Objective: To investigate the short-term and long-term results of surgical treatment for Abdominal Aortic Aneurysm (AAA) in patients older than 85 years old. Methodology: A retrospective study was conducted involving 106 patients older than 85 years old who underwent surgical treatment through graft replacement (GR) or endovascular aneurysm repair (EVAR) for AAA between 1989 and 2010. For the 13 patients with ruptured AAA, GR was indicated. As for the 93 patients with non-ruptured AAA, GR was indicated in 67 while EVAR was indicated in 26. The life expectancy was 5.37 (2.96–7.97) years at the time of surgery. Results: The hospital mortality for ruptured AAA cases was 30.8%. In non-ruptured cases, the hospital mortality after GR was 6.0% and after EVAR was 0% which were remarkably low. The overall survival rate was 74.2% at 3 years and 46.0% at 5 years. Comparing GR and EVAR in non-ruptured cases, survival rate at 3 years (78.1%/71.1%) and at 5 years (50.0%/71.1%) showed no significant difference (p=0.544). Among 54 patients with non-ruptured AAA whose life expectancy has passed, 25 had died before the period of life expectancy and 29 (53.7%) had lived for life expectancy. Conclusions: Our surgical strategy for AAA in patients over 85 years old could be justified in the aspect of life expectancy.
A few decades ago, the quality of anesthesia for elderly patients and patients with severe diseases was not good and anesthetic techniques were not satisfactory; however, many problems have been solved by the development of intravenous anesthetics and ultrasound devices. Target-controlled infusion systems, replacing conventional infusion methods such as dose per time, have enabled accurate adjustment of anesthesia depth leading to suitable anesthesia conditions and high-quality emergence. Transesophageal echocardiography (TEE) has enabled not only decision-making for surgical indications during surgery but also appropriate management for fluid therapy using real-time measurement of left ventricular volume and function. The development of ultrasound-guided nerve blocks has enabled us to avoid general anesthesia which has a risk of causing unstable hemodynamics. Dexmedetomidine, which has organ-protective effects, can improve the condition of the patient after surgery. We have a mission over the next decade to change the experience to evidence. If we accomplish this, we will be able to provide patients and surgeons the most preferable and suitable conditions for surgery. Since we believe that this is what we must do, we continue doing daily anesthetic management and research to accomplish this mission.
Walking impairment questionnaire (WIQ) was evaluated after rehabilitation and percutaneous transluminal angioplasty (PTA) or surgical treatment in 40 patients with peripheral artery disease (PAD). Ankle-Brachial Index (ABI) score after treatment showed that all cases were improved. WIQ score were also significantly increased after revascularization and rehabilitation. Quality of life was also noted to be improved. We could evaluate the ability of walking exercise objectively and we have set the target in individual rehabilitation by adapting WIQ for rehabilitation.
In this study, we retrospectively reviewed 36 cases that required surgical treatment in the femoropopliteal regions (46 regions) because of the development of obstructions after stent placement in these patients. Of the 46, stents were placed in 37 involved regions (80.4%) that included the common femoral and popliteal arteries; such as the common femoral, entire length of superficial femoral, or popliteal arteries, and the anastomosis site created during femoropopliteal bypass surgeries (Group A). In contrast, 9 involved regions (19.6%) did not include the common femoral or popliteal arteries; the stents were primarily localized in the superficial femoral artery (Group B). Symptoms of stent occlusion were more severe in the former group of patients, who subsequently required peripheral artery bypass surgery. These results indicate that placement of stents in the common femoral artery and popliteal arteries should be avoided.
We analyzed 20 judgments of medical malpractice suits at the issue of pulmonary thromboembolism. The judgment results almost corresponded to tendencies of public opinion to the Japanese medical systems. The main issues of the malpractice suits were uselessness or delay of heparin as a medical treatment, lack or misdiagnosis of primary examinations, and delay of appropriate treatments. The judgments using the Venous Thromboembolism (VTE) guideline were reasonable.
A risk management strategy to prevent thromboembolism is described. 1. Some patients with thrombi in varicose veins show defects on lung perfusion scintigrams and a case of venous thromboembolism (VTE) was encountered after stripping of varicose veins. 2. Emergent surgical treatment is now selected when patients suffer from thrombi adjacent to a deep vein and spinal anesthesia has been changed to general anesthesia for early ambulation. Furthermore, elastic stockings are now used instead of elastic bandages for hemostasis. 3. In order to prevent postoperative VTE, the VTE Working Group prepared a checklist of vascular disorders for all patients scheduled for surgical treatment in all departments. High risk patients visit the vascular division, and the appropriate preventive measures are discussed by our staff. 4. The Anticoagulant Working Group is evaluating the use of medicines and dietary supplements of all patients scheduled for surgery. As a general rule, anticoagulants should be stopped before the operation; however, in some patients, heparin is used for the prevention of cerebral thromboembolism. Stripping of varicose veins can be performed safely without stopping anticoagulants. In conclusion, the significance of thromboembolism should be recognized by all hospital staff and systematic steps should be taken to prevent its occurrence.
The number of aortic valve stenoses (AS) caused by arteriosclerosis increases recently. The aim of this study was to determine the association of AS and arteriosclerosis-related disease. 60 patients with valvular AS and peak aortic jet pressure gradient of more than or equal to 36 mmHg, diagnosed by Doppler echocardiography, were identified in our database from 1995 to 2005. In patients who underwent aortic valve replacement (AVR), survival rate of patients with peripheral artery disease (PAD) was 63%, 50%, and 33% while survival rate of patients without PAD was 100%, 85%, and 59% at 1, 5, and 10 years. In patients who have not undergone AVR, survival rate with PAD was 63% and 13%, while those without PAD was 96% and 61% at 1 and 5 years. All patients with PAD complicated another arteriosclerosis-related disease and most of them died from cardiovascular disease. This study is a retrospective study. Although the population is not large enough and the evaluation of AS is diagnosed only by pressure gradient of echocardiography, this study indicates the possibility that combination with PAD influence the mortality rate of AS. It may be important to control progression of arteriosclerosis for improvement in survival rates of AS.
Objectives: One form of etiology in coronary spastic angina (CSA) is vascular endothelial cell dysfunction which causes vascular distensibility disorder. On the other hand, cardio-ankle vascular index (CAVI) is a new parameter of arterial stiffness. This study aims to reveal the relationship between CSA and CAVI. Methodology: The subjects included were 41 patients who received the induction examination of coronary spasm with angiography. We evaluated the CSA (S) Group and the normal (N) Group, and compared the two groups. The laboratory findings (lipid and glucose profile), blood pressure, smoking, age, sex, ankle-brachial index (ABI), and CAVI were analyzed. Results: CAVI in the S Group was significantly higher than in the N Group (S: 8.78±0.82, N: 7.73±1.04, P=0.004). There were no significant differences in the other analyzed findings. Conclusion: The study revealed that vascular endothelial dysfunction caused CSA and increased CAVI.
The purpose of this study was to investigate the prevalence and characteristics of renal artery stenosis (RAS) in patients with chronic kidney disease (CKD) by duplex ultrasonography. From April 2007 to July 2010, renal artery duplex scanning was performed in 219 patients. CKD was defined as having estimated glomerular filtration rate (eGFR) of less than 60 mL/min/1.73 m2 or proteinuria. In 113 patients with CKD, RAS was found in 20 patients (18%). It was significantly higher than the non-CKD group (6%) (p=0.006). Renal duplex ultrasonography is a useful diagnostic tool for identification of RAS in patients with CKD.
We reviewed the results of thromboembolectomy, which was performed for the treatment of chronic thromboembolic pulmonary hypertension, 1 year after the operation. We obtained hemodynamic and respiratory data of 60 patients from the 112 patients who were operated at our institute. The hemodynamic parameters such as mean pulmonary arterial pressure, pulmonary vascular resistance, and cardiac index were significantly improved after the operation, and this improvement of pulmonary hemodynamics persisted even a year after the operation. A significant improvement in gas exchange was observed immediately after the operation and a further elevation in the partial pressure of oxygen in arterial blood (PaO2) was observed 1 year after the operation.
A 73-year-old man presented with complaints of chest, back, abdominal, and foot pain. Enhanced computed tomography scan demonstrated acute Stanford type B aortic dissection and acute abdominal aortic occlusion with lower ischemia. Axillo-bifemoral bypass operation was performed. There were no complications and postoperative course was excellent.
A 66-year-old man presented complaining of postprandial abdominal pain. A contrast-enhanced CT scan of the abdomen showed a low-density area surrounding the superior mesenteric artery and the left internal iliac artery. Retroperitoneal fibrosis (RPF) was diagnosed and steroid therapy was initiated. The retroperitoneal mass subsequently regressed and the symptoms resolved. Recent reports suggest that RPF is associated with IgG4-related disease and with inflammatory abdominal aortic aneurysm. Vascular surgeons, therefore, should consider RPF as part of their differential diagnoses.
Recently, comparing the results of endovascular therapy with surgical technique to repair adult aortic coarctation is discussed. Surgical treatment still has some advantages. Although there are a number of surgical options, the most appropriate strategy is unclear. We reported our mid-term result of patch aortoplasty for three adult patients with coarctation.
The patient was a 62-year-old female who was diagnosed with peripheral artery disease and underwent distal bypass operation of the lower extremities with saphenous vein graft. After the operation, the pulsation of dorsalis pedis artery was well and necrotic digitus pedis was cleared. Four months later, graft flow pattern worsened and graft flow velocity decreased on vascular ultrasound. Graft stenosis was confirmed by angiography of the lower extremities. PTA was performed and graft flow velocity recovered to the same level at early postoperative period. A regular check by vascular ultrasound after lower extremity revascularization was useful to prevent graft obstruction.