Abdominal aortic aneurysm (AAA) is a vascular disease that involves the gradual dilation of the abdominal aorta followed by its rupture. AAA is closely associated with weakening of the vascular wall due to oxidative stress, chronic inflammation, and degradation of the extracellular matrix. No effective drug therapy is currently available for preventing aneurysm progression or rupture. Adipocytes in the vascular wall are reportedly closely associated with AAA development and rupture. Fiber degradation in the aneurysm wall is enhanced by increased numbers of adipocytes, and rupture risk may increase as well. Recent studies suggested that appropriate control of adipocytes in the vascular wall may be an important strategy to prevent AAA rupture, and further studies may aid in the establishment of a method for preventing AAA rupture by therapeutic drugs or functional foods. In this review, we summarize adipocyte function and the correlation between AAA and adipocytes.
Tenascins are a family of large extracellular matrix (ECM) glycoproteins. Four family members (tenascin-C, -R, -X, and -W) have been identified to date. Each member consists of the same types of structural domains and exhibits time- and tissue-specific expression patterns, suggesting their specific roles in embryonic development and tissue remodeling. Among them, the significant involvement of tenascin-C (TNC) and tenascin-X (TNX) in the progression of vascular diseases has been examined in detail. TNC is strongly up-regulated under pathological conditions, induced by a number of inflammatory mediators and mechanical stress. TNC has diverse functions, particularly in the regulation of inflammatory responses. Recent studies suggest that TNC is involved in the pathophysiology of aneurysmal and dissecting lesions, in part by protecting the vascular wall from destructive mechanical stress. TNX is strongly expressed in vascular walls, and its distribution is often reciprocal to that of TNC. TNX is involved in the stability and maintenance of the collagen network and elastin fibers. A deficiency in TNX results in a form of Ehlers–Danlos syndrome (EDS). Although their exact roles in vascular diseases have not yet been elucidated, TNC and TNX are now being recognized as promising biomarkers for diagnosis and risk stratification of vascular diseases.
As more than 320,000 patients are currently receiving hemodialysis treatment in Japan, the creation and maintenance of hemodialysis access is a major concern. The national guidelines recommend autogenous arteriovenous hemodialysis, and the brachial–basilic arteriovenous fistula has been the focus of attention, because the need for secondary, tertiary, or even more vascular access is growing. Although favorable results have been reported in terms of patency and access-related complication, this fistula involves various unsolved or controversial issues, with limitations including complex procedures, which might contribute to the lower prevalence at this point in Japan. This review addresses those issues and discusses the role of fistula in Japan.
Objective: We aimed to assess the efficacy of preoperative antibiotic therapy for the treatment of prosthetic graft infection.
Materials and Methods: We retrospectively analyzed the treatment strategies used for managing patients with prosthetic vascular graft infections between 2000 and 2016. The patients were divided into two groups: early antibiotic (EA) group, those who were administered with antibiotics ≥2 weeks preoperatively and late antibiotic (LA) group, those who were administered with antibiotics <2 weeks preoperatively. We evaluated the outcomes including surgical procedures, length of hospital stay, and surgical revision.
Results: All the surgical procedures performed in the EA group were elective surgeries. Three of the 11 surgeries performed in the LA group were emergency surgeries (P=0.16). No significant differences were observed in the operative procedure (P=0.64), operation time (P=0.37), and blood loss (P=0.63) of the two groups. Although the length of postoperative hospital stay did not significantly differ (P=0.61), the total length of hospital stay was longer in the EA group (P=0.02). Surgical revisions were performed for five patients in the LA group and for none in the EA group (P=0.04).
Conclusion: Preoperative antibiotic therapy provided excellent outcomes in terms of avoiding surgical revisions in the treatment of vascular graft infection.
Objective: This study was performed to determine whether open surgical decompression (OSD) decreased the mortality associated with abdominal compartment syndrome (ACS) following open repair (OR) of ruptured abdominal aortic aneurysm and iliac aneurysm (rAAA), and to investigate the risk factors associated with OSD.
Material and Methods: Total 113 consecutive patients with rAAA underwent OR in our institution. Ninety patients underwent primary abdominal closure; however, three of them developed ACS and required OSD. Prophylactic OSD was performed at the initial OR in 23 patients.
Results: The in-hospital mortality rate was higher in those who underwent OSD than in those who did not undergo OSD [27.0% (7/26) vs. 6.9% (6/87), respectively; p=0.01]. However, no ACS-related death occurred in the OSD group. Multivariate analyses revealed that a preoperative/intraoperative base excess (BE)<−11 [p=0.045; odds ratio (OR), 3.33; 95% confidence interval (CI), 1.021–10.850], performance of left thoracotomy (p=0.038; OR, 5.17; 95%CI, 1.098–24.357), and intraoperative blood transfusion >1,800 mL (p=0.012; OR, 4.30; 95%CI, 1.386–13.322) were associated with OSD.
Conclusion: The prevalence and mortality rates of ACS were low at our institution. OSD is considered to be useful for the prevention and treatment of ACS after repair of rAAA. OSD should be considered in patients with the above-mentioned factors.
Objective: Flow reduction is required to preserve vascular access in cases with high flow access (HFA). We report a new flow reduction procedure, the graft inclusion technique (GIT).
Methods: The GIT procedure developed by us involves the intraluminal placement and suturing of a 4-mm polytetrafluoroethylene graft to the anastomosis and outflow tract to plicate the enlarged anastomosis and maintain lower flow volumes. Flow reduction for HFA was retrospectively assessed in a series of 25 patients (age 65±12 years; 17 males and 8 females) to evaluate flow volume and patency rate, wherein 10 patients underwent conventional methods of flow reduction and 15 underwent GIT.
Results: Compared with preprocedure values, mean flow volume (MFV) was significantly lower after the procedure with both the conventional methods (1,817 vs. 586 ml/min; P<0.05) and the GIT (2,262 vs. 890 ml/min; P<0.05). An increase in MFV occurred during follow-up after conventional flow reduction (586 vs. 1,036 ml/min), while GIT could maintain lower MFV (890 vs. 791 ml/min), suggesting that GIT can significantly lower MFV levels (2,262 vs. 791 ml/min; P<0.05) and maintain these lower MFV levels during follow-up. Secondary patency rate for the GIT was 100% at 1 year and 83% at 3 years.
Conclusion: The GIT may be used as an access-preserving, reliable, long-term, and stable flow-reducing procedure that does not require flow adjustment during surgery.
Objective: To evaluate outcomes after transmetatarsal amputation (TMA) in peripheral arterial disease (PAD) limb salvage in an Asian population and identify risk factors associated with TMA failure.
Methodology: A retrospective review of 147 patients with PAD, who had undergone TMA between 2008 and 2014, was carried out. Univariate and multivariate analysis were used to identify predictors of TMA failure. Kaplan–Meier survival analysis was used to calculate major amputation and all-cause mortality rates.
Results: The mean age was 66 years. 92% were diabetic patients and 78% had preceded angioplasty. 56% of TMAs were healed via secondary intention, 8% required subsequent split-thickness skin graft closure, 24% required further debridement while 37% had wounds, which failed to heal and required below-knee amputations (BKA). Multivariate analysis showed that diabetes is the only independent predictor of TMA failure (odds ratio (OR) 7.11, p=0.064). Patients with TMA failure were at increased risk of developing nosocomial infections (p=0.025) and faced a higher risk of 30-day re-admission rate (p=0.002).
Conclusion: The success rate for PAD limb salvage TMA was 63% and diabetes was an independent predictor of TMA failure. Patients with TMA failure were at increased risks of nosocomial infections, and 30-day re-admissions; hence the risks and benefits of TMA for diabetic foot limb salvage must be individualized for each patient.
Objective: The aim of this study was to elucidate the long-term results of crossover bypass (CB) for iliac atherosclerotic lesions in the era of endovascular treatment (EVT).
Methods: A retrospective multicenter cohort study was performed. CB was performed in 242 patients between 2003 and 2014 by vascular surgeons at multiple medical centers in Japan.
Results: Perioperative mortality was 1.7%. Primary patency rates were 86% at 5 years and 82% at 8 years. Univariate analysis showed that critical limb ischemia (Rutherford class 4–6), vein graft, and superficial femoral artery occlusion were significantly associated with low primary patency. In multivariate analysis, only critical limb ischemia influenced primary patency. The secondary patency rate was 87% at both 5 and 8 years. The limb salvage rate was 98% at both 5 and 8 years. The overall survival rates were 71% at 5 years and 49% at 8 years.
Conclusion: The long-term results of CB were good in our study, compared with previous reports. Our results suggest that CB remains an option for the arterial reconstruction in unilateral iliac occlusive disease after EVT failed.
Objective: Native fistula creation for hemodialysis in patients who have exhausted all their superficial veins presents a challenge to vascular practice. We review our experience in transposed basilic vein fistula (BVT) creation and its usage for hemodialysis.
Materials and Methods: We analyzed the hospital operative registry from January 2009 till June 2012 to identify the total number of BVT created in our center. Medical records of all patients were traced, and patients were interviewed using a standard proforma. In our center, BVT is performed as a two-stage procedure. All patients were routinely assessed with duplex scan preoperatively and postoperatively.
Results: Two hundred thirty-nine patients were recruited in the study. Of these patients, 50.6% were male and 49.4% were female. Mean age was 53.4 years. Of these patients, 81.2% had history of other previous fistula creation. Risk factors profile includes diabetes mellitus in 59.8%, hypertension in 86.2%, and smoking in 13.0%. Of these patients, 84.5% had no operative complication. Commonest complication was wound infection, 6.3%, followed by hemorrhage or hemotoma required surgical intervention, 5.9%, and pseudoaneurysm, 1.3%. Primary and secondary patencies were at 84.2% and 86.1% at 1 year and 67.7% and 70.5% at 3 years, respectively.
Conclusion: BVT is a credible option for challenging patients with absence of superficial veins for native fistula creation with good patency and low operative complication rate. Preoperative ultrasound assessment improves patient selection and outcome of BVT.
Objective: To evaluate limb-salvage surgery including vascular resection for lower-extremity soft-tissue sarcomas and carcinomas for adult patients.
Materials and Methods: Eight consecutive patients (median age, 59 years) who underwent vascular replacement during surgery for malignant tumors in the lower limbs between November 2006 and March 2018 were evaluated. Patient data were retrospectively obtained in a computerized database. Arterial and venous reconstructions were performed for seven patients, with one additional patient receiving venous reconstruction only. Autologous-vein (n=6) and synthetic bypasses were used for arterial repairs, whereas only autologous veins were implanted for venous repairs.
Results: Morbidity was 62.5%, and in-hospital mortality was 12.5%. At a median follow-up of 24 months, the primary patency rates of arterial and venous reconstructions were 85.7% and 62.5%, respectively. Limb salvage was achieved in all cases.
Conclusion: Early and mid-term bypass patency rates, the high percentage of limb salvage, and the oncologic outcome underline the efficacy of en bloc resection of soft-tissue tumors involving major vessels of the lower limbs. The anticipated need for vascular resection and reconstruction should not be a contraindication to sarcoma and carcinoma resections. However, efforts to achieve better control over systemic spread are required for long-term survival.
We report the case of a 75-year-old man who underwent right femoral-popliteal bypass surgery. Anastomotic stenosis was overlooked in indocyanine green (ICG) angiography due to opacification on the bypass graft. X-ray angiography revealed slit-shaped stenosis in the distal graft anastomosis that required revision. Although blood flow may be maintained despite of anastomotic stenosis, small decreases in blood flow cannot be detected in ICG angiography. We describe and discuss the pitfalls of qualitative graft assessment using ICG angiography, and compare ICG fluorescence luminance intensity between primary and revised grafts.
We present a case of ruptured thoracic aortic aneurysm (TAA) with type B aortic dissection in which hybrid repair, namely, the frozen elephant trunk (FET) technique with thoracic endovascular aortic repair (TEVAR), was performed. The TAA extended to the proximal descending aorta at the level of the pulmonary trunk bifurcation. We thus employed the FET technique to control the blood flow into the TAA. After performing the FET technique, intraoperative catheter aortography revealed slight type 1B endoleak. We therefore performed additional TEVAR to control the blood flow into the TAA. The patient’s postoperative course was uneventful.
A 69-year-old man presented with abdominal pain. Enhanced computed tomography (ECT) showed abdominal aortic aneurysm (AAA) with vessel wall thickening. Follow-up ECT on day 3 of admission showed expansion of the AAA. Endovascular abdominal aortic repair (EVAR) was urgently performed. Since preoperative blood cultures revealed Campylobacter jejuni infection, the antibiotics imipenem/cilastatin were administered for five weeks, followed orally by Clarithromycin. The patient was discharged on postoperative day 45. There was no recurrence of the aneurysm at 9 months after EVAR. To the best of our knowledge, this is the first report of EVAR for infected AAA caused by Campylobacter jejuni.
Primary leiomyosarcoma of the left common iliac artery with development of an arteriovenous fistula is extremely rare. Here we report the case of a 78-year-old woman with primary vascular leiomyosarcoma that presented as acute heart failure involving an arteriovenous fistula. She underwent surgery; however, after the diagnosis of leiomyosarcoma, she did not seek active treatment. She died 8 months after the surgery. This case report supports the need to document and follow-up a primary leiomyosarcoma of the iliac artery, especially when a case includes the presentation of an arteriovenous fistula (AVF). Vascular leiomyosarcoma should be included in the differential diagnosis of an AVF.
Two-dimensional perfusion angiography (2DPA) is utilized in hybrid operating rooms. 2DPA produces color map images and functional parameters to provide more robust visual and quantitative evaluations than conventional angiography. Its efficacy was suggested in five patients following bypass surgery; unexpected results were obtained in one patient, leading to a decision to perform surgical re-anastomosis. Furthermore, we found that the general anesthesia eliminates body movements that tend to disrupt 2DPA results. 2DPA was more useful during surgical revascularization than conventional angiography and provided more detailed information.