Antineutrophil cytoplasmic antibodies (ANCA) are well known to be associated with small vessel vasculitic diseases such as microscopic polyangiitis (MPA), allergic granulomatous angiitis (AGA), and Granulomatosis with poly angiitis: GPA (Wegener's). Disease assessment by 1) vasculitic activity, 2) damage resulting from vasculitis, and 3) patient function, were the required endpoints for the therapeutic trials in ANCA- associated vasculitis (AAV). Harmonized steroids and cyclophosphamide or azathioprine are effective for active AAV. In evaluating tools for monitoring disease, titers of ANCA and the levels of CRP were found useful in AAV. However, it will be important for clinicians to observe AAV patients more closely and reduce immunosuppressive drug doses more cautiously, especially to prevent several infections (i.e., deep mycosis, pneumocystis jirovecii pneumonia and cytomegalovirus). We indicated that strategy of infection control in immunosuppressive therapy for AAV. (J Jpn Coll Angiol, 2009, 49: 93-99)

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A genome analysis of mouse models may shed some light on the complex clinicopathological manifestations of systemic vasculitis. In the study of susceptibility loci to vasculitis in MRL mouse models, we found that systemic vasculitis developed through the cumulative effect of multiple gene loci, each of which by itself did not have a significant effect in inducing the related phenotype, thus indicating a polygenic system.The mice developed vasculitis in an additive manner with a hierarchical effect. Some of the susceptibility loci seemed to be common to those in other collagen diseases. Moreover, the loci controlling tissue specificity of vasculitis were present. One of the positional candidate genes for vasculitis showed an allelic polymorphism in the coding region, thus possibly causing a qualitative difference in its function. As a result, a particular combination of polygenes with such an allelic polymorphism may thus play a critical role in leading the cascade reaction to develop vasculitis, and also a regular variation of systemic vasculitis. This is designated as the polygene network in systemic vasculitis. (J Jpn Coll Angiol, 2009, 49: 11-16)

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The recent development of biologic therapies capable of selectively targeting components of the immune system has revolutionized the treatment of infl ammatory arthritides. The increase in the use of biologic agents coupled with expansion in the knowledge of the pathogenesis of vascular infl ammation has led to their application in the treatment of primary systemic vasculitis. Biological therapies appear to have a place in the therapeutic strategy for ANCA-associated systemic vasculitides, at least for patients whose disease is refractory to conventional therapy. The use of biologics as targeted therapies has also, in reverse, improved our understanding of the pathophysiology of vascular infl ammation. However, the precise indications for TNF-alpha inhibitors or anti-CD20 monoclonal antibodies have not yet been defi ned. These biologics must be prescribed extremely cautiously and only in trial settings, especially in view of the adverse effects. (*English Translation of J Jpn Coll Angiol, 2009, 49: 75-79)

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Objective: To determine a treatment strategy based on the outcomes of various previous interventions for critical limb ischemia in arteriosclerosis obliterans (ASO).Material and Methods: We examined outcomes of 292 ASO patients who had had critical limb ischemia between May 1995 and July 2009. Patients underwent the following procedures in 167 cases: aortofemoral bypass (n = 14), femorofemoral crossover bypass (n = 29), femoropopliteal bypass (n = 104) and femorotibial bypass (n = 40). Other procedures included bypass only (n = 147), bypass combined with thromboendarterectomy (n = 10), bypass combined with endovascular therapy (n = 6), bypass combined with lumbar sympathectomy (n = 2), endovascular therapy combined with thromboendarterectomy (n = 4), endovascular therapy (n = 19), lumbar sympathectomy (n = 6), conservative therapy (n = 65), and major amputation (n = 31). We also calculated P3 risk scores and measured transcutaneous oxygen pressure(tcPO2)and skin perfusion pressure (SPP) before and after therapy.Results: The limb salvage rate was 87% at 2 years in the arterial reconstruction group. In the low-risk group (a P 3 risk score of 3), the 1-year amputation-free survival rate was 96%. In the medium-risk group(a P 3 risk score of 4-7), the 1-year amputation-free survival rate was 88%. In the high-risk group (a P 3risk score of 8), the 1-year amputation-free survival rate was 66%. The hospital death rate in the arterial reconstruction group was 3.2%, all of whom were patients who underwent bypass. The survival rate at 5years was 65% and 36% in the conservative therapy only group. Ulcers healed in 140 out of 144 patients.The 4 patients with unhealed infections had tcPO2 or SPP values of more than 30 mmHg after treatment.Major amputations were performed in 4 of 5 patients who had tcPO2 or SPP values from 20 to 30 mmHg after treatment. Major amputations were performed in all 6 patients who had tcPO2 or SPP values of less than 20 mmHg after treatment.Conclusion: In cases with tcPO2 or SPP values of more than 30 mmHg, an ulcer will probably heal, except in infected cases. We suggest that, if these values are less than 30 mmHg, complete revascularization should be performed. The P3 risk score was useful in predicting limb salvage in the current series.Hybrid therapy in bypass and endovascular therapy must be performed in cases where patients are in a generally poor condition. It is important to attempt amelioration in limb salvage and to control the operative mortality rate with sufficient perioperative control. (English Translation of Jpn J Vasc Surg2011;20:905-911)

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Objectives: Multiple injuries may lead to traumatic thoracic aortic rupture (TTAR), which can be fatal.We evaluated the relationship between the clinical findings and outcomes of 26 patients with TTAR who were treated at our institution.Methods: A total of 26 patients (men, 21; women, 5; average age, 45.8 ± 19.6 years) with a diagnosis of TTAR received from 1999 to 2009 were studied. We categorized patients into groups based on the outcome(survival or death) and investigated the relationship between the outcome and the following factors: injury mechanism, vital signs, other combined injuries, injury severity score (ISS), revised trauma score, and probability of survival (Ps).Results: Of the 26 TTAR patients, 7 underwent emergency operations, 5 underwent delayed operations,1 received conservative treatment, and 13 suffered cardiopulmonary arrest immediately after consultation and died. Of the 13 patients who died, 11 died within 2 hours after injury because of bleeding. Two of the7 patients who underwent emergency operations died within 1 day of consultation, whereas all those who underwent delayed operations survived. Patients who underwent TTAR repair had a relatively favorable outcome. Analysis of the relationship between the clinical data and outcome showed that a young age was significantly correlated with survival, and that the Glasgow coma scale (GCS), heart rate, respiratory rate, or occurrence of shock were not significantly related to the outcome. The abbreviated injury scale(AIS) was used to score the severity of multiple injuries, and ISS was calculated from the AIS score. ISS was significantly higher in the death group (P = 0.007). ISS did not significantly differ among body parts(P = 0.077), but ISS of the extremities was higher than those of other parts. Pelvic fractures were frequent in the death group. Our strategy, whereby the patient initially underwent pelvic external fixation followed by TTAR repair was found to be very effective. The P-values calculated by the trauma and injury severity score method were significantly higher in the survival group (both, P = 0.007).Conclusion: To treat TTAR, it is important to accurately evaluate the damage due to multiple injuries and apply an appropriate treatment strategy. Immediate repair of TTAR after bleeding due to combined injury improves the outcome. (English Translation of Jpn J Vasc Surg 2012; 21:5-9)

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Objectives: The management of intractable leg ulcers requires a team approach which includes vascular surgeons and plastic surgeons. We retrospectively reviewed the results of the management of intractable leg ulcers by plastic surgeons.
Patients and Methods: A total of 73 patients with intractable leg ulcers, (79 limbs) were treated at the Department of Plastic Surgery at our institution. Skin perfusion pressure (SPP) around the ulcer on the limb was measured before and after arterial reconstructive procedures. Local ulcer management involved intra-wound continuous negative pressure and irrigation therapy or negative pressure wound therapy. We examined the rates of wound healing and associated prognostic factors.
Results: There were 21 limbs without ischemia (non-peripheral arterial disease [Non-PAD] group) and 58 limbs with ischemia (PAD group). The healing rates were 66% in the PAD group and 81% in the Non-PAD group, but the difference between the groups was not significant. A total of 41 limbs in the PAD group underwent revascularization, which involved bypass surgery in 18 limbs and endovascular therapy in 23 limbs. The salvage rate of the revascularized limbs was 83% at 1 year. The primary patency rates at 1 year were 87% for bypass surgery and 58% for endovascular therapy. The healing rate of the revascularized limbs was 66%, and the presence of concomitant hemodialysis, infected ulcers, and limbs without improved SPP were shown to be poor prognostic factors. Limbs treated with bypass surgery had a better healing rate than limbs treated with endovascular therapy, but the difference was not significant.
Conclusion: Good ulcer-healing rates were achieved by effective revascularization and aggressive local management. These results suggest that a team approach is useful for the management of intractable leg ulcers. (English translation of Jpn J Vasc Surg 2011; 20: 913-920).

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Objective: The management of arteriovenous malformations (AVMs) remains challenging due to the high rate of recurrence of these lesions. Surgical resection is the only potential cure; however, it is often difficult to perform and carries a risk of massive hemorrhage. The purpose of this study was to review our experience with AVMs treated by surgical resection.Materials and Methods: We retrospectively reviewed the medical records of nine patients with AVM, treated with surgical resection. We treated these patients with excision surgery with or without embolotherapy.Results: Eight were treated with surgical resection with embolotherapy and one was treated with a simple surgical resection. Five patients with AVMs were cured. However, two cases of AVM recurred after total excision, and AVMs remained in two cases of partial excisional surgery in which the lesions involved the joints.Conclusions: Total excision of AVMs leads to a cure; however, total excision is not adequate in cases of AVMs involving the joints. Multidisciplinary treatment may offer good results in reducing the morbidity. To minimize complications related to surgery, aggressive control of blood flow to the lesion, preoperatively, with appropriate embolotherapy is essential, and a complete resection with a chance of cure will be increased.

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Background: The ankle-brachial pressure index (ABI) is widely used as a standard screening method for arterial occlusive lesion above the knee. However, the sensitivity of ABI is low in hemodialysis (HD) patients. Exercise stress (Ex-ABI) may reduce the false negative results.Patients and Methods: After measuring resting ABI and toe-brachial pressure index (TBI), ankle pressure and ABI immediately after walking (Post-AP, Post-ABI) were measured using one-minute treadmill walking in 52 lower limbs of 26 HD patients. The definition of peripheral arterial occlusive disease (PAD) required an ABI value of less than 0.90, TBI value of less than 0.60, and decrease of more than 15% of the Post-ABI value and 20 mmHg of Post-AP in Ex-ABI. Computed tomographic angiography (CTA) was performed in 32 lower limbs of 16 HD patients. PAD is defined as presence of stenosis of more than 75% in the case of lesions from an iliac artery to knee on CTA.Results: The accuracy of Ex-ABI (Sensitivity, 85.7%; Specificity, 77.7%) was higher than those of ABI(Sensitivity, 42.9%; Specificity, 83.3%) or TBI (Sensitivity, 78.6%; Specificity, 61.1%).Conclusion: Ex-ABI with one-minute treadmill walking is the most useful tool for the screening of arterial occlusive lesions above the knee in maintenance HD patients.

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Objective: This study aims to evaluate the accuracy of AVF and AVG duplex ultrasound (US) compared to angiographic findings in patients with suspected failing dialysis access.Materials and Methods: From July 2008 to December 2010, US was performed on 35 hemodialysis patients with 51 vascular accesses having clinical feature or dialysis parameter suspicious of access problem. Peak systolic velocity ratio of ≥2 was the criteria for diagnosing stenosis ≥50%. Fistulogram was performed in all these patients. Results of US and fistulogram were compared using Kappa and Receiver Operator Characteristic (ROC) analyses.Results: In 51 accesses (35 AVF, 16 AVG), US diagnosed significant stenosis in 45 accesses according to the criteria and angiogram confirmed 44 significant stenoses. In AVF lesions, Kappa was 0.533 with 93.3% sensitivity and 60% specificity for US whereas in AVG lesions, Kappa was 0.636 with 100% sensitivity and50% specificity. Overall Kappa value of 0.56 meant fair to good agreement. ROC demonstrated area under the curve being 0.79 for all cases and was significant (p= 0.016). Using the ≥50% criteria for stenosis diagnosed by US yielded the best sensitivity (95.5%) and specificity (57.1%).Conclusion: Duplex ultrasound study, using ≥50% criteria, is a sensitive tool for stenosis detection in patients with suspected failing AVF and AVG.

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Outcomes of abdominal aortic aneurysm (AAA) repair have improved in the 2 decades since the emergence of endovascular aneurysm repair (EVAR). However, EVAR is considered a contraindication for shaggy aorta because of the high risk of shower embolization. Recently, statins have been implicated in preventing embolization in patients with shaggy aorta via its pleiotropic effects, including atheroma reduction and coronary artery stabilization. We selected pitavastatin, a statin with potent effects, discovered and developed by a Japanese company because it has shown excellent pleiotropic effects on atheromatous arteries in the Japanese population. A randomized comparison study of dose-dependent effects of pitavastatin in patients with AAA with massive atheromatous aortic thrombus (PROCEDURE study) has begun. PROCEDURE has an enrollment goal of up to 80 patients with AAA with massive aortic atheroma(excluding intrasac atheroma), randomly allocated into 2 groups receiving pitavastatin at a dose of 1 or4 mg/day. The endpoints of the PROCEDURE study include change in atheroma volume, major adverse events related to shower embolization after aneurysm repair, and lipid-lowering effects. When complete, results of the PROCEDURE study should provide objective evidence to use statins preoperatively for AAA with massive aortic atheroma.

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We developed a novel large-diameter graft “Triplex^®" that uses a non-biodegradable material as a coating material. This time, in order to demonstrate the physical properties of Triplex^® grafts, we conducted physical tests in accordance with the international guidelines, using the collagen coated vascular grafts(Hemashield, Boston Scientific, Natick, Massachusetts, USA) as the controls. The grafts were tested with regard to strength (burst strength, circumferential tensile strength, longitudinal tensile strength), suture retention strength, integral water permeability, water leakage (needle puncture, after using clamp), and change in luminal diameter following pacing stress according to ISO7198 and FDA guidance. As indicated by the results, we experimentally demonstrated that uniquely designed vascular graft Triplex^® led to less blood leakage from the vascular graft and less leakage from the needle puncture, although it has fundamental physical properties comparable to those of the vascular grafts using biodegradable material that has been utilized conventionally in clinical settings. Triplex ^®is expected to play its role as a clinically beneficial next-generation vascular graft.

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Objectives: Thoracic outlet syndrome (TOS) consists of a group of distinct disorders that are caused by compression of the brachial plexus and/or subclavian artery and vein. The aim of this study was to highlight the different modalities of diagnosing and treating vascular TOS and evaluate outcomes.Methods: We conducted a retrospective cohort study between 1999 and 2011 using the medical records database from a teaching hospital.Results: During the study period, 54 cases with vascular TOS were identified in 38 patients. Bilateral TOS was in 16 patients. The median age of the patients was 33 years (range 12-49), and the majority (79%) were female. Arterial TOS represented forty-nine cases (90.7%). Preoperative information derived from plain x-ray, duplex scanning and in selected cases computed tomography (CT) and/or angiography.Decompression of the TOS was performed through a supraclavicular approach in all cases with scalenectomy coupled with either cervical rib excision (70%), 1st rib excision alone (15%) and excision of both cervical and 1st ribs (15%). Adjunctive vascular reconstructive procedures were done in 11 cases (20.3%);9 arterial cases and 2 venous cases. There was no mortality; however, postoperative complications occurred in 7 cases (13%).Conclusion: The use of advanced radiological imaging and careful surgical planning for Vascular TOS in a high volume center resulted in good outcomes.

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Objective: To review our experience of thoracic endovascular aortic repair (TEVAR) in patients with prior open aortic repair (OAR).Materials and Methods: Stent-grafts were deployed in the arch, descending thoracic and thoracoabdominal aortae of 39, 13 and 5 patients, respectively, and in a deteriorated extra-anatomical prosthesis in one. The access route was the femoral artery in 10 of 23 patients with, and in 30 of 35 patients without a prior abdominal prosthesis. Prior prostheses and elephant trunks comprised 57 of 116 landing zones and 23proximal landing zones, respectively.Results: Three patients died before discharge. Type II endoleaks developed in six patients, and Types Iand III developed in one patient each. Type I endoleaks were not found at landing zones comprising prosthetic grafts. The overall actuarial three-year survival rate including early mortality was 86.5%.Conclusion: The clinical outcomes of TEVAR were excellent, even in patients with prior OAR. Prosthetic grafts, including elephant trunks, provided good landing zones for TEVAR. Prostheses with larger-caliber designs are recommended for iliac artery reconstruction in future TEVAR.

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Although it is rare, acute aortic dissection after cardiac surgery predisposes the patients to critical condition such as rupture, tamponade and death. Prompt diagnosis and treatment is mandatory for this fatal complication. We present our case in which acute aortic dissection occurred 7 years after aortic valve replacement.

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A 74-year old man on hemodialysis developed a mycotic aneurysm caused by Clostridium difficile. To the best of our knowledge, this is only the second case of such an aneurysm reported in the literature. He had previously undergone axillobifemoral bypass grafting because of symptomatic infrarenal aortic stenosis.Although no blood flow was detected in his occluded right common iliac artery, it expanded rapidly despite intensive antibiotic therapy. As the blood supply to the lower limbs was already secured, only resection of the infected arteries was performed.

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An emergent operation was performed on a 73-year-old woman with massive hematuria and serious shock. A computed tomography (CT) revealed that the cause of the shock was hemorrhage from an aneurysm into the ureter, with resultant massive hematuria. During surgery, we observed that the ureter was encased into the wall of the aneurysm, with exposure of the pre-positioned ureteric stent inside the aneurysmal space. Reconstruction of the ureter was performed by wrapping the tissues with the ureteric stent inside. Postoperative recovery was uneventful, and CT angiography showed complete exclusion of the right internal iliac artery with the in situ ureteric stent.

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We experienced a rare case of acute ischemia of the lower extremity due to embolism caused by an occluded prosthetic graft late after axillary-femoral artery bypass. A 67-year-old woman developed acute right lower extremity ischemia 7 years after axillary-femoral artery bypass, which had been performed for lower limb ischemia as a complication of acute aortic dissection (Stanford B). The graft was occluded, and the native vessel had re-canalized by the time of the present admission. She was successfully treated by disconnection of the graft followed by revascularization.

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An inferior mesenteric artery (IMA) aneurysm is the rarest among visceral artery aneurysms. A 69-yearold man was referred to our hospital with an asymptomatic IMA aneurysm associated with occlusion of the superior mesenteric artery (SMA) and celiac artery (CA). After revascularization of the SMA with an8-mm expanded polytetrafluoroethylene (ePTFE) graft, the aneurysm was resected, and the IMA was reconstructed. The “jet disorder" phenomenon has been thought to cause an IMA aneurysm in the case of CA and SMA obstruction. We consider it better to revascularize not only an IMA but also an SMA or CA for preventing that phenomenon.

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Surgery was performed on a 53-year-old male patient with a painful mass in front of the elbow. The mass originally occurred after needle insertion during a routine health checkup and grew in size during a1-year period. Intravenous tumor with arterio-venous fistula was diagnosed, and it was resected. Histopathological diagnosis of intravenous lobular capillary hemangioma was made. Occurrence of this tumor after a routine health checkup is rare. The etiology of this tumor occurring simultaneously with arterio-venous fistula is discussed.

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