Background: Acute pulmonary embolism (APE) has high mortality. Some APEs with circulatory collapse or cardiopulmonary arrest have been treated by percutaneous cardiopulmonary support (PCPS) in Japan. But there have been no reports with a large number of series of APE treated with the use of PCPS. Methods and Results: We collected all the reported cases with acute thrombotic pulmonary embolism treated with PCPS before surgical embolectomy or those without surgical embolectomy in Japan, and assessed the effectiveness of PCPS. PCPS was combined with surgical embolectomy in 35% (68 of 193), thrombolytic therapy in 62% (120/193), and catheter therapy in 24% (46/193). The survival rate treated with PCPS was 73% (80% in surgical embolectomy, 71% in thrombolytic therapy, and 76% in catheter therapy). Logistic regression analysis showed that the mortality rate was elevated in cases with cardiopulmonary arrest (odds ratio [OR], 3.41; 95% confidence interval [CI], 1.52–7.67; p-value, 0.003) but not by surgical embolectomy (OR, 0.99; 95% CI, 0.39–2.53; p-value, 0.98), catheter therapy (OR, 0.71; 95% CI, 0.30–1.72; p-value, 0.45), and thrombolysis (OR, 1.60; 95% CI, 0.64–3.99; p-value, 0.31) as regards to the concomitant therapies with PCPS. Conclusion: PCPS might improve the survival rate in APE patients with circulatory collapse or cardiopulmonary arrest, but there was no differences in outcome among cases treated by surgical embolectomy, catheter therapy, and thrombolysis as the concomitant therapies.
Objective: To determine whether a violation of the standard of care for prevention of pulmonary embolism by preventing deep vein thrombosis occurred in 1999. Materials and methods: Themes from past general meetings of the three societies that comprise the Japanese Board of Cardiovascular Surgery that pertained to venous thromboembolism from 1999 to 2006 were examined and analyzed for an appeal hearing to determine whether a violation had occurred. Results: The first pertinent session on a method for the prevention of pulmonary embolism was presented in 2006 by the Japanese Society for Vascular Surgery. Thus, the medical treatment performed in this case did not violate the standard of care in 1999. Conclusion: The “standard of medical treatment at the time”, can be discerned by tracing consensus agreement at session meetings. If the consensus from each session is recorded, a more detailed analysis can be made of the agreement reached by board members.
Objective: This study intended to confirm whether skin perfusion pressure (SPP) could predict the outcome of ischemic wound healing. Patients and methods: Sixty-two limbs in 53 patients with conservative therapy were enrolled in this study. A SPP value of 40 mmHg was adopted as the criterion for making clinical decisions. The outcome one month after SPP measurement was classified as “improved” (diameter of ulcer decreased ≥ 20% or demarcation of gangrene became well defined) or “no change or worse” (others), and the fate of wound was classified as “healed” or “not healed”. The evaluated influential factors on the outcome at one month included age, sex, presence of arteriosclerosis obliterans, collagen disease, hypertension, diabetes mellitus, hemodialysis, wound infection, wound management, and SPP ≥ 40 mmHg. Results: Using a criterion of SPP ≥ 40 mmHg, the outcome at one month could be predicted with a sensitivity: of 75.0%, a specificity: of 82.6%, and an accuracy: of 80.6%. The receiver operating characteristic curve indicated our criterion to be appropriate. Logistic regression analysis showed SPP ≥ 40 mmHg to be an independent factor (P < 0.0001) with the odds ratio of 14.2 (95% CI 3.6–55.8). Conclusions: SPP, using a cutoff value of 40 mmHg, can predict the ischemic wound healing with conservative therapy.
Objective: To analyze relationships between plaque-morphology classified by intravascular ultrasound (IVUS) and risk factors in patients with peripheral arterial disease (PAD). Methods: We performed IVUS in 203 patients with PAD. Multiple regression and logistic analysis were used to assess relationships between plaque-morphology (degree of calcification, presence of a lipid core, intimal flap and thrombus) and risk factors including diabetes mellitus, hypertension, dyslipidemia, estimated glomerular filtration rate (eGFR), HbA1c and the homeostasis model assessment-insulin resistance ratio (HOMA-IR). Results: IVUS data led to 22% of lesions being classified as soft, 18% as fibrous, 32% as calcified, and 28% as mixed. Calcification was present in the superficial and deep layers in 65% and 35% of cases, respectively, and a lipid core, intimal flap and thrombus were found in 31%, 5.4% and 3.0%, respectively. The calcified angle correlated with HbA1c and eGFR (p < 0.05). Associations were found between deep calcification and HOMA-IR (odds ratio: 4.4, p < 0.05) and a lipid core and hypercholesterolemia (odds ratio: 3.2, p < 0.05). The odds ratio for intimal flap was 15.6 times with hypercholesterolemia (p < 0.05) and 16.9 times with a high HOMA-IR (p < 0.01). Conclusion: Plaque calcification and morphology are associated with chronic kidney disease, insulin resistance and dyslipidemia in PAD patients.
Although endovascular approach can be widely applied to occlusive aortoiliac segment, aortofemoral bypass (AFB) continues to offer superior long term patency. In an effort to reduce the morbidity of AFB, LAFB (laparoscopic AFB) has been developed. We report our initial experiences to determine the feasibility and safety. From September 2005 to May 2008, LAFB was performed in 12 patients. A transabdominal retrocolic approach with pneumoperitoneum or direct approach was preferred. LAFB consisted of aortic dissection, vascular control with or without intracorporeal anastomosis. Last two cases were performed using da Vinci system for secure proximal anastomosis as an end to side fashion. Laparoscopic procedures were successfully performed in 11 patients. One patient underwent open conversion due to small bowel injury and bleeding. Mean operating time and aortic clamping time was 446 minutes and 87.5 minutes. The time to return of bowel function was about 2.1 days (2.1 ±1.2). Compartment syndrome was developed in one patient at immediate postoperatively. During this study period, operating time was shown in decreasing tendency. Although LAFB is challenging procedure with steep learning curve, it is feasible technique and appears to ease patient’s postoperative course.
A Gunther tulip vena cava filter was implanted in a patient with pulmonary embolism from deep venous thrombosis. The filter became unnecessary after therapy. However, retrieval by the standard method employing a vascular sheath placed via the transjugular approach in combination with a snare device was impossible. A thrombus occupying the apical hook made it difficult to snare the hook, also one filter leg was incorporated into the inferior vena cava wall. Therefore we modified an existing method to withdraw the filter. As the first step, the filter cone was snared using the snare-over-guide wire loop technique, and the cephalad site of the filter was introduced into the sheath. Then, a 12-French sheath was advanced from the femoral vein and, using a pusher, the distal legs of the filter were pushed, which resulted the filter leg that was incorporated into the inferior vena cava wall became detached. Finally the filter was successfully retrieved.
Perigraft seroma usually occurs both polyester and polytetrafluoroethylene (PTFE) graft which are placed superficially for axillofemoral and femorofemoral bypasses, while it is a rare complication of conventional abdominal aortic and iliac arterial aneurysm repair. The cause of the seroma has not been elucidated, and several hypotheses have been proposed such as immunologic response to graft materials, discharge of serous fluid through the graft wall, and so on. The seroma sac occasionally increases their size finally leading to rupture. The treatment of perigraft seroma has not been established so far; there have been various recommended procedures including aspiration, graft removal followed by other material graft replacement, cessation of antithrombotic drugs, and careful observation. We report two cases of perigraft seroma after conventional aortoiliac aneurysm repair with a knitted polyester graft via left pararectal retroperitoneal approach, which were gradually shrinking by theirselves.
Surgical management of abdominal aortic aneurysm (AAA) with concomitant malignancy remains controversial. Commercial availability of a stentgraft may change the treatment strategy for such patients. We present a case of AAA with concomitant colon cancer, in which two-stage surgery consisting of EVAR and subsequent laparoscopic colectomy was performed with an interval of six days. The patient’s postoperative course was uneventful. For high-risk patients, application of endovascular AAA repair and laparoscopic surgery may decrease the risk of surgical morbidity and mortality.
A 50-year-old man presented with an abdominal bulge 2 years after receiving a ventriculoperitoneal (VP) shunt for hydrocephalus. Chest radiography revealed that the peritoneal end of the catheter had migrated into the right pulmonary artery. Exploration through a small neck incision revealed that the shunt catheter had entered the internal jugular vein. The catheter was extracted and positioned in the subcutaneous space in preparation for reimplantation. This type of shunt migration is quite unusual, but it could cause lethal pulmonary infarction or arrhythmia. Follow-up radiography should be scheduled to detect such complications.
Right-sided aortic arch with aberrant left subclavian artery is an uncommon anomaly. We describe a case of Kommerell’s diverticulum involving the distal portion of a right-sided aortic arch and the origin of an aberrant left subclavian artery in a 74-year-old man with hoarseness. The patient underwent successful endovascular repair of the aneurysm with use of a Gore TAG thoracic endoprosthesis and coil embolization of the left subclavian artery. Postoperative computed tomography showed complete exclusion of the lesion, without endoleaks. Endovascular repair is feasible and can be effective in such cases.
We describe a case of successful surgical treatment for spontaneous rupture of an iliac artery aneurysm into a ureter. An 80-year-old man was admitted with massive hematuria. Immediate enhanced abdominal computed tomography scan and cystoscopy were suspicious for a uretero-arterial fistula caused by aneurysmal rupture. Emergent surgical intervention was performed because of the high mortality rate of this condition. Intraoperative findings revealed the fistula between the true aneurysm of the right common iliac artery and the ureter. Repair of the aneurysm and ligation of the ureter was performed, with an uneventful postoperative course.
Untreated symptomatic patients with Paget-Schroetter syndrome can suffer chronic disability due to venous obstruction, with arm swelling, pain, and early exercise fatigue. Although systemic or catheter-directed thrombolysis followed by anticoagulation and surgical intervention is recommended, there is no definite consensus about treatment. Here, we report the clinical usefulness of hybrid intervention with a combination of thrombectomy, thrombo-aspiration and balloon PTA, which has not been reported previously for this condition. These procedures were successful, and the patient has been free of symptoms for 6 years.
Only 5 cases of ruptured aneurysm of the persistent sciatic artery have been previously reported to date. We experienced a case of ruptured aneurysm of the persistent sciatic artery presenting acute lower limb ischemia. Physical examination showed a pulsatile mass with a subcutaneous hemorrhage in the left buttock, drop foot and paresthesia of the foot due to limb ischemia. An enhanced computed tomography scan showed a ruptured aneurysm of the left persistent sciatic artery at the level of the greater trochanter. An exclusion of the aneurysm and creation of common iliac to popliteal artery bypass was performed as an emergency operation.