There is a growing body of evidence that cumulative hyperglycemic exposure plays a central role in the development and progression of atherosclerotic cardiovascular disease in diabetic patients. Monosaccharides, such as glucose, fructose, and glyceraldehyde can react non-enzymatically with amino groups of proteins, lipids, nucleic acids to form senescent macromolecules termed advanced glycation end products (AGEs), whose formation and accumulation has been known to progress in diabetic patients, especially in those with a long history of disease. The sustained accumulation of AGEs could contribute to the phenomenon of metabolic memory or legacy effects observed in long-term follow-up clinical studies of diabetic patients. AGE modification alters the structural integrity and function of various types of macromolecules, and interaction of AGEs with a receptor for AGEs (RAGE) has been shown to evoke inflammatory and thrombotic reactions. Therefore, the AGE–RAGE axis is a novel therapeutic target of atherosclerotic cardiovascular disease in diabetic patients. In this paper, we briefly review the pathological role of AGEs and their receptor RAGE system in atherosclerotic cardiovascular disease, including peripheral artery disease and discuss the clinical utility of measuring AGEs in evaluating the severity of atherosclerosis in patients with diabetes.
Type II endoleak is a common complication that develops after endovascular aneurysm repair. Patients with type II endoleak, which has persisted for 6 months, have a significantly higher rate of aneurysmal sac enlargement, reintervention, and rupture. To date, several studies have examined the effectiveness of preoperative embolization of branch vessels for the prevention of type II endoleak. Particularly, the embolization of the large inferior mesenteric artery (IMA) seems to be a precise, safe, and effective method. IMA is a significant risk factor for type II endoleak. However, there is currently no strong evidence to prove which patients would benefit from preventive IMA embolization. In addition, considering the incidence of type II endoleak and the adverse event rate, routine embolization seems to be unreliable and time-consuming. Moreover, previous reports of preoperative IMA embolization were retrospective. Thus, prospective and randomized studies are necessary so that the usefulness of IMA embolization can be proved and the potential benefits can be assessed. To establish preventive IMA embolization as one of the effective therapeutic strategies to prevent type II endoleak and to maximize its therapeutic effect, we should provide a wide range of therapeutic strategies to suit the state of the patient.
Pulmonary embolism (PE) contributes substantially to the global disease burden. A key determinant of early adverse outcomes is the presence (and severity) of right ventricular dysfunction. Consequently, risk-adapted management strategies continue to evolve, tailoring acute treatment to the patients’ clinical presentation, hemodynamic status, imaging and biochemical markers, and comorbidity. For subjects with hemodynamic instability or ‘high-risk’ PE, immediate systemic reperfusion treatment with intravenous thrombolysis is indicated; emerging approaches such as catheter-directed pharmacomechanical reperfusion might help to minimize the bleeding risk. Currently, direct, non-vitamin K-dependent oral anticoagulants are the mainstay of treatment for acute PE. They have been shown to simplify initial and extended anticoagulation regimens while reducing the bleeding risk compared to vitamin K antagonists. (This is a review article based on the invited lecture of the 37th Annual Meeting of Japanese Society of Phlebology.)
The preoperative and postoperative infection control measures for critical limb ischemia treatments were described. The treatment strategies for severe ischemic limbs were showed according to the presence and extent of infection. If the treatment strategy for a severe ischemic limb with infection is mistaken, infection will spread and make worse the situation of the ischemic limb, and eventually it can result not only in limb loss but also life threatening. A surgical strategy is very important in the bypass material, the selection of anastomotic site, the use of postoperative antibacterial drugs, and the wound treatment. Infection troubles are the most familiar and indispensable problem for surgeons, the countermeasures against infection especially in critical limb ischemia is the key point along with revascularization. (This is a translation of Jpn J Vasc Surg 2018; 27: 129–132.)
Sudden death associated with patients with severe motor and intellectual disabilities (SMID) have been thought to be caused in part by venous thromboembolism (VTE), but actual situation of VTE in SMID is not clear. We examined the prevalence and location of deep venous thrombosis (DVT), and the relation of the development of crural veins in 16 patients with SMID, using ultrasonography. The maximum diameter of soleal vein was 1.6±0.5 mm. In most cases, DVT was found in the femoral veins. We could not detect thrombus in the soleal veins. In the present study, the detection ratio of DVT was high in patients with SMID who had restricted mobility capability and were bedridden, and we found the veins centrally from popliteal veins in DVT in SMID, not soleal veins, as the initial sites of the DVT. In the literature, the mean diameter of soleal veins, in healthy adults is 6.7±1.8 mm, that in contrast in SMID being smaller. Underdevelopment of intramuscular veins is possibly related to the mechanism of DVT in SMID. In the current guidelines for the management of VTE, there is limited in scope of ambulatory adults and no application cases who exhibit to SMID restricted mobility of the lower extremities and are bedridden associated with cerebral palsy and developmental motor disabilities, and such patients have associated high risk of the complications of DVT. According to our present study, it is necessary to provide appropriate guidelines for DVT in SMID considering characteristic features. (This is a translation of Jpn J Phlebol 2017; 28: 29–34.)
Recently, with the spread of laser ablation therapy, it has been called into question whether flush ligation of the great saphenous vein (GSV) reduces varicose vein recurrence after surgery. Because we thought such recurrence was caused by a narrow branch resection area, we developed a new method of flush ligation (the avulsion technique method). Materials and Methods: A total of 214 limbs in 180 patients whose GSV had become varicose were studied. In our procedure, we dissect the GSV, lift its proximal stump, and expose the tributaries. We pull out the distal side of the tributaries without ligature as far as possible. We evaluate the area of subcutaneous ecchymosis within a 15-cm radius of the inguinal incision visually on the third post-operative day. Results: We were able to pull out over 10 cm per branch by this method. The area of subcutaneous ecchymosis was mostly less than 10%. No hematoma or pain was observed after the operation. Conclusion: This method was safe, with subcutaneous ecchymosis occurring only rarely. We expect this method to reduce saphenofemoral junction recurrence after the operation. (This is a translation of Jpn J Phlebol 2017; 28: 11–16.)
Objective: To review the outcomes of central venoplasty in the treatment of symptomatic central vein stenosis in patients undergoing haemodialysis via an ipsilateral arteriovenous fistula (AVF).
Methods: Data were collected retrospectively, and included all the consecutive cases of central venoplasty between January 2008 and December 2015.
Results: A total of 132 central venoplasties in 76 patients were performed, with incidence of symptomatic central vein stenosis at 7.4%. Of the patients, 66% were male and the mean age was 61 years. The most frequent indication was decreased dialysis access flow rates (58%) and 52% of all the patients had symptoms of upper limb swelling. The patients who had previous ipsilateral tunneled internal jugular vein dialysis catheters made up 58% of the patients. The mean time from AVF creation to first central venoplasty was 24 months, and 74% of the cases required a second central venoplasty and the mean time to second venoplasty was 7 months. The overall post intervention assisted primary patency rate was 87%, 74%, 63%, and 42% at 6, 12, 18, and 24 months respectively. Statistically significant differences were found in primary assisted patency (p=0.025) and time to second procedure (p=0.039) comparing those with and without a history of ipsilateral tunneled dialysis catheter.
Conclusion: Central venoplasty is technically feasible with low procedural risk. The maintenance of the AVF patency usually requires multiple procedures at average interval of 7 months. Patients with a history of upper limb tunneled dialysis catheter ipsilateral to the side of central vein stenosis or AVF have a less favorable outcome compared to those without.
Objective: To investigate the predictors of acute kidney injury (AKI) following surgery for abdominal aortic aneurysm.
Materials and Methods: Subjects were 642 non-hemodialysis patients (open aortic repair [OAR] group, n=453; endovascular aortic repair [EVAR] group, n=189) who underwent elective surgery between 2009 and 2015. AKI was assessed according to the Kidney Disease Improving Global Outcomes criteria. In-hospital mortality and incidence of AKI were compared between the OAR and EVAR groups. The effect of AKI on outcomes and predictors of AKI were examined in both groups.
Results: In-hospital mortalities were 0.7% (3/453) in the OAR group and 0.5% (1/189) in the EVAR group. The incidence of AKI increased in the OAR group (14.1% vs. 3.7%, P<0.01). In the OAR group, in-hospital mortality (0% vs. 4.7%, P<0.01) increased in patients with AKI. In the OAR group, hemoglobin level <10 g/dL, estimated glomerular filtration rate <60 mL/min/1.73 m2, operation time >300 min, history of ischemic heart disease, and amount of bleeding >1,000 mL were predictors of AKI. In the EVAR group, amount of transfusion>1,000 mL was a predictor of AKI, but AKI was not found to worsen outcomes.
Conclusion: AKI affected outcomes of OAR. Knowledge of predictors may optimize perioperative care.
Objective: Although autologous veins are the first-choice conduit for femorotibial artery bypass, if there are no appropriate autologous veins, we perform femorotibial artery bypass using polytetrafluoroethylene (PTFE) with a distal vein cuff for patients with critical limb ischemia (CLI). This study examined the long-term outcomes of femorotibial artery bypass using PTFE with a Miller’s cuff.
Materials and Methods: Using prospectively collected data for 444 distal bypasses, a retrospective analysis was conducted for 32 femorotibial PTFE bypasses with a Miller’s cuff (PTFE-Miller’s cuff) performed for patients with CLI from April 1994 to December 2016.
Results: Primary and secondary patency rates of PTFE-Miller’s cuff at 3 years were 35.8% and 51.2%, respectively. Limb salvage rate of PTFE-Miller’s cuff at 3 years was 71.0%.
Conclusion: Although the patency rate was low and failed to yield satisfactory results, the limb salvage rate remained relatively high. Femorotibial PTFE bypass with a Miller’s cuff was a useful technique of limb salvage for patients with CLI in whom an appropriate autologous vein could not be used.
Objective: We aim to share our experience regarding the surgical management and outcome of extremity vascular trauma in level-1 trauma centres in Pakistan.
Patients and methods: All consecutive patients with traumatic extremity vascular injury (TEVI) fulfilling the inclusion criteria; between June 2012 and June 2017 were included. The demographics, clinical presentation, management, and outcome measures were recorded.
Results: The study included 81 patients. The mean age±standard deviation was 28.6±14.5 years and 81.5% (n=66) of the patients were males. Blunt TEVI was found in 65.4% (n=53) of the cases. Partial laceration was the most common type of arterial injury (64.2%, n=52) and autologous interposition venous grafting was the most common repair performed (60.5%, n=49). Fasciotomy was performed in 67.9% (n=55) of the patients. The limb salvage rate was 82.7%. The amputation rate was higher in the blunt trauma group when compared with that of the penetrating trauma group. The length of the intensive care unit stay and the use of polytetrafluoroethylene as interposition graft were two independent predictors of limb loss. The mortality rate in this series was 8.6%.
Conclusion: Blunt TEVI is associated with higher morbidity and limb loss. The use of synthetic graft should be discouraged. The liberal use of autologous interposition venous graft and the judicious use of fasciotomies are helpful to achieve favorable outcomes.
Objective: To compare patency rates between one- and two-stage (first-stage arteriovenous anastomosis followed by second-stage superficialization) creation of brachial-basilic transposition arteriovenous fistula (BBT-AVF) in an Asian population.
Methods: A retrospective review of BBT-AVFs was conducted between July 2008 and March 2015. Kaplan–Meier survival analysis and log-rank test were used to evaluate patency.
Results: In total, 103 BBT-AVFs were created in 86 patients (mean age, 61 years; men, 57%). The overall primary, assisted primary, and secondary patency rates at 12, 24, 36, and 48 months were 70%, 48%, 38%, and 35%; 86%, 70%, 62%, and 59%; and 90%, 77%, 70%, and 63%, respectively. There was no significant difference in demographics and preoperative vessel caliber between the groups. The primary failure rate was 24% in the one-stage group, compared with 21% in the two-stage group (p=0.803). There were no statistically significant differences in primary, assisted primary, and secondary patency rates between the groups.
Conclusion: There was no significant difference in primary failure and patency rates between the two groups. Both one-stage and two-stage procedures conferred good outcomes with overall 12-month primary patency, secondary patency, and primary failure rates of 70%, 90%, and 23%, respectively.
Objective: To assess the use of a nitinol stent to treat symptomatic stenoses or occlusions of the native superficial femoral artery (SFA).
Materials and Methods: Seventy-four patients were treated at 12 Japanese sites. The primary endpoint, freedom from target-limb failure (TLF), was a composite of device- or procedure-related death, target-limb amputation, target-vessel revascularization (TVR), or restenosis compared to an objective performance goal (OPG) at 12 months. Secondary endpoints, including primary patency, freedom from TVR/target-lesion revascularization (TLR), improvements in clinical parameters, and major adverse events (MAEs) were evaluated through 36 months.
Results: The mean overall lesion length was 80.7±38.9 mm (mean stented length: 98.8±46.1 mm). Freedom from TLF was 81.2% (p<0.001 compared to OPG) with a Kaplan–Meier estimate of 84.2% [95% confidence interval (95%CI) 73.3%, 90.9%] at 12 months. Primary patency was 71.0% at 12 months and 67.8% at 36 months. A total of 94.7% of patients improved by at least one Rutherford category and 70.2% of patients improved ankle–brachial indices ≧0.10 from baseline to 36 months. Freedom from TVR/TLR (Kaplan–Meier) was 90% at 12 months and 79.5% at 36 months. Four MAEs were reported; none were found to be device or procedure related.
Conclusion: A self-expanding stent was used safely to treat stenotic and occlusive lesions of the SFA in a Japanese patient population. The composite endpoint, freedom from TLF, was superior to an historical control at one year, with low rates of revascularization and good functional and clinical outcomes through three years.
Digital ischemia is a serious problem in peripheral artery diseases (PAD) patients. Case 1: A 60-year-old woman with large arteriovenous fistula (AVF) complained of digital ischemia symptoms. The patient underwent dissection of AVF and distal bypass to the palmar arch with successful repair. Case 2: A 47-year-old female, diagnosed with renal failure, and scleroderma, complained of a digital gangrene. A bypass was performed from the left brachial artery to the superficial palmar arch. The digital gangrene showed a complete recovery within 2 months after surgery. Distal bypass to the palmar arch thus appears to be a useful procedure to re-establish digital circulation in PAD patients.
Fistulas between an aneurysm branching off the abdominal aorta and the thoracic duct are rare. We report a case of aneurysmal-thoracic duct fistula diagnosed by angiography when aneurysm ruptured, and we successfully treated by catheter embolization. A 42-year-old man was referred to our hospital with a chief complaint of sudden back and chest pain. Computed tomography showed both post-mediastinal and retroperitoneal hematomas, with the aneurysm from the aorta being connected to the thoracic duct. After confirming the aneurysmal-thoracic duct fistula by angiography, we performed embolization of the aneurysm. The patient has remained well for 3 postoperative months, to date.
We present here a case of Kommerell diverticulum (KD) with annuloaortic ectasia, in which single-stage surgical repair was performed via a median sternotomy using frozen elephant trunk (FET) technique. We used this technique for the following reasons: firstly, we could perform surgery only via a median sternotomy without thoracotomy; secondly, we were able to deliver the FET using a guidewire through the severely angulated aortic arch. We here investigate this technique as it could potentially be a good treatment option of KD.
Listeria monocytogenes infection and rupture of the aneurysm sac, after endovascular aneurysm repair (EVAR), are both rare. We report the case of an 82-year-old man who presented with a ruptured aneurysm by infection with L. monocytogenes after EVAR. We successfully treated him by in situ reconstruction with a bifurcated expanded polytetrafluoroethylene (ePTFE) graft, with partial removal of the infected stent graft. At 30 months from the reoperation, the patient was in good health at home, with no symptoms of infection, and the gallium-67-citrate single-photon emission computed tomography/computed tomography (SPECT/CT) fusion images confirmed no fluid accumulation.
Treatment by thoracic endovascular aortic repair (TEVAR) for type B dissection has improved outcomes. We tried the procedure named “Full Petticoat technique” in which the proximal entry tear was excluded with a covered stent and extended bare metal stents were placed to the aortic bifurcation for three complicated type B dissection cases with dynamic obstruction of the common iliac artery. Follow-up computed tomography revealed favorable aortic remodeling in which the true lumen was expanded. The short-term result of this procedure has shown acceptable aortic remodeling. The significance of this procedure is still unknown in the long term; hence long-term follow-up is necessary to completely understand the usefulness of this technique.
Venous thromboembolism (VTE) is a major healthcare problem that results in significant mortality, morbidity, and expenditure of resources. It compounds with pulmonary embolism (PE) and deep vein thrombosis (DVT). Phlegmasia cerulea dolens (PCD) is an uncommon but potentially life-threatening complication of acute DVT characterized by marked swelling of the extremities with pain and cyanosis, which in turn may lead to arterial ischemia and ultimately gangrene with high amputation and mortality rates. The key in treating such patients is to provide quick and effective treatment to save the limbs and the patient.
We report a case with aortic intimal sarcoma who presented with left upper limb arterial embolization from tumor. A 79-year-old female patient presented with paleness and left upper limb paralysis. A transesophageal echocardiogram revealed a mobile and fragile mass attached in the aortic arch. Contrast-enhanced computed tomography showed a massive irregular tumor in the aortic arch with left common carotid and subclavian artery occlusion. Total arch replacement was performed, and tumor was resected en bloc. Although the postoperative course was uneventful, multiple metastasis to the limbs was observed. The patient died 6 months postoperatively.
Acute limb ischemia (ALI) is associated with high morbidity and mortality rates, even with the advent of technical advances. Although myocardial infarction is one of the causes of ALI along with intraventricular thrombus formation and subsequent embolism, ALI with concomitant acute myocardial infarction (AMI) is extremely rare. Here, we report a complicated ALI case with concurrent AMI and prolonged limb ischemic duration. The cause may be attributed to thrombosis with atherosclerotic disease of the coronary and peripheral arteries triggered by dehydration. We successfully treated the patient using simultaneous revascularization in a hybrid operating room with the aid of intraoperative hemodialysis for preventing life-threatening reperfusion syndrome.
Fibromuscular dysplasia (FMD) mainly develops in medium-sized arteries, including renal, extracranial, and extremity arteries, but it rarely causes abdominal aortic aneurysm (AAA). A 69-year-old woman with AAA diagnosed on ultrasonography by a home doctor visited our hospital. Contrast-enhanced computed tomography revealed a saccular aneurysm of terminal abdominal aorta. We performed abdominal aortic replacement and resected the section with aneurysm. Pathological examination of the wall tissue of the resected aneurysm revealed findings that are consistent with FMD. We report this case of AAA caused by aortic FMD because of its rarity.
A 79-year-old man with a heavy smoking history presented with threatened lower limbs due to acute exacerbation of peripheral artery disease (PAD). He underwent emergent distal bypass surgery for the right leg and external iliac stenting for the left leg. Fatal coronary artery spasm (CAS) with ST segment changes on electrocardiography was observed 28 h after the procedures, resulting in cardiac arrest. Coronary angiography showed widespread CAS with improvement after intra-arterial nitroglycerin infusion. We should keep in mind that CAS may occur more frequently than expected in PAD patients, especially those who have not stopped smoking prior to revascularization.
It is unclear whether arterial healing occurs beyond 1 year following paclitaxel-coated stent implantation in peripheral artery disease. An 81-year-old woman with superficial femoral artery disease underwent endovascular therapy with a paclitaxel-coated stent. An angiography 21 months later revealed peri-stent contrast staining in the superficial femoral artery, and optical frequency domain imaging demonstrated incomplete stent apposition with significant positive vascular remodeling. High-resolution angioscopy detected positive vascular wall remodeling and in-stent yellow plaque more clearly than conventional angioscopy. Refractory superficial femoral arterial wall healing was apparent more than 20 months after paclitaxel-coated stent implantation.
This is an annual report indicating the number and early clinical results of annual vascular treatments performed by vascular surgeons in Japan during 2011, as analyzed by database management committee (DBC) members of the Japanese Society for Vascular Surgery (JSVS).
Materials and Methods: To survey the current status of vascular treatments performed by vascular surgeons in Japan, the DBC members of the JSVS analyzed the vascular treatment data provided from National Clinical Database (NCD), including the number of treatments and early clinical results such as operative and in-hospital mortality. Given that NCD data were prospectively built by a nationwide registration, this annual report reports prospective clinical data.
Results: In total 71,707 vascular treatments including open repairs and endovascular treatments were registered by 992 institutions in 2011. This database is composed of 7 fields including treatment of aneurysms, chronic arterial occlusive disease, acute arterial occlusive disease, vascular injury, complication of vascular reconstruction, venous diseases, and other vascular treatments. The number of vascular treatments in each field was 17,524, 11,278, 3,799, 1,030, 1,615, 19,371, and 17,510, respectively. In the field of aneurysm treatment, 13,218 cases with abdominal aortic aneurysms (AAA) including iliac aneurysms were registered, including 1,253 ruptured cases. Forty-five percent of AAA cases were treated by stent graft. The operative mortality of ruptured and non-ruptured AAA was 18.8% and 0.8%, respectively. Regarding chronic arterial occlusive disease, open repair was performed in 7,115 cases including 984 distal bypasses to the crural or pedal artery, whereas endovascular procedures were performed in 4,163 cases. For acute arterial occlusive disease, more than 90% of cases were treated with open repair. Vascular injury treatment included 81 venous injury cases and 949 arterial injury cases, and 60% of arterial injuries were iatrogenic. Treatment for complication of previous vascular treatment included 445 cases of graft infections, 240 cases of anastomotic aneurysms, and 811 cases of graft revision operations. The venous treatment included 18,864 varicose vein treatments, 343 cases with lower limb deep venous thrombosis, and 67 cases with vena cava reconstructions. Regarding other vascular operations, 16,296 cases of vascular access operations and 1,037 amputation surgeries are included.
Conclusions: This vascular surgery database indicates not only the number of vascular treatments but also the early clinical outcomes for each treatment procedure, thereby representing a useful source for researching the clinical background of poor outcomes and for finding improvements in the quality of treatment. Continuing this work will provide information regarding changing the treatment modality in response to the changing structure of disease and societal needs. (This is a translation of Jpn J Vasc Surg 2017; 26: 45–64.)
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 purpose of this project is to clarify the current status of the medical practice for the patients with CLI to contribute to the improvement of the quality of medical care. This database, called JAPAN Critical Limb Ischemia Database (JCLIMB), was created on the National Clinical Database and collects data of patients’ background, therapeutic measures, early results, and long term prognosis as long as five years after the initial treatment. The limbs managed conservatively are also registered in JCLIMB, together with those treated by surgery and/or endovascular treatment. In 2015, 1138 CLI limbs (male, 796 limbs [70%]) were registered by 92 facilities. Arteriosclerosis obliterans has 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. (This is a translation of Jpn J Vasc Surg 2018; 27: 155–185.)