The majority of aortic aneurysms comorbid with atherosclerosis can be asymptomatic and are discovered incidentally on routine physical examination or on imaging studies for other indications. Transthoracic echocardiography is a basic modality to assess patients with coronary artery disease and can be used for the screening of aortic aneurysm. Acute aortic dissection is a highly lethal cardiovascular emergency and requires prompt recognition. Although cardiovascular echo has a suboptimal accuracy rate for detecting aortic dissection, it is noninvasive, readily available, and easy to use. Recently, the concept of point-of-care ultrasound (POCUS) refers to the use of portable ultrasound at the patient’s bedside for diagnostic and therapeutic purposes. POCUS could become an important tool in the screening and primary diagnosis for acute aortic dissection. Transesophageal echocardiography (TEE) was established to detect aortic dissection and determine the therapy. However, the use of TEE has decreased with the progress of contrast-enhanced computed tomography. Currently, attention is paid to TEE in the monitoring for the operation of aortic dissection, the use on bedside, and in emergency room, and the precise evaluation of aortic dissection for the patient with a history of allergy of contrast media and/or renal disturbance.
Acute limb ischemia (ALI) is a rapid decrease in lower limb blood flow due to acute occlusion of peripheral artery or bypass graft, and in ALI not only limbs but also life prognosis will be poor unless quick and appropriate treatment is given. The etiology is broadly divided into embolism and thrombosis with various comorbidities. The symptoms of ALI are abrupt with pain, numbness, and coldness of lower limb, and paresthesia, contracture, and irreversible purpura will appear with the exacerbation of ischemia. Severity and treatment strategy should be determined based on physical findings and image findings. Considering life prognosis, limb amputation should be done without hesitation when the limb was diagnosed as irreversible. ALI can be treated by means of open surgical revascularization, endovascular, or hybrid approach with rapid systemic administration of heparin. In any cases, evaluating the lesions by intraoperative angiography and appropriate additional treatment are important. ALI is a serious disease requiring urgent treatment, and it is essential to promptly perform the best initial treatment that can be performed at each facility. (This is a translation of Jpn J Vasc Surg 2018; 27: 109–114.)
With the global epidemic of diabetes, diagnosis of critical limb ischemia (CLI) has become very complex due to mixture of microangiopathy, infection and sometimes neuropathy with the pure ischemia. We still sometimes encounter the patients with extensive tissue loss due to misdiagnosis of ischemia or infection in previous hospital. For adequate decision making of proper treatment selection for each critical ischemic limb without missing the adequate intervention timing, a new classiﬁcation system good for not only vascular specialists but also gate keeping clinicians working in the era of diabetes has been desired. Responding to marked demographic shift, Society for Vascular Surgery issued new classiﬁcation named WIfI system which evaluate the foot lesion comprehensively by three factors; Wound (W), Ischemia (I), and foot Infection (fI). Guidelines for peripheral arterial disease recommend use of WIfI classiﬁcation system. To decide treatment strategy of CLI as well as managing those limbs after revascularization, it is important to popularize adequate diagnostic system using WIfI classiﬁcation as common language by not only for vascular specialists but also other clinicians facing CLI patients. (This is a translation of Jpn J Vasc Surg 2018; 27: 187–195.)
In this article, I would like to discuss on the two different treatment options (Open vs EVAR) for pararenal abdominal aortic aneurysm (the term “PRAAA” is not clearly defined and classified). Recently, complex endovascular treatment [Fenestrated EVAR (F-EVAR), Chimney (Snorkel) EVAR (C-EVAR, S-EVAR), Branched EVAR (B-EVAR)] have been developed and applied in selected patients, with encouraging early results; however, the high rate for secondary reinterventions and long-term results remain uncertain. This article introduce new devices and a new concept with endovascular aneurysm sealing (EVAS) are currently available on the market for the treatment of PRAAA. Open repair of PRAAA can be performed with low mortality and long-term survival is favorable from single-center experience in the real world and others. We conclude that open repair remains the golden standard treatment in most centers for PRAAA. However, EVAR of PRAAA may represent an alternative option in high-risk patients. Because the indications and circumstances for PRAAA vary based on patient-specific comorbidities and anatomy, it is recommended that vascular surgeons should be familiar with both treatment strategies and tailor-made strategy for improved long-term results for PRAAA. (This is a translation of Jpn J Vasc Surg 2018; 27: 303–308.)
Thoracic endovascular aortic repair (TEVAR) for thoracic aortic disease constitutes a paradigm shift in the treatment strategy of aortic dissection, as well as thoracic aortic aneurysms. Conventionally, most patients with Stanford type B acute aortic dissection are treated using conservative medical treatment during the acute phase. However, in patients with complicated type B aortic dissection who present with life-threatening complications, TEVAR has been introduced as a novel and less-invasive alternative and has shown better early results than those observed with conventional therapy. Recently, TEVAR was reported to be effective in not only promoting thrombosis of the false lumen but also in preventing aortic enlargement observed at long-term follow-up. TEVAR has been established as first-line therapy for complicated type B aortic dissection. In contrast, a considerable number of patients who received acute phase medical treatment required surgical intervention for chronic dissecting aortic aneurysms. With the increasing popularity of TEVAR for the treatment of complicated type B aortic dissection, prophylactic and pre-emptive TEVAR has been considered in patients with uncomplicated type B aortic dissection. However, supportive evidence for this strategy is limited, and reassessment is mandatory because it is continuously evolving. Although acute type A aortic dissection is a life-threatening condition, the results of open surgery continue to improve in the modern surgical era. Open surgical treatment is well established and recognized as a gold standard even in the endovascular era. Presently, the application of TEVAR for ascending aortic dissection has undergone a change, and TEVAR is considered a viable rescue option for patients with type A aortic dissection who are not eligible for open surgical repair. However, TEVAR for the descending aorta is well-established treatment for retrograde type A dissection. Several conceptual and technical issues remain unresolved, and technological advances would lead to the development of innovative disease-specific devices and solutions in the future for endovascular treatment of acute aortic dissection. (This is a translation of Jpn J Vasc Surg 2018; 27: 337–345.)
The aim of this systematic review is to establish the efficacy of revision using distal inflow (RUDI) on the primary endpoints of complete dialysis access steal syndrome (DASS) resolution and arteriovenous fistula (AVF) longevity. An electronic search of literature from 1966 to 2017 in CINAHL, Medline, Embase and the Cochrane library according to PRISMA standards was conducted. Quality evaluations and recommendations for practice were examined. Data on power, age, gender, comorbidities, arterial inflow, conduit material, fistulae type, follow-up, failure incidence, ischaemia grade, modality of diagnosis, morbidity and mortality were subjected to pooled analysis of prevalence at a 95% confidence interval (CI). Eleven studies involving 130 individuals with a median age of 57 [interquartile ranges (IQR), 54–65] and equal gender distribution were conducted. Of the patients with diabetes mellitus (67.3%), the most common type of AVF with DASS was brachiocephalic AVF (73.7%). Overall, the prevalence of success was 82.0% (95%CI, 74.4%–89.6%) over 12 months (IQR, 1–40 months). Grade 3 ischaemia was the most common type of DASS (49.2%). Grade 4 had the worst outcomes compared with grades 2 and 3. The overall morbidity was 3% with no mortality. Overall, RUDI is an effective treatment for various grades of DASS and their longevity.
Objectives: We aim to assess the effect and significance of ultrasound-guided axillary nerve block on the diameter of basilic vein in vascular access surgery.
Methods: 78 consecutive patients who underwent vascular access surgery with ultrasound-guided axillary nerve block were studied retrospectively. Diameter of basilic vein at the elbow level before and after the nerve block were measured and the dilatation rate was also calculated to assess the effect of nerve block on venous diameter.
Results: Basilic vein diameter increased from 3.0±1.1 mm before the block to 4.1±1.2 mm after the block (p<0.001). Mean dilatation rate was 143±34%. The dilatation rate was inversely correlated with venous diameter before the block (p<0.001).
Conclusion: Ultrasound-guided axillary nerve block induces significant basilic venous dilatation and that make the anastomotic procedure involving basilic vein possible, or much easier. This anesthetic technique was considered to be an effective option in vascular access surgery. (This is a translation of Jpn J Vasc Surg 2017; 26: 235–239.)
Objective: We examined the effects of the introduction of endovascular aortic repair (EVAR) on treatment for abdominal aortic aneurysms (AAAs).
Subjects: We compared patients in the following three periods: period I (January 2002–December 2006, 105 patients), period II (January 2007–December 2011, 242 patients, duration of 5 years after the introduction of EVAR), and period III (January 2012–December 2016, 237 patients, duration of 5 years after period II). We used the American Society of Anesthesiologists (ASA) classiﬁcation for risk assessment.
Results: In the Open repair (OR) group, the incidences of ASA class 2 increased and classes 3 and 4 decreased signiﬁcantly in periods II and III compared with period I. In all periods, there were no in-hospital deaths. Suprarenal aortic cross-clamping was required in 18 patients (19.1%) in period III and 5 patients (6.3) in period I, and the difference was signiﬁcant (P<0.05). In the EVAR group, no differences in age, sex, or ASA classiﬁcation class were observed between periods II and III. In period II, one patient died due to aneurysm rupture during surgery. Signiﬁcant differences were observed when comparing both groups in periods II and III: patients in the EVAR group were older (P<0.01) and the OR group had a higher proportion of ASA class 2 patients and the EVAR group had a higher proportion of ASA class 3 or 4 patients (P<0.01). Among all AAA surgeries, rupture occurred in 25 patients (23.8%) in period I, 18 patients (7.4) in period II, and 16 patients (6.8) in period III. The number of ruptures was signiﬁcantly lower in periods II and III than in period I (P<0.01).
Conclusions: The ﬁndings of this study suggest that EVAR should be indicated for high-risk patients and had the good outcome of AAA treatment. (This is a translation of Jpn J Vasc Surg 2018; 27: 27–32.)
Objectives: Uncomplicated type B aortic dissection is generally treated with medical management including antihypertensive therapy. The purpose of this study is to investigate risk factors associated with the aortic enlargement in medically treated patients.
Methods: Between July 2004 and April 2016, 127 consecutive patients with acute type B aortic dissection were treated in our institution. Of these, 104 patients diagnosed with uncomplicated type B dissection were managed medically as an initial treatment. According to the diameter of the dissected aorta, these patients were retrospectively placed into 2 groups: 1) enlargement group (group E: n=36); and 2) unchanged group (group U: n=68).
Results: There was statistically signiﬁcant difference regarding the initial diameter of the dissected aorta (group E: 42±7 mm, group U: 36±7 mm) (p<0.01). As regards the aneurysm growth rate, a signiﬁcant difference between both groups was noted (group E: 10±32 mm/half-year, group U −3±19 mm/half-year) (p<0.05). In all 104 patients, 42 patients (40.4%) had patent false lumen with the average number of 1.5 intimal tears. Multivariate analysis showed the relationship for aortic enlargement were patent false lumen (p<0.05, 95%CI 0.407–0.935) and initial aortic diameter (p<0.01, 95%CI 1.076–1.158). Aortic event free survival (1/5/10 years) was 100/86/77% in group E and 92/79/79% in group U, respectively no differences between two groups (p=0.747).
Conclusions: The medically managed patients with uncomplicated chronic type B dissection showed excellent survival rate during long-term follow-up. The results of surgical or endovascular treatment in patients underwent initial medical therapy were also satisfactory. The patent false lumen and aortic diameter at the onset may impact on aortic enlargement. Considering our results, the feasibility of elective endovascular repairs in stable dissection remains controversial even in the endovascular era. (This is a translation of Jpn J Vasc Surg 2018; 27: 55–60.)
Immunoglobulin G4 (IgG4)-related disease, that is characterized by the elevation of circulating IgG4 level and the tissue-inﬁltration of IgG4-positive plasma cells, can target the cardiovascular tissue, although the diagnosis of IgG4-related cardiovascular lesion is not easy owing to the substantial risk for the tissue sampling. We herein examined the serum IgG4 levels among cardiac patients. In patients who were admitted to the cardiology department (n=477) and those who underwent computed tomography coronary artery angiography (n=401), elevated serum IgG4 level (≥135 mg/dL) was found 23 (4.8%) and 17 (4.2%), respectively. However, among those with elevated serum IgG4, only two patients could be clinicopathologically diagnosed with IgG4-related disease. Cardiovascular organ involvement may aggravate the prognosis of IgG4-related disease which in general not life-threatening. Considering that the non-negligible prevalence of high IgG4 level among cardiac patients who were not diagnosed with IgG4-related disease, however, physicians should not count too much on the serum IgG4 levels for the diagnosis of IgG4-related cardiovascular lesions, especially when histopathologic ﬁndings are not available, or when other-tissue involvement of IgG4-related disease is not apparent. (This is a translation of J Jpn Coll Angiol 2017; 57: 91–98.)
Kumamoto was hit by a series of strong earthquakes beginning on April 14, 2016. We treated many deep vein thrombosis (DVT) patients and pulmonary thrombosis (PTE) patients. We came up with a strategy for diagnosis and therapy of venous thromboembolism (VTE). For VTE patients, we prescribed anticoagulant drugs, mainly direct oral anticoagulant (DOAC). To evaluate the validity and safety of the medical strategy for VTE in disasters, we investigated the prognosis of VTE patients at 4 months after the initial quake. In the two months following the initial quake we attended to 43 VTE patients, 11 PTE patients (including 9 patients with both DVT and PTE) and 32 DVT patients. We prescribed DOAC to 34 patients and Warfarin to 4 patients. Based on the survey at 4 months after the ﬁrst tremblor, the period of anticoagulation therapy was 95.0±17.2 days for PTE and 57.1±36.5 days for DVT and 12 patients were continuing to take anticoagulant drugs. There were no recurrent VTE or bleeding events. DOAC therapy of VTE is therefore considered effective and safe in the event of a natural disaster. (This is a translation of J Jpn Coll Angiol 2017; 57: 33–40.)
Prediction of postoperative cerebral infarction after cardiovascular surgery is difﬁcult. The present study investigated whether quantitative evaluation of preoperative cerebral blood ﬂow used in the Japanese EC-IC Bypass Trial (JET) study is useful for the prediction of postoperative cerebral infarction after cardiovascular surgery. First, patients were divided into two groups based on preoperative cerebral blood ﬂow. In an evaluation using preoperative imaging, patients with good or mildly decreased preoperative cerebral blood ﬂow, divided into clinical stage I or II by quantitative evaluation showed no postoperative cerebral infarction. However, 24% of patients with poor cerebral blood ﬂow who were categorized as clinical stage II, experienced postoperative cerebral infarction. The incidence rate was not statistically signiﬁcantly different when the groups were compared. Second, patients were divided into two groups based on the anatomical area of the brain affected corresponding to clinical stage II. Patients with a 10% and greater brain involvement had a signiﬁcantly higher incidence of postoperative cerebral infarction (38%) compared to others (0%, p<0.01). This method may be useful for the prediction of postoperative cerebral infarction after cardiovascular surgery, but a further prospective study is needed. (This is a translation of J Jpn Coll Angiol 2017; 57: 125–133.)
Objective: Postimplantation syndrome (PIS) is a postoperative syndrome that occurs after endovascular aneurysm repair (EVAR), accompanied by high fever, leukocytosis, and high serum C-reactive protein (CRP). Its pathogenesis and clinical meaning are still under discussion. Here, we evaluate the relationship between postoperative fever after EVAR and graft fabric focusing on Endologix Powerlink® and AFX® (EPL/AFX).
Materials and Methods: From January 2015 to July 2017, data on elective EVAR for abdominal aortic aneurysm (AAA) using mainbody were retrospectively collected. The primary endpoint was maximal postoperative fever.
Results: We identified 128 patients who underwent elective EVAR for AAA (105 males, 82%; aged 57–90, median: 74 years). The median maximal postoperative fever was 37.8°C (36.6–39.7°C): polyester graft, 38.2°C (37.1–39.7°C); Excluder®, 37.8°C (36.6–39.2°C); and EPL/AFX, 37.7°C (37–38.7°C). The maximal postoperative fever with a polyester graft was significantly higher than that with an expanded polytetrafluoroethylene (ePTFE) graft (p<0.001). However, there was no difference between Excluder® and EPL/AFX (p=0.214).
Conclusion: In this study, it was found that polyester grafts are significantly associated with PIS after elective EVAR for AAA. If patient anatomy is permitted, it may be better to choose the ePTFE graft, especially for patients with a poor general condition.
Objective: We assessed the effectiveness and appropriateness of our original off-the-job training (Off JT) system using data acquired from recruited medical students and doctors.
Materials and Methods: We presented our original homebuilt Off JT system, which is simple and inexpensive. In our unique system, we performed anastomosis at the bottom of a plastic pot, which mimics the actual open surgical procedure at a deep site. There were four evaluation points: (A) operating time, (B) performance of anastomosis by semi-automatically analyzing the image with the coefficient of variation (standard deviation/length) of the “bite” and the “pitch,” (C) scoring of the total surgical skill evaluated by the trainers according to the Operative Performance Rating System (OPRS), and (D) the relationship of these three factors (A, B, and C).
Results: The procedural time and coefficient of variation of the bite and pitch decreased and the OPRS score increased after training. There was a strong correlation between procedural time, anastomotic performance, and OPRS score.
Conclusion: The effectiveness of our original homebuilt system was shown by reduced procedural time, improved anastomotic quality, and increased OPRS score.
Objective: To determine the effect of switching from the initial direct oral anticoagulant (DOAC) to another DOAC on exacerbation of deep vein thrombosis (DVT).
Materials and Methods: We retrospectively reviewed the data of patients with advanced cancer who experienced exacerbated DVT during initial treatment with DOAC due to new venous thromboembolism (VTE). After switching to another DOAC for VTE recurrence, changes in the thrombus and bleeding were evaluated for 3 months. Eighteen patients met these criteria. We compared the effect of anticoagulant switching on the switched-drug group in those 18 patients with the effect of no anticoagulant switching on the single-drug group of patients (n=78) with a similar background.
Results: The recurrence rate of VTE in the switched-drug group was 6%. Non-major bleeding occurred in 11% of patients. Recurrent VTE occurred in 6% of patients in both the switched-drug and single-drug groups, respectively [risk ratio (RR): 0.9, 95% confidence interval (CI): 0.11–7.6]. Non-major bleeding occurred in 11% and 14% of patients in the switched-drug and single-drug groups, respectively (RR: 0.79, 95%CI: 0.19–3.2).
Conclusion: Switching DOAC may be a treatment option for exacerbation of DVT in patients with advanced cancer.
Objective: Persistent left superior vena cava without bringing vein (PLSVC w/o BV) is a common thoracic venous anomaly, while aberrant left brachiocephalic vein (ALBCV) is an uncommon condition. We compared the incidences of the two venous anomalies and assessed congenital cardiovascular diseases (CCDs) in adults using computed tomography (CT).
Materials and Methods: We reviewed the recorded reports or CT images of 49,494 adults for PLSVC w/o BV and ALBCV in two hospitals. We determined incidences of two venous anomalies and the rate of associated CCDs.
Results: 76 PLSVCs w/o BV and 27 ALBCVs were found. The incidence of PLSVC w/o BV was 0.15% and the incidence of ALBCV was 0.055%. PLSVC w/o BV had higher incidence than ALBCV (p<0.001). Four PLSVCs w/o BV and one ALBCV were associated with congenital heart diseases. Two PLSVCs w/o BV and four ALBCVs were associated with congenital aortic arch anomaly (CAAA). ALBCV had higher incidence of associated CAAA than PLSVC w/o BV (P=0.02).
Conclusion: The incidence of ALBCV was <50% that of PLSVC w/o BV. The two venous anomalies found on CT during adulthood were rarely associated with CCDs.
We present the first case of a large true uterine artery aneurysm, with a 5-cm diameter, in a 35-year-old nulliparous woman who presented with lower abdominal pain and dyspareunia. She underwent successful ligation and excision of the aneurysm using the Pfannenstiel approach. The diagnostic modalities and treatment option for such a case is discussed herein.
Total arch debranching and thoracic endovascular repair of an aortic arch aneurysm with a left aberrant vertebral artery are rare procedures. A small artery is difficult to reconstruct and anastomose in a narrow thoracic space with a large aneurysm. We describe an 85-year-old man with a fusiform aortic arch aneurysm and left aberrant vertebral artery who underwent a hybrid procedure with reconstruction of the left aberrant vertebral artery at a surgical site in the neck. Postoperative computed tomography images confirmed exclusion of the aneurysm and patency of all arch vessels, including the left vertebral artery.
Here we describe the case of a 33-year-old woman who was diagnosed with interrupted aortic arch (IAA) type A and who underwent radical surgery in her infancy. She developed a 42-mm anastomotic pseudoaneurysm in the distal aortic arch. We decided to perform thoracic endovascular aortic repair because of the patient’s special request to avoid open surgery. We selected a reversed taper-type leg stent graft for the iliac artery and successfully implanted it without problems. However, the long-term outcomes of the stent graft in young people remain unclear, and careful regular follow-up for a long period is mandatory.
Intravascular fasciitis is a rare variant of nodular fasciitis, which can be easily misdiagnosed as a tumorous condition. We had a patient with an intravenous mass of a neck vein, and surgical excision was successful. Although all preoperative imaging studies and intraoperative pathologic reports suggested certain tumorous conditions as differential diagnosis results, the final diagnosis confirmed that it was an intravascular fasciitis based on its fibromixoid tissues with the proliferation of spindle cells and positive immunohistochemical staining for smooth muscle actin. Unless a physician has an insight of the disease or a suspicion to initiate running differential markers, it may be confused with other intravascular lesions and cause unnecessary radical surgery. Here we report our experience with a patient having this rare vascular disease.
We report the cases of three patients who underwent thoracic endovascular aortic repair for type B aortic dissection in which transesophageal echocardiography (TEE) was used to guide the procedure in addition to fluoroscopy. TEE was found to be advantageous because it can visualize vascular structures along with the guidewire and devices. Furthermore, it provides real-time hemodynamic and hematological information without the need for contrast injection or radiation exposure. Although TEE assessment requires expertise, the efficient use of TEE appears to be helpful for further improving the outcomes of endovascular surgery for aortic dissection.
We report a rare case of delayed paraplegia triggered by gastrointestinal (GI) bleeding 8 months after thoracic endovascular aortic repair (TEVAR). A 78-year-old male underwent TEVAR of a descending thoracic aortic aneurysm without a postoperative neurological deficit and was discharged. Magnetic resonance image showed spinal cord infarction from Th8 to L1, and enhanced computed tomography showed a patent Adamkiewicz artery. The ostium of the intercostal artery connected with the Adamkiewicz artery was occluded. Patients with a history of TEVAR might be more vulnerable to spinal cord ischemia around the Adamkiewicz artery, which can be triggered by common hemorrhagic diseases, such as GI bleeding, even remote from the procedure.
Thoracic endovascular repair (TEVAR) is a safe treatment alternative to open repair for blunt traumatic aortic injury (BTAI). A 29 year-old-female had multiple traffic injuries, including BTAI located in lesser curve of the isthmus close to the left common carotid artery with an isolated left vertebral artery. TEVAR with simple covering of the left subclavian artery was not adequate to prevent the endoleak. We considered fenestrated TEVAR with RELAY® PLUS to ensure blood flow to the left common carotid artery and reconstruction of the left isolated vertebral and left subclavian artery. The fenestrated TEVAR with a debranching technique provided good results without device-related complications.
Pseudoaneurysm of the deep femoral artery (FAP) due to penetrating trauma is less common and can be a challenging condition for surgeons. The conventional treatment strategy for FAP due to penetrating trauma is open surgical repair. With emerging technologies, less invasive techniques are being used in these patients. We report a 37-year-old male patient with delayed presentation of FAP secondary to a stab wound and treated successfully with ultrasound-guided thrombin injection.