Stent-grafts for endovascular repair of thoracic aortic aneurysms have been commercially available for more than ten years in the West, whereas, in Japan, a manufactured stent-graft was not approved for the use until March 2008. Nevertheless, endovascular thoracic intervention began to be performed in Japan in the early 1990s, with homemade devices used in most cases. Many researchers have continued to develop their homemade devices. We have participated in joint design and assessment efforts with a stent-graft manufacturer, focusing primarily on fenestrated stent-grafts used in repairs at the distal arch, a site especially prone to aneurysm. In March 2008, TAG(W.L. Gore & Associates, Inc., Flagstaff, Arizona, USA) was approved as a stent graft for the thoracic area first in Japan, which was major turning point in treatment for thoracic aortic aneurysms. Subsequently, TALENT (Medtronic, Inc., Minneapolis, Minnesota, USA) was approved in May 2009, and TX2 (COOK MEDICAL Inc., Bloomington, Indiana, USA) in March 2011. Valiant as an improved version of TALENT was approved in November 2011, and TX2 Proform as an improved version of TX2 began to be supplied in October 2012. These stent grafts are excellent devices that showed good results in Western countries, and marked effectiveness can be expected by making the most of the characteristics of each device. A clinical trial in Japan on Najuta(tentative name)(Kawasumi Labo., Inc., Tokyo, Japan)as a line-up of fenestrated stent grafts that can be applied to distal arch aneurysms showing a high incidence, and allow maintenance of blood flow to the arch vessel was initiated. This trial was completed, and Najuta has just been approved in January of 2013 in Japan, and further development is expected. In the U.S., great efforts have recently been made to develop and manufacture excellent stent grafts for thoracic aneurysms, and rapid progress has been achieved. In particular, in the area of the aortic arch, in which we often experience aneurysmal change, but there are no commercially available devices which are urgently needed. Companies are competing keenly to develop devices. To our knowledge, more than 4 manufacturers are involved in the development of functionally new stent grafts in this area. The introduction of branched stent grafts may not be faraway.
A great numbers of cardiovascular disease patients all over the world are suffering in the poor outcomes. Under this situation, cardiac regeneration therapy to reorganize the postnatal heart that is defined as a terminal differentiated-organ is a very important theme and mission for human beings. However, the temporary success of several clinical trials using usual cell types with uncertain cell numbers has provided the transient effect of cell therapy to these patients. We therefore should redevelop the evidence of cell-based cardiovascular regeneration therapy, focusing on targets (disease, patient's status, cardiac function), materials (cells, cytokines, genes), and methodology (transplantation route, implantation technology, tissue engineering). Meanwhile, establishment of the induced pluripotent stem (iPS) cells is an extremely innovative technology which should be proposed as ES cellularization of post natal somatic cells, and this application have also showed the milestones of the direct conversion to reconstruct cardiomyocyte from the various somatic cells, which does not need the acquisition of the re-pluripotency. This review discusses the new advance in cardiovascular regeneration therapy from cardiac regeneration to cardiac re-organization, which is involved in recent progress of on-going clinical trials, basic research in cardiovascular regeneration, and the possibility of tissue engineering technology.
Introduction: Maggots are potent debriding agents capable of removing necrotic tissue and slough; however, it is still unclear which wounds are most likely to benefit from maggot debridement therapy (MDT). Thus, we performed this retrospective review to gain insight into the patient and therapy characteristics influencing outcome. Patients and Methods: We reviewed patients with foot ulcers caused by critical limb ischemia, encountered during the period between June 2005 and May 2010. The treatment outcomes were defined as effective or ineffective. Results: There were 16 patients with 16 leg ulcers. The patients were 13 men and 3 women, with an average age of 67.2 years (range, 47–85 years). Ten (63%) of the 16 ulcers were treated effectively. According to univariate analyses, an ankle brachial pressure index (ABI) lower than 0.6 (p = 0.03) had a negative impact on the outcome of MDT; however, outcome was not influenced by gender, obesity, ischemic heart disease, diabetes mellitus, hemodialysis, smoking, or laboratory findings. Conclusions: Some patient characteristics, such as gender, obesity, ischemic heart disease, diabetes mellitus, hemodialysis, and smoking, do not seem to contraindicate eligibility for MDT. However, a limb with an ABI lower than 0.6 is less likely to benefit. (*English Translation of J Jpn Coll Angiol 2011; 51: 209-213.)
Background: Lack of high-fidelity simultaneous measurements of pressure and flow velocity in the aorta has impeded the direct validation of the water-hammer formula for estimating regional aortic pulse wave velocity (AO-PWV1) and has restricted the study of the change of beat-to-beat AO-PWV1 under varying physiological conditions in man. Methods: Aortic pulse wave velocity was derived using two methods in 15 normotensive subjects: 1) the conventional two-point (foot-to-foot) method (AO-PWV2) and 2) a one-point method (AO-PWV1) in which the pressure velocity-loop (PV-loop) was analyzed based on the water hammer formula using simultaneous measurements of flow velocity (Vm) and pressure (Pm) at the same site in the proximal aorta using a multisensor catheter. AO-PWV1 was calculated from the slope of the linear regression line between Pm and Vm where wave reflection (Pb) was at a minimum in early systole in the PV-loop using the water hammer formula, PWV1 = (Pm/Vm)/ρ, where ρ is the blood density. AO-PWV2 was calculated using the conventional two-point measurement method as the distance/traveling time of the wave between 2 sites for measuring P in the proximal aorta. Beat-to-beat alterations of AO-PWV1 in relationship to aortic pressure and linearity of the initial part of the PV-loop during a Valsalva maneuver were also assessed in one subject. Results: The initial part of the loop became steeper in association with the beat-to-beat increase in diastolic pressure in phase 4 during the Valsalva maneuver. The linearity of the initial part of the PV-loop was maintained consistently during the maneuver. Flow velocity vs. pressure in the proximal aorta was highly linear during early systole, with Pearson's coefficients ranging from 0.9954 to 0.9998. The average values of AO-PWV1 and AO-PWV2 were 6.3 ± 1.2 and 6.7 ± 1.3 m/s, respectively. The regression line of AO- PWV1 on AO-PWV2 was y = 0.95x + 0.68 (r = 0.93, p <0.001). Conclusion: This study concluded that the water-hammer formula (one-point method) provides a reliable and conventional estimate of beat-to-beat aortic regional pulse wave velocity consistently regardless of the changes in physiological states in human clinically. (*English Translation of J Jpn Coll Angiol 2011; 51: 215-221)
Persisting incompetent great saphenous vein (GSV) below the knee and residual incompetent perforating veins (IPV) are often found after selective stripping of GSV from the groin to upper calf. The aim of this study is to evaluate the venous function when the calf GSVs or calf perforating veins are incompetent after stripping surgery. One hundred-thirty-one limbs were treated by stripping from the groin to upper calf with stab avulsion or sclerotherapy of varices. One month and twelve months after surgery, the patients were examined clinically to establish the extent of persisting varices by duplex ultrasonography and air-plethysmography. Venous filling index (VFI) was a little higher in those who had residual calf GSV reflux 12 months later; it was also higher in the group with incompetent perforating veins than the group without. The chief complaints were found to have improved in all groups. The findings suggest that removal of the saphenous vein below the knee is not necessary, but it is important to take care of the incompetent perforating veins. (*English Translation of J Jpn J Phlebol 2011; 22: 239-244.)
We performed transposed brachiobasilic arteriovenous fistula (TBBAVF) in 24 patients from January 2006 to August 2010. The operative time was 90–210 minutes (mean: 136 minutes). All patients had edema of an upper extremity and 2 patients had wound complications. Major complications were not seen. The primary patency rates at one and two years were 89.7% and 69.0%, respectively. The secondary patency rates at one and two years were 95.7% and 73.6%, respectively. TBBAVF has good primary and secondary patency rates with few severe complications. (*English Translation of Jpn J Phlebology 2011; 22: 33-38.)
Objective: Compared with conventional open surgery (COS), endovascular aneurysm repair (EVAR) has been reported to decrease the 30-day mortality rate in patients with ruptured abdominal aortic aneurysms (rAAAs). We developed an EVAR-first strategy for rAAAs that incorporates the Shonan ruptured abdominal aortic aneurysm protocol (SRAP). We describe short-term results with this protocol at our institution and compare them with outcomes in patients who underwent COS. Methods: The records of all 57 patients in whom a rAAA was repaired during a 7-year period were reviewed retrospectively. Patients in the COS group (n = 30) were treated between January 2005 and December 2009; those in the SRAP group (n = 27) were treated between January 2010 and March 2012. The two groups were compared with respect to patient characteristics at admission, including severity of condition; operative and in-hospital variables; and 30-day mortality. Results: The baseline patient characteristics in the COS and SRAP groups were similar except that the SRAP group had a significantly higher rate of cerebrovascular disease. The 30-day mortality rate was significantly higher in the COS group (43% vs. 19%), as were the intraoperative mortality rate (27% vs. 5%) and the in-hospital mortality rate (57% vs. 26%; P < 0.05 for all comparisons). The technical success rate for EVAR was 96%; no conversions to open surgery were required. Conclusions: Use of the SRAP is a promising strategy for improving initial outcomes in patients with rAAAs.
Objective: Persistent Type 2 endoleaks (PT2) after endovascular aortic aneurysm repair (EVAR) for abdominal aortic aneurysm (AAA) are associated with increased adverse outcomes, including aneurysmal sac enlargement and rupture. The aim of this study was to report early clinical outcomes of coil embolization (CE) to aortic branched vessels prior to EVAR and assess the effectiveness of this strategy in terms of prevention of sac growth due to PT2. Materials and Methods: Between May 2007 and April 2012, EVAR was performed for 215 cases, divided into two groups (150 cases in Group A, before introduction of CE; 21 in Group B, receiving CE before EVAR). Early clinical outcomes were compared between groups. Results: Fifty percent of cases in Group B had a marked reduction of aneurysmal sac diameter based on multidetector row computed tomographic angiography (MDCTA) findings at the 6-month follow-up after EVAR, whereas, only 25% of cases in Group A had shrinkage of the aneurysmal sac during the same time period after EVAR. Conclusion: This strategy has the possibility of improving late outcomes of EVAR by reducing endoleak volumes beforehand.
Objectives: To clarify whether ultrasound findings of skin and subcutaneous tissue represent the severity of lymphedema. Materials and Methods: Thirty-five patients with secondary lower extremity lymphedema caused by intrapelvic lymph node dissection during cancer surgery, who first visited our clinic between April 2009 and March 2012, were studied retrospectively. At their first visit, skin thickness, subcutaneous tissue thickness, and subcutaneous echogenicity were assessed at 8 points on the thigh and leg of both legs using an 11-MHz ultrasound transducer. These findings correlated with the International Society of Lymphology (ISL) clinical stage. Results: Skin thickness, subcutaneous tissue thickness, and subcutaneous echogenicity all showed significant positive correlation with the ISL stage. However, measuring skin and subcutaneous tissue thicknesses was not feasible in 29%-71% of scanning points in stage III legs because of poor delineation of boundaries at the dermo-hypodermal junction and the upper boundary of the muscular fascia. However, subcutaneous echogenicity was assessable at all scanning points and was linearly correlated with ISL stage. Conclusion: Evaluating subcutaneous echogenicity is feasible even with low-resolution ultrasound and reflects the ISL stage. These findings may thus be valuable to objectively represent the severity of extremity lymphedema.
Objective: Our study focuses on the long term result of open surgery and endovascular abdominal aortic aneurysm repair (EVAR) using the Zenith stentgraft. Materials and Methods: A total of 237 patients underwent elective abdominal aortic aneurysm (AAA) repair between April 1999 and December 2006. Nineteen patients underwent EVAR, whereas 218 patients underwent open surgery. The mean follow-up time for EVAR group was 73.8 ± 49 months (range; 25-150 months), and 69.7 ± 46 months (range; 1-156 months) for open surgery group. Results: One open surgery patient (1/218, 0.46%) died of aspiration pneumonia, whereas all the EVAR patients survived the operation. Remote complications requiring reintervention occurred in 8 patients (8/174, 4.6%) in open surgery group. Six EVAR patients (6/19, 31.6%) developed late aneurysm expansion, among whom four patients (4/19, 21.1%) required reinterventions after 3 or more years postoperatively. The need for reintervention persisted even at 11 years after initial EVAR. There was no significant intergroup difference in late mortality. Conclusions: There was no statistically significant intergroup difference in early and long term mortality. Complications requiring reinterventions, however, were more frequent in EVAR than in open surgery, especially in the late period. Long term follow-up is mandatory for comparison of the clinical results between open surgery and EVAR.
A 44-year-old man with an isolated anomaly of azygos continuation of the inferior vena cava (IVC) presented with dyspnea due to pulmonary thromboembolism and deep-vein thrombosis (DVT). Sonographic examination disclosed not only pulmonary hypertension and DVT, but also infrahepatic interruption of the IVC with azygos continuation. A rare anomaly of azygos continuation of IVC could cause DVT and pulmonary thromboembolism. Vascular echo could play an important role in the examination of DVT and/or venous anomalies.
A 64-year-old woman underwent surgical resection of a posterior inferior pancreaticoduodenal arterial aneurysm in the subacute phase of acute aortic dissection (AAD). Concomitantly, a distal pancreatectomy was also required. The aneurysm was approximately 20 mm in diameter. Surgical resection of the aneurysm was performed because endovascular treatment was considered to be technically difficult due to dissecting lesions that had remained at the abdominal aorta. Histopathological findings suggested this aneurysm to be a pseudoaneurysm, which had arisen as a result of segmental arterial mediolysis. Approximately 1 year after surgery, no recurrence of the aneurysms was detected.
A 49-year-old woman with a 27-year history of systemic lupus erythematosus (SLE) was admitted to our hospital with sudden-onset severe back pain. An emergency multidetector computed tomography (MDCT) revealed a ruptured thoracoabdominal aortic aneurysm (TAAA) 80 mm in diameter. Considering her condition and comorbidities, we performed an emergency hybrid treatment: visceral reconstruction followed by endoluminal aneurysm exclusion. She recovered uneventfully, except for the need for temporary hemodialysis. TAAA complicated with SLE is extremely rare. To our knowledge, this is the first successful report in the English literature of a ruptured TAAA in a patient with SLE who underwent hybrid treatment.
A 76-year-old woman underwent ascending aorta replacement due to acute type A aortic dissection. She suffered from a deglutition disorder, had a gastric fistula and received enteral nutrition after the operation. Two months later, a large amount of pus was discharged from the sternotomy wound. Methicillin-resistant Staphylococcus aureus (MRSA) was detected from the pus culture. She was successfully treated by two applications of sufficient debridement and vacuum-assisted closure therapy. Her nutritional status was normal during the period of the tubal feeding. At the 1-year follow-up, there was no sign of recurrence.
We present a case of an aortocaval fistula without bleeding because a clot was covering the fistula. A 60-year-old man was diagnosed as having a ruptured abdominal aortic aneurysm and an aortocaval fistula, by enhanced computed tomography. After the aneurysm had been opened, the fistula was detected, but there was no bleeding because it was covered with clot. After graft repair, bleeding from the fistula occurred when the clot was removed by suction. Direct closure of the fistula was achieved after bleeding was controlled by digital compression.
A 77-year-old man with a history of hemodialysis was referred due to swelling of the right groin. Enhanced computed tomography (CT) showed extravasation of the medium from the superficial femoral artery (SFA) with surrounding large hematoma. Three-dimensional CT angiography revealed rupture of SFA just distal to common femoral artery with pseudoaneurysmal formation. At an emergent surgery, SFA was ruptured over 1/2 circumferentially in a 2-cm length. Patch repair using great saphenous vein was performed successfully. Postoperative CT angiography showed no aneurysmal formation. Histopathological findings of operative specimen disclosed no sign of infection or arteriolitis.
Osteochondromas or exostoses are the most common benign bone tumors. This is a case of a 16-year-old boy with multiple osteochondromatosis which caused the popliteal pseudoaneurysm and a subsequent distal embolism. Vascular complications, especially acute limb ischemia, caused by osteochondromas are very rare. This abnormality should be searched for when dealing with young patients with acute limb ischemia.
Perigraft seroma is a rare complication after open abdominal aortic aneurysm (AAA) repair. We successfully treated large seroma after polytetrafluoroethylene (ePTFE) aortobiiliac graft repair endovascularly. The patient was an 81-year-old lady with the history of five times laparotomy. She could not take any food because of vomiting. Contrast enhanced computed tomography (CT) revealed giant seroma compressing small intestine. Total relining of the graft with a ExcluderTM endoprosthesis and open drainage of the seroma was performed. After the surgery, she became asymptomatic and seroma disappeared by CT 2 years later. This modality would be a good option for this rare complication.
Endovenous laser ablation (EVLA) has two pitfalls: endovenous heat-induced thrombosis (EHIT) and great saphenous vein (GSV) recanalization. To eliminate these complications, we developed ultrasonography-guided high ligation (UGHL) using a puncture-sized incision as an adjunct treatment to EVLA. UGHL combined with EVLA was used in 20 patients. The GSV was encircled with 2-0 silk thread at 2 cm distal to the saphenofemoral junction through two incisions of 2–3 mm by using a Deschamps aneurysm needle under ultrasonographic guidance. UGHL was technically feasible in all cases, and no case presented with complications. UGHL may be used in addition to EVLA.
A shaggy aorta with unstable atheromatous plaques has a high risk of neurologic complications in cases of arch aneurysm. We report the use of a modified arch-first technique involving arch replacement for a beating heart after reconstruction of supra-aortic vessels while maintaining normal blood pressure. The procedure was performed in a patient who had an arch aneurysm, complicated by an aberrant right subclavian artery (ARSA) and a shaggy aorta ascending to the aortic arch. This modified arch-first technique is an alternative surgical approach that is used for arch aneurysms involving a shaggy aorta, in order to prevent embolic debris-related complications.
A 61-year-old woman underwent right axillobifemoral bypass using a reinforced expanded polytetrafluoroethylene T-shaped graft for high aortic occlusion. One year later, anastomotic pseudoaneurysm of the axillary artery was noted. We performed pseudoaneurysmectomy and graft interposition at the same anastomotic site through an infraclavicular approach. Unfortunately, the pseudoaneurysm recurred four months later. Therefore, we performed a second reoperation through a supraclavicular approach, in addition to the infraclavicular one. We were able to achieve better exposure from the axillary artery to the distal part of the subclavian artery, and reconstruct the bypass with secure and safe arterial clamping and reanastomosis.