Frailty is a well-known geriatric syndrome of impaired physiological reserve and increased vulnerability to stressors. Sarcopenia is also used as a parameter of physical impairment characterized by muscle weakness. As population aging has become more prominent in recent years, both modalities are now regarded as clinically important prognostic tools defined by multidimensional factors that may affect clinical outcomes in various clinical settings. A preoperative surgical risk analysis is mandatory to predict clinical and surgical outcomes in all surgical practices, particularly in high-risk surgical patients. In vascular surgical settings, frailty and sarcopenia have been accepted as useful prognostic tools to evaluate patient characteristics before surgery, as these may predict perioperative clinical and surgical outcomes. Although minimally invasive surgical approaches, such as endovascular therapy, and hybrid approaches have been universally developed, achieving good vascular surgical outcomes for high-risk cohorts remains to be challenge due to the increasing prevalence of elderly patients and multiple preoperative co-morbidities in addition to frailty and sarcopenia. Therefore, to further improve clinical and surgical outcomes, these preoperative geriatric prognostic factors will be of great importance and interest in vascular surgical settings for both physicians and surgeons.
Objectives: Appropriateness of device selection, procedure protocol and aortic remodeling effects of entry closure (TEVAR) with stent-graft (SG) for patent false lumen type B aortic dissection (TBAD) were compared between the patients with narrow true lumen (narrow group) and those with aneurysmal dilated false lumen (aneurysmal group).
Methods: Twenty-six patients with narrow true lumen (narrow group) and 20 patients with aneurysmal false lumen (aneurysmal group) were included in this study. In narrow group, straight SG was implanted from Zone 3 regardless the distance between the left subclavian artery and entry. In aneurysmal group, straight or taped SG was implanted with proximal landing zone length 20 mm or more. Thoracic aortic anatomy was evaluated by CT and aortic remodeling was defined as true lumen diameter ≥50% of the aortic diameter and occlusion of false lumen. Aorta related death, retrograde type A aortic dissection (RTAD), stentgraft induced new entry (SINE) and aortic maximum diameter enlargement 5 mm or more (aortic expansion) were included in the aortic event.
Results: There was no procedure related complication in narrow group and 1 patient died due to aortic rupture in aneurysmal group, Type Ia endoleak by enhanced CT 7 days after TEVAR was detected in one patient in each group. Achievement of aortic remodeling was significantly better in narrow group. Aortic event occurred in only one patient in narrow group, in whom aortic expansion was observed. In aneurysmal group, aortic event occurred 12 patients (60%) and 2 RTAD, 5 SINE, and 8 aorta expansion were observed. Aortic event free rate was significantly better in narrow group.
Conclusion: TEVAR procedure for the TBAD patients with narrow true lumen seemed to be appropriate, however, different TEVAR procedure or additional procedures would be required for those with aneurysmal dilated false lumen to obtain favorable outcomes. (This is secondary publication from Jpn J Vasc Surg 2021; 30: 347–357.)
Objectives: We investigated the relationship between plasma lipoprotein(a) [Lp(a)] level and long-term prognosis, cardiovascular events, or pure leg events (LE) in patients with peripheral arterial disease (PAD).
Materials and Methods: We prospectively enrolled 1104 PAD patients. The endpoints were LE, cerebrovascular- or cardiovascular-related death (CVRD), all-cause death (ACD), and major adverse cardiovascular events (MACE).
Results: The incidences of LE, CVRD, ACD, and MACE were correlated with Lp(a) level (P<0.05). Lp(a) was positively correlated with low-density lipoprotein cholesterol and C-reactive protein (CRP) and negatively correlated with estimated glomerular filtration rate (eGFR). In the Cox multivariate regression analysis, high Lp(a), CRP, age, low ankle-brachial pressure index (ABI), eGFR, albumin, critical limb ischemia (CLI), cerebrovascular disease (CVD), and diabetes were associated with LE; high Lp(a), age, CRP, low ABI, body mass index, eGFR, albumin, CLI, coronary heart disease (CHD), CVD, and diabetes were associated with CVRD; high Lp(a), CRP, age, low ABI, eGFR, albumin, CLI, and CVD were associated with ACD; and high Lp(a), CRP, age, low eGFR, albumin, CLI, CHD, and diabetes were associated with MACE (P<0.05). Statins improved all endpoints (P<0.01).
Conclusion: Lp(a) was a significant residual risk factor for LE, CVRD, ACD, and MACE in PAD patients.
Iatrogenic arteriovenous fistula (AVF) rarely develops around the proximal subclavian artery, although open surgical repair of this etiology is known to be complicated as deep dissection is required around the fistula surrounded by dilated veins. In this study, we present the case of a 64-year-old man, who was referred to our hospital, with AVF between the right subclavian artery and the right vertebral vein. He had a history of accidental puncture of the right subclavian artery. An endovascular repair using a covered stent was successfully performed, and the AVF disappeared. Thus, covered stent placement should be considered as the first-line treatment for a deeply developed AVF, if anatomically feasible.
A case of a giant popliteal venous aneurysm that caused massive pulmonary thromboembolism with an arteriovenous fistula draining into the adjacent proximal femoral vein is reported herein. Deep veins in the lower leg were occluded by thrombi. The inlet and outlet orifice inside the aneurysm was closed and aneurysmorraphy was performed. The fistula was retained on the estimation that it would maintain the blood flow and prevent thrombus formation inside the femoral vein. The aneurysm was shrunk, the femoral vein was patent, and the fistula was not observed 1 year later, although it still existed 1 week after the operation.
Chronic limb-threatening ischemia (CLTI) is an important issue for elderly patients with peripheral artery disease. Here, we present the case of a 91-year-old man with CLTI, residing in a rural district. The onset of CLTI rapidly deprived him of ambulation because of a foot infection. Given that he had difficulty with long-distance transportation, limb salvage for extensive tissue loss was performed at a district facility, based on his and his family’s request. Finally, skin grafting on the cutting plane of the right ankle bones resulted in wound healing in six months after incomplete revascularization and multiple minor amputations.
A 76-year-old female developed progressive local groin bulging. She received regular hemodialysis using a left-thigh polytetrafluoroethylene arteriovenous graft in the loop configuration. Lower extremity enhanced computed tomography showed a large low-density area around the graft 18 months after its creation, and perigraft seroma (PS) was suspected. The patient underwent PS excision followed by graft wrapping with two local hemostatic agents, oxidized regenerated cellulose, and a fibrin sealant. Local PS recurrence was not detected four months after surgery. We herein describe a surgical case of refractory PS successfully treated by graft wrapping using two local hemostatic agents.
Since 2013, the Japanese Society for Vascular Surgery has started the project of nationwide registration and tracking database for patients with critical limb ischemia (CLI) who are treated by vascular surgeons. The objective of this project is to elucidate the current status of the medical practice for CLI patients to contribute to the improvement of the quality of medical care. This database, called JAPAN Critical Limb Ischemia Database (JCLIMB), is created on the National Clinical Database (NCD) and collects data of patients’ background, therapeutic measures, early results, and long-term prognosis as long as 5 years after the initial treatment. The limbs managed conservatively are also registered in JCLIMB, together with those treated with surgery and/or endovascular treatment (EVT). In 2019, 1070 CLI limbs (male: 725 limbs, 68%) were registered by 83 facilities. Arteriosclerosis obliterans (ASO) accounted for 98% of the pathogenesis of these limbs. In this manuscript, the background data and the early prognosis of the registered limbs are reported. Although the registration format for the simultaneous surgery of bilateral limbs in NCD was changed to one patient and two limbs, JCLIMB still counted two patients and two limbs to eliminate discrepancy with the past annual reports. (This is a translation of Jpn J Vasc Surg 2022; 31: 157–185.)