Traditionally, the surgical management of acute type B aortic dissections was reserved for patients with signs of malperfusion, rapid expansion, retrograde dissection or rupture. The adjunct of endovascular techniques has brought a paradigm shift, leaning towards preventing long term dissection complications. Multiple risk factors have been proposed to identify patients at risk for long term aortic complications. The patients, who are offered a prophylactic endovascular therapy for uncomplicated aortic dissection, should be selected carefully, and offered intervention by an experienced team in a high-volume center. (This is a review article based on the invited lecture of the 57th Annual Meeting of Japanese College of Angiology.)
Current Trend in the Treatment of Vascular Diseases in Patients with Endstage Renal Disease on Hemodialysis
Recent years, multiple studies regarding clinical efficacy and risks of Warfarin therapy in dialysis patients have been reported, and not a few reports conclude that clinical advantage of Warfarin is questionable in dialysis patients. Conversely, its hemorrhagic risk might be a little more serious in dialysis patients comparing to non-dialysis patients. Basically, it is assumed that long-term administration of Warfarin accelerates the development of vascular athelosclerosis because of the abolished anti-calcification effect of Gla-protein activation by decreased vitamin K activity. This assumption is recently confirmed by multiple reports, suggesting that the Warfarin administration might be worse harmful than ever expected in dialysis patients who are essentially considered to have higher risk of calcification comparing to non-dialysis patients. In addition, it is recently well considered that the Warfarin administration would be a risk factor to cause Warfarin skin necrosis or calciphylaxis, therapy resistant ulcerative skin lesions, which are considered to be highly related to the Warfarin-induced transient hypercoagulable state or acceleration of calcification. Therefore, it is considered that the indication of Warfarin administration to dialysis patients should be carefully assessed. (This is a translation of Jpn J Vasc Surg 2017; 26: 83–90.)
According to expansion of dialysis-dependent population, more than half of patients with critical ischemic limbs are dialysis-dependent in Japan. Although patients with end-staged renal disease are well-known as poor life prognosis, well-managed dialysis patients in Japan can survive much longer compared to dialysis patients in the United States and Europe. Therefore, some dialysis patients can enjoy the long-term benefits of bypass surgery. To decide the indication of bypass surgery, patient’s general condition, nutrition status, and vein availability are more important rather than arterial disease anatomy. Ultrasound guided nerve block anesthesia blocking both sciatic and femoral nerve is contributing greatly to quick postoperative recovery of high risk patients. Preoperative ultrasound examination also contribute to not only vein mapping but also find out the graftable segment of artery. The selection of distal target should be decided based on the degree of arterial disease (luminal surface as well as wall calcification), and arterial run-off. Several tips regarding anastomosis to heavily calcified artery have been established including how to create bloodless operative field without arterial clamps. Adequate wound management after bypass surgery is also important. Detection of deep infection such as osteomyelitis and the adequate treatment may avoid major amputation of salvageable limbs. In the era of endovascular treatment, the evidences guiding how to select dialysis patients suitable for bypass surgery are awaiting. (This is a translation of Jpn J Vasc Surg 2017; 26: 33–39.)
Selection from the Journal of Japanese College of Angiology 2016
Objective: To assess medical economic adequacy of endovascular aneurysm repair (EVAR) for abdominal aortic aneurysm (AAA).
Methods: Cost-utility analysis. A total of 21 patients with AAA treated at Ibaraki Prefectural Central Hospital in 2014 were divided into non-ruptured EVAR (Group E) and open surgery (OS) (Group O), and ruptured OS (Group R) groups, and hospital costs were aggregated with a medical accounting system. Mid-level hospital costs were estimated by a diagnosis-procedure-combination analysis system. Incremental life years were extrapolated from the results of randomized controlled trials in the UK (EVAR Trial 1 and 2), a life table, and the Pancreas Cancer Registry in Japan. Quality-adjusted life years (QALY) were estimated under the assumption of a certain quality weight.
Results: Incremental cost-effectiveness ratio (ICER) of EVAR compared with the OS was calculated to be 31.0 million yen/QALY, which is economically inadequate. ICER of EVAR compared with conservative treatment was inadequate in some subgroups of extremely old patients and in patients operated for far-advanced cancer.
Conclusion: EVAR is inadequate with respect to medical economics as a substitute for OS for patients in whom both procedures are available. The indication for EVAR in patients ineligible for OS should be different from that for surgery in usual patients with AAA. (This is a translation of J Jpn Coll Angiol 2016; 56: 123–130.)
Surgical revascularization is performed to preserve limb and to maintain functional status of patients with critical limb ischemia (CLI). The PREVENT III risk score helps to predict the postoperative course of CLI. However, this score is not available to estimate the risk of amputation or death properly in patients with hemodialysis (HD) and tissue loss (HD: 4 points, Tissue loss: 3 points), because they are classified as a high-risk group. Therefore, we investigated 213 patients with revascularized HD for CLI and proposed prognosis amputation or death for patients with HD risk score (PAD for HD risk score). PAD for HD risk score (non-ambulation: 3 points, ulcer/gangrene: 2 points, GNRI<92: 2 points, CRP>0.3 mg/dl: 1 point, Age≥75: 1 point) is more accurate for the prediction of amputation or death than the PREVENT III risk score (area under the curve [AUC]: 0.79 [95% confidence interval: CI: 0.71–0.87], p<0.01 vs. AUC: 0.63 [95%CI: 0.56–0.71]). The patients were stratified into three groups by total score in ascending order. The rate of 1-year amputation-free survival and independent ambulatory status were significantly different among three groups. PAD for HD risk score is useful for rehabilitation planning in patients with HD and CLI. (This is a translation of J Jpn Coll Angiol 2016; 56: 85–91.)
Objectives: Although pulmonary hypertension (PH) caused by left heart disease (PH-LHD) is more common in PH, little is known about its properties of pulmonary artery (PA) in PH-LHD. The purpose of this study was to measure pulmonary regional pulse wave velocity (PWV) and to quantify the magnitude of reflected waves in patients with PH-LHD by the analysis of the pressure–velocity loops (PU-loop).
Methods: High-fidelity PA pressure (Pm) and PA velocity (Vm) were measured in 11 subjects with PH-LHD (mean Pm>25 mmHg), 1 subject with atrial septal defect (ASD) without PH and 12 control subjects, using multisensor catheters. PWV was calculated as the slope of the initial part of the PU-loop in early systole. The similarity in the shapes of the pressure and flow velocity waveforms over one PU-loop was quantified as the magnitude of reflected wave by calculating the standard error of the estimate (Sy/x) from linear regression analysis between Pm and corresponding Vm. PWV and Sy/x during a Valsalva maneuver (VM) were also assessed in nine control subjects.
Results: The contour of PU-loop was so characteristic between control and PH-LHD. Max. PWV (349 cm/s) was recorded in PH-LHD and min. PWV (111 cm/s) was recorded in ASD. VM increased Pm (12 [7–15] mmHg vs. 50 [18–110] mmHg; p=0.009) and PWV (200 [148–238] cm/s vs. 260 [192–306] cm/s; p=0.009) significantly without significant increase of Sy/x (19.6 [12.7–28.9]% vs. 28.2 [19.3–40.7]%; p=0.079). Although Sy/x was significantly higher in PH-LHD than in control and ASD (31.0 [14.3–36.3]% vs. 17.5 [8.4–28.9]%; p=0.009, ASD: 18.2%) , no significant difference was found in PWV between PH-LHD and control (269 [159–349] cm/s vs. 203 [154–289] cm/s; p=0.089).
Conclusions: 1) The magnitude of wave reflection was elevated in PH-LHD significantly as compared with control and ASD. 2) Despite the significant increase in PA-PWV caused by abrupt elevation in Pm during VM in control, chronic elevation in Pm did not increase PA-PWV in PH-LHD significantly. It was hypothesized that the PA constituted a self-regulating system for maintaining the arterial stiffness stable against the chronic elevation in Pm in PH-LHD by a remodeling of increasing proximal pulmonary arterial crosssectional area gradually, which was compatible with the Moens–Korteweg equation. The PU-loop could provide a new simple and conventional method for assessing the pulmonary arterial properties, clinically. (This is a translation of J Jpn Coll Angiol 2016; 56: 45–53.)
Objective: To study the association between a high preoperative neutrophil lymphocyte ratio (NLR) and red cell distribution width (RDW) with arteriovenous fistula (AVF) failure, as well as to determine the cut-off values in a South Asian population.
Materials and Methods: A total of 150 consecutive patients with a failed fistula who presented in the Department of Vascular Surgery between January 2014 and January 2016. Patients fulfilling the inclusion criteria were selected as defined as Case. They were compared with 150 patients who had matured fistulae (Control).
Results: A significant difference was found between the Case and Control groups in mean preoperative NLR (3.3±0.5 versus 2.2±0.9, P value=0.011) and RDW (15.9±2.9 versus 13.6±1.1%, P value of 0.02), respectively. Multivariate analysis revealed that NLR (Odds Ratios (OR) 1.39; 95% Confidence Intervals (CI) 1.02 to 2.08; P<0.001) and RDW (OR 1.39; 95%CI 1.11 to 1.69; P<0.001) were strong independent predictors of AVF failure. A receiver operating characteristic curve analysis showed a cut-off value of 2.65 (specificity 80%, sensitivity 98%) and 15.1 (specificity 79%, sensitivity 98%) for NLR and RDW, respectively.
Conclusion: Increased preoperative NLR and RDW were associated with a high rate of AVF failure in a South Asian population.
Background: Although endovascular repair for abdominal aortic aneurysm has been found to be beneficial in very elderly patients, some patients have contraindications to this procedure. For nonagenarians, the results of open repair remain unclear. The purpose of this study was to compare the outcomes of open vs. endovascular repair for abdominal aortic aneurysm in nonagenarian patients.
Methods and Results: Fourteen patients undergoing open surgical repair and 24 undergoing endovascular repair for abdominal aortic aneurysm were evaluated. There was no significant difference in early mortality between the open and endovascular groups (0% vs. 4.1%, p=0.16). The open repair group required much longer hospital stays (26.4 vs. 10.6 days, respectively, p=0.003). Finally, 12 patients (86%) undergoing open repair vs. 21 (88%) undergoing endovascular repair returned home (p=0.49). During a mean follow-up period of 23.4±23.5 months, cumulative estimated 1- and 3-year survival rates were 90.0% and 48.0%, respectively in the open repair group and 90.6% and 54.9%, respectively in the endovascular repair group (p=0.51).
Conclusion: Although endovascular repair for abdominal aortic aneurysm was superior in terms of recovery, the results of conventional open repair were acceptable even in nonagenarian patients. Open repair remains an alternative for patients with contraindications to endovascular repair.
Objective: To review patient characteristics and outcomes after peripheral arterial disease (PAD)-related below-knee amputation (BKA), and identify risk factors predicting subsequent above-knee amputation (AKA).
Materials and Methods: A retrospective study of 210 BKAs between May 2008 and December 2015.
Results: The mean age of the study population was 66 years. Most of the patients had cardiovascular comorbidities, and 33% had end-stage renal failure (ESRF); 89% were American Society of Anesthesiologists 3 or 4. Previous ipsilateral lower-limb minor amputation was present in 49% and previous contralateral lower-limb major amputation was present in 20% patients. Limb salvage revascularization via angioplasty prior to BKA was performed in 73%, while 27% had extensive tissue loss that was not suitable for limb salvage. Postoperatively, 20% had BKA wound infection, with 3% requiring further surgical debridement, and 9% (19 patients) required subsequent AKA within 1 month. Overall survival analysis at 1–5 years was 75%, 66%, 64%, 59%, and 58%, respectively. Multivariate analysis showed ESRF (Odds Ratio [OR]=3.85; p=0.01) and preoperative non-ambulatory status (OR=5.58; p=0.01) to be independent risk factors in predicting for subsequent AKA.
Conclusion: Patients with underlying ESRF or preoperative non-ambulatory status may benefit from direct AKA if major amputation is required.
Objective: The aim of this study was to evaluate outcomes of combined popliteal-to-distal bypass and endovascular treatment (EVT) for femoropopliteal lesions in patients with critical limb ischemia (CLI).
Patients and Methods: We reviewed data of 14 CLI patients who were treated by popliteal-to-distal bypass combined with femoropopliteal EVT. The femoropopliteal lesions included 3 TASC II-A, 8 TASC II-B, and 3TASC II-C but no TASC II-D, and balloon dilatation was performed in 9 cases and a stent was placed in 5 cases. The saphenous vein graft was used in all bypasses, and the target arteries were the dorsalis pedis artery in 12 cases and the posterior tibial artery in 2 cases.
Results: At 12 and 24 months, primary patency rates were both 79%, primary assisted and secondary patency rates were both 93%, limb salvage rates were both 93%, and survival rates were 92% and 84%, respectively. Restenosis after femoropopliteal EVT occurred in 2 cases, and both were successfully revised by additional endovascular balloon dilatation.
Conclusion: Combined popliteal-to-distal bypass and femoropopliteal EVT might be a useful therapeutic option for appropriately selected CLI patients. Intensive follow-up for endovascular treated lesions and vein graft is mandatory.
Objective: We aimed to study venous leg ulcer (VLU) healing and recurrence rates of VLU using a self-care-based treatment strategy.
Methods: The study included 36 patients (43 legs) who visited our clinic between April 2009 and June 2015 because of non-healing VLUs and who had been treated by us for more than a year (until June 2016). Patients or their caregivers were first provided instructions for performing the “no-intentional-stretch” bandaging technique using ordinary elastic bandages. Wounds were cleansed with tepid water daily, and bandages were re-applied by patients or their caregivers; this was continued until VLUs were healed. Compression was discontinued after healing, but was restarted if persistent swelling and/or dermatitis was noticed on their legs.
Results: The median ulcer size was 6.5 cm2 (range, 1–105 cm2). The median number of clinic visits until healing was six (range, 3–35). The 6- and 12-month healing rates were 67% and 86%, respectively. Twenty (44%) legs required compression therapy after VLU healing. The cumulative recurrence-free rate at 60 months was 86%.
Conclusion: Reasonable healing and recurrence rates were achieved by applying a self-care-based VLU treatment strategy.
Postoperative pseudoaneurysm at the gallbladder fossa is a rare complication of cholecystectomy. The typical clinical presentations of this condition are intraparenchymal or intraperitoneal hemorrhage or rupture into the gastrointestinal tract, and this may be life-threatening. For the treatment of pseudoaneurysms, percutaneous transarterial embolization is considered first-line. We present a case of pseudoaneurysm at the gallbladder following cholecystectomy, which was successfully treated with echo-guided percutaneous transhepatic direct embolization using N-butyl cyanoacrylate, after the failure of transarterial embolization.
In this study, the case of a 46-year-old female patient with localized aortic root dissection and a superior mesenteric artery (SMA) aneurysm is described. Computed tomographic angiography could not clearly delineate an intimal flap in the aortic root, but it detected SMA aneurysm, which implied the presence of a vulnerability of the aortic wall. Finally, transesophageal echocardiography (TEE) evidently showed the intimal flap localized in the aortic root. The present case suggests that TEE is of paramount importance for detecting localized aortic root dissection. In addition, a coexisting vascular lesion may be a clue to diagnose another vascular lesion.
A 76-year-old woman with a 2-week history of dyspnea on exertion was admitted to our hospital. A computed tomography scan showed a 70-mm diameter aortic arch aneurysm containing a large thrombus that was compressing the pulmonary artery. Echocardiography showed severe pulmonary stenosis and no shunt flow. Operative findings revealed an aneurysmal thrombus protruding into the lumen of the pulmonary artery through a foramen. A ductus arteriosus aneurysm was diagnosed. After the thrombus removal, arch replacement and ductus closure with a prosthetic patch were performed. Histological examination showed that the thrombus had no vascular components. The patient’s symptoms were relieved, and she was discharged.
Persistent sciatic artery (PSA) is a rare anomaly that may cause various symptoms, such as aneurysm, rupture, thromboembolism, and sciatica. Direct surgery can be performed to treat PSA aneurysm (PSAA), but is associated with complications; e.g., anatomical problems such as sciatic nerve injury. Herein we report a case of a 74-year-old woman with acute limb ischemia that developed from a distal embolism caused by a thrombus in the left PSAA; favorable results were obtained for her by treatment with a stent-graft after rapid anticoagulation therapy for limb salvage.
Isolated abdominal aortic dissection (IAAD) is a rare form of aortic dissection involving usually the infrarenal part of the abdominal aorta. A 45-year-old male presented with lumbar pain and claudication. Computed tomography angiography (CTA) revealed an infrarenal IAAD extending to the left external iliac artery (EIA), causing ≥90% narrowing of the lumen. An endovascular approach was decided, with deployment of an aortic stent-graft and two balloon expandable stents in both common iliac arteries (IAs), applying the kissing stents technique. Post-surgical course was uneventful; 12 month follow-up showed excellent vessel patency. Endovascular therapy seems to be a feasible treatment option with promising long-term follow-up results.
Extrapulmonary involvement of tuberculosis occurs in 10–40% of reported cases. However, tuberculous mycotic aneurysm is very rare. We report herein tuberculous mycotic aneurysm of left common iliac artery secondary from ureteric tuberculosis in a 63-year-old man who presented with left flank pain for 1 month, and review the literature of all reported cases of tuberculous aneurysm of iliac artery.
Osteochondroma is the most common benign bone tumor, which can sometimes cause vascular complications. Here we report two rare cases (a 48-year-old woman and a 28-year-old woman) presenting with pain and a pulsatile mass in the popliteal region. Computed tomography revealed pseudoaneurysm in the popliteal artery, which was closely associated with a protrusion of a femoral osteochondroma. Surgical repairs were performed, and the patients remained asymptomatic during follow-up. Therefore, considering the potential risk of vascular complications, close observation is mandatory in patients with femoral osteochondroma.
A 73-year-old woman had undergone hemiarch replacement with primary entry resection for treating acute type A dissection 6 years ago. Postoperative computed tomography (CT) showed a patent false lumen (FL) in the aortic arch and a reentry tear in the right subclavian artery. The remaining aortic arch enlarged, which resulted in formation of a 55-mm-diameter aneurysm. We performed reentry occlusion using embolization with glue and coil. The patient’s clinical course after the procedure was uneventful, and subsequent CT showed that FL was thrombosed and had decreased in size.
A 69-year-old man with a type IA endoleak that developed approximately 21 months after endovascular abdominal aortic aneurysm repair (EVAR) of a 46 mm diameter aneurysm was referred to our department. He had impaired renal function, Parkinson’s disease, and previous cerebral infarction. Computed tomography angiography showed a type IA endoleak with neck dilatation and that the aneurysm had grown to 60 mm in diameter. We decided to perform aortic banding. The type IA endoleak disappeared after banding and the patient was discharged on postoperative day 10. Aortic banding may be effective for type IA endoleak after EVAR and less invasive for high-risk patients in particular.
Herein, we report a rare case of type B aortic dissection that occurred after endovascular aortic aneurysm repair (EVAR). A 66-year-old man underwent successful EVAR for an abdominal aortic aneurysm (AAA). Computed tomography (CT) 2 years after EVAR showed a type B aortic dissection with stent-graft migration and AAA expansion. Juxtarenal aortic expansion precluded simple stent-graft placement. He underwent hepato-spleno-renal bypass followed by stent-graft placement just below the superior mesenteric artery. Postoperative CT showed no endoleaks. This case reconfirms the importance of regular follow-up after EVAR and illustrates the usefulness of a hybrid approach.
The 10th Korea-Japan Joint Meeting for Vascular Surgery