Annals of Vascular Diseases Vol. 7(2014) No. 4

After the Great East-Japan Earthquake, the prevalence of deep vein thrombosis (DV T) in disaster shelters in Ishinomaki (Pacific coast, Miyagi, Japan) was found much higher than that ever reported in Japan. In Ishinomaki, twelve patients were found to have pulmonary thromboembolism for one month since the earthquake and DV T was found in 10 of those patients. The calf DV T was examined using ultrasonography in the shelters (from March to July 2011) and in temporary emergency housings (from August to December 2011). Calf DV T was found in 190 of 701 evacuees. DV T prevalence was higher in the tsunami-flooded shelters (34.2%) than in that in the non-flooded shelters (19.1%). This indicated that deteriorated and crowded condition in the tsunami-flooded shelters might induce thrombogenesis in calf veins. Therefore, evacuees were recommended to leave tsunami-flooded areas. DV T prevalence in the shelters was gradually reduced, however, that was still higher in the temporary emergency housings (8.9%) than in the non-disaster area in Japan (2.2% in Yokohama city). The risk of calf DV T in the temporary emergency housings was increased because of reduced blood flow in the calf veins caused by immobility. The residents of the housings were required to be physically active to avoid calf DV T. (English translation of Jpn J Phlebol 2013; 24: 380–384)

We undertook this study using ultrasonography to examine structural changes occurring in the subcutaneous tissue with lymphedema. Ultrasonographic images were taken in 178 outpatients and 29 inpatients, with the images of the subcutis fluid accumulation , which was categorized into three types ( grade 0: absent, grade 1: a minimal amount of water, grade 2: stone-paved image due to excess water). Initial percentage of excess volume was correlated with the tissue fluid (grade 0: 7.5%, grade 1: 17.1%, grade 2: 30.5%, p <0.01). The higher the grade of fluid accumulation, the more important was the absolute reduction of lymphedema volume (grade 0: 2.5%, grade 1: 14.8%, grade 2: 33.2%, p <0.01) . The percentage of severe lymphedema (stage2b + 3) was higher in inpatients than outpatients(89.3% vs. 45.8%), however, a significant decrease in the percentage of volume reduction was found for inpatients (29.4 ± 15.1% vs. 15.4 ± 14.2%, p <0.01). Echographic images can help to determine whether compression therapy will reduce lymphedema and to evaluate the treatment results by measuring tissue fluid. For severe lymphedema, a compression bandage was more effective than an elastic stocking. (English translation of Jpn J Phlebol 2013; 24: 287–294)

Objectives: This study we compare the duplex-derived parameters of reflux in patients with early and advanced superficial venous insufficiency (SVI) to identify parameters reflecting this.Methods: Two thousand and one hundred sixty limbs with primary reflux, categorized according to the CEAP (clinical, etiologic, anatomic and pathophysiologic) classification, and the patients were divided into two groups (group I [C_1–3, E_p, A_s, P_r]; group II [C_4–6, E_p, A_s, P_r]) were studied. The vein diameter, reflux duration(s), mean reflux velocity (MRV; cm/s), peak reflux velocity (PRV; cm/s), and total reflux volume (TRV; ml/s) were determined at the sapheno-femoral junction (SFJ), great saphenous vein (GSV) and sapheno-popliteal junction (SPJ).Results: Age and the proportion of males were greater in group II. MRV, PRV and TRV were greater in group II at the SFJ, SPJ and in GSV (p <0.01 for all), although the duration of SPJ reflux was non-discriminatory (p = 0.78). From receiver operating characteristic (ROC) curve, optimal cut-off points of 27.8, 47.8, and 36.2 cm/s for the PRV at the SFJ (p <0.01), GSV (p <0.01), and SPJ (p <0.01) discriminated between the two groups.Conclusion: PRV and MRV improved discrimination between early and advanced SVI compared to reflux duration.

Objective: We evaluated early and long-term results of atherosclerotic aneurysm repair with custom-made endografts.Materials and Methods: Eighty-one consecutive patients underwent thoracic endovascular aortic repair with custom-made endografts. Fenestrated grafts were used in 37 patients (45.7%) to maintain blood flow of the neck and a landing zone for as long as possible for distal arch or proximal descending aneurysms. The rates of perioperative mortality, stroke, paraplegia, and primary endoleaks were assessed to evaluate in-hospital safety. The rates of endoleak development, survival, and freedom from aortic-related death were assessed to evaluate long-term efficiency.Results: Twenty-four patients (29.6%) underwent urgent operations, and 38 (46.9%) underwent distal arch or proximal descending aortic aneurysm repair. There was one case (1.2%) of in-hospital mortality and no cases of stroke. Permanent spinal injury occurred in one patient (1.2%). Early and late endoleaks occurred in one and 16 patients, respectively. The actuarial survival rates were 88.9%, 64.9%, and 51.7% at 1, 5, and 10 years, respectively. The actuarial rates of freedom from endoleaks were 90.1%, 81.3%, and 68.6% at 1, 5, and 10 years, respectively.Conclusion: Early results of custom-made endografts were excellent, and fenestrated endografts were safe for distal arch and proximal descending aortic aneurysms.

Objective: In this exploratory study, we used ultrasound speckle-tracking methods, originally used for analyzing cardiac wall motion, to evaluate aortic wall motion.Materials and Methods: We compared 19 abdominal aortic aneurysm (AAA) patients with 10 healthy volunteers (diameter, 48 mm vs. 15 mm). Motion pictures of the axial view of the aneurysm using ultrasonography were analyzed. Circumferential strain and strain rate at 6 equally divided segments of the aorta were semiautomatically calculated. We termed ‘peak’ strain and strain rate as the maximum of strain and strain rate in a cardiac cycle for each segment. We also evaluated the coefficient of variation of peak strain rate for the six segments.Results: In the aneurysm and control groups, the mean values of peak strain along the 6 segments were 1.5% ± 0.6% vs. 4.7% ± 1.6% (p <0.0001), respectively. The coefficient of variation of the peak strain rate was higher in the AAA group (0.74 ± 0.20) than in the control group (0.56 ± 0.12; p <0.05).Conclusions: Aortic wall compliance decreased in the more atherosclerotic AAA group. The higher relative dispersion of strain rates in the AAA group is indicative of the inhomogeneous movement of the aortic wall.

Objective: To assess the performance of magnetic resonance venography (MRV) for pelvis and deep vein thrombosis in the lower extremities before surgical interventions for varicose veins.Materials and Methods: We enrolled 72 patients who underwent MRV and ultrasonography before stripping for varicose veins of lower extremities. All images of the deep venous systems were evaluated by time-of-flight MRV.Results: Forty-six patients (63.9%) of all were female. Mean age was 65.2 ± 10.2 years (37–81 years). There were forty patients (55.6%) with varicose veins in both legs. Two deep vein thrombosis (2.8%) and three iliac vein thrombosis (4.2%) were diagnosed. All patients without deep vein thrombosis underwent the stripping of saphenous veins, and post-thrombotic change was avoided in all cases.Conclusion: MRV, without contrast medium, is considered clinically useful for the lower extremity venous system.

Objective: To determine the relationship between arterial stiffness measured in different aortic segments and the presence and extent of ascending thoracic aortic aneurysm (ATAA).Methods: Patients at a Thoracic Aortic Diseases clinic at a University teaching hospital were compared to patients attending a Cardiology outpatient Clinic at the same institution. A non-invasive measure of vascular stiffness was performed using pulse wave velocity (PWV) measurement of several vascular segments—carotid-femoral pulse wave velocity (cfPWV), heart-femoral pulse wave velocity (hfPWV) and brachial-ankle pulse wave velocity (baPWV). Aortic dimensions were measured on echocardiogram.Results: Patients with ATAA (N = 32) were 66 years and the same age as those without ATAA (N = 46). There was no significant difference between those with or without aortic aneurysm with respect to cfPWV, hfPWV or baPWV. In ATAA, there was a significant (p <0.05) inverse correlation between aortic diameter at the sinuses of Valsalva and cfPWV, as well as hfPWV, but not with baPWV. This relationship was not evident in persons without ATAA.Conclusion: Reduced aortic stiffness (increased compliance), assessed by cfPWV or hfPWV, correlates with larger aortic size of ATAA at the level of the sinuses of Valsalva but not at the ascending aorta, suggesting cfPWV may be a useful method to assess the size of ATAA at the level of the sinuses of Valsalva. Overall aortic stiffness assessed by PWV did not differentiate persons with or without an ATAA, in individuals who do not have a genetic or inheritable cause of their ATAA.

A 25-year-old woman committed suicide with a high-rise fall and presented hypovolemic shock caused by blunt thoracic, abdominal injury. Enhanced computed tomography scan showed the pelvic hemorrhage and the transection of the descending thoracic aorta. After urgent transcatheter arterial embolization to stabilize bleeding from pelvic fracture, the thoracic aortic injury was treated with endovascular aortic repair using a GORE TAG endograft. She recovered from her injuries, and there was no evidence of endoleak in the follow-up computed tomography scan. In the treatment of traumatic aortic injury with associated severe injuries, the management of bleeding from associated injuries is important.

Transvenous placement of inferior vena cava (IVC) filters is commonly performed in selected patients with deep venous thrombosis and pulmonary embolism. However, filter placement is sometimes associated with serious complications. A common complication is asymptomatic perforation of the IVC and penetration of adjacent organs by the filter. Here, we report a case of an 83-year-old man whose prophylactic IVC filter penetrated the aorta. The patient was closely followed without surgical intervention for more than a year, and no additional complications were observed.

Adventitial cystic disease is a rare non-atherosclerotic vascular disease. We report a 36-year-old man with right intermittent claudication by adventitial cystic disease. computed tomography (CT) and magnetic resonance imaging (MRI) revealed an ovoid cystic mass compressing the right popliteal artery and causing severe stenosis of the lumen. Percutaneous aspiration was performed, which improved his symptoms. However, he complained of identical intermittent claudication two weeks later. Radiographic findings revealed that the cystic lesion had progressed rapidly. The cystic lesion was resected and the affected arterial segment was interposed. We consider that conventional surgical intervention remains the favored treatment option in the management of adventitial cystic disease.

A 67-year-old man was referred to our hospital for an ascending aortic aneurysm, thoracoabdominal aortic aneurysm and aortic regurgitation. Graft repair of the thoracic aortic arch and aortic valve replacement was given priority and completed, however he developed descending aortic rupture before the second scheduled surgery, and endovascular stent grafting was performed. He subsequently developed tracheobronchial obstruction and esophageal perforation. The patient underwent urgent esophagectomy and enterostomy with continuity later reestablished. However, he died of sepsis 5 months after surgery. Despite the less invasive nature of endovascular treatment, esophageal perforation can nevertheless occur and postoperative vigilance is well warranted.

Renal insufficiency and allergy for iodinated contrast are the main contra-indications for Endovascular Aortic Repair (EVAR). Various techniques have been used to minimize utilization of contrast in order to prevent contrast induced nephropathy. EVAR can be performed without nephrotoxic contrast, using additional duplex-guidance. This report describes three cases of duplex-assisted EVAR in patients with chronic renal insufficiency.

A spontaneous intercostal arterial rupture in patients without associated illness or trauma is extremely rare. We present a 58-year-old man with an idiopathic and spontaneous arterial rupture restrained by conservative management. He was admitted to our institute with an intermittent back pain lasting for 3 days. His past history included no notable diseases and chest trauma. An enhanced computed tomography revealed an effusion of blood around the descending aorta and hematoma from right 10th intercostal artery. Management of blood pressure and administration of tranexamic acid were performed and he was uneventfully discharged at 11 days after onset.

During surgery for an abdominal aortic aneurysm, various problems can occur at the proximal anastomosis. Adequate exposure must be secured, and the proximal anastomosis must be sutured firmly. We have used a malleable U-shaped retractor to easily secure exposure of the proximal anastomosis. Despite recent advances in endovascular treatment, abdominal aortic aneurysm repair often requires open surgery. We describe our malleable U-shaped retractor technique, which is very easy and facilitates the creation of a secure proximal anastomosis.