation and rupture. Here, we describe a patient who presented with ALI and received tibioperoneal trunk bypass using a varicose autogenous graft. The patient has been doing well during the 72-month follow-up without recurrent symptoms or revision. The follow-up images showed a favorably patent graft with mild aneurysmal changes at the valve cusp adjacent to the knee. If there are no other appropriate autologous veins for revascularization, a varicose autogenous vein graft may be a useful option for limb salvaging in selected patients with multilevel arterial occlusive diseases.