Medical management for Stanford B type aortic dissection includes lowering blood pressure and heart rate, and controlling pain to prevent further propagation of the dissection and lessen the risk for aortic rupture. Intravenous vasodilators including calcium channel blockade and beta blockade are initially administered. In the acute phase, oral and adhesive medications are administered as alternatives of intravenous medications to stabilize patients. In the chronic phase, hypotension and bradycardia should be noted. Beta blockade can be most appropriate to reduce aortic wall stress affected by the velocity of ventricular contraction (dP/dt).
Kumamoto was hit by a series of strong earthquakes beginning on April 14, 2016. We treated many deep vein thrombosis (DVT) patients and pulmonary thrombosis (PTE) patients. We came up with a strategy for diagnosis and therapy of venous thromboembolism (VTE). For VTE patients, we prescribed anticoagulant drugs, mainly direct oral anticoagulant (DOAC). To evaluate the validity and safety of the medical strategy for VTE in disasters, we investigated the prognosis of VTE patients at 4 months after the initial quake. In the two months following the initial quake we attended to 43 VTE patients, 11 PTE patients (including 9 patients with both DVT and PTE) and 32 DVT patients. We prescribed DOAC to 34 patients and Warfarin to 4 patients. Based on the survey at 4 months after the first tremblor, the period of anticoagulation therapy was 95.0±17.2 days for PTE and 57.1±36.5 days for DVT and 12 patients were continuing to take anticoagulant drugs. There were no recurrent VTE or bleeding events. DOAC therapy of VTE is therefore considered effective and safe in the event of a natural disaster.
Endovenous laser ablation (EVLA) for varicose veins with dilated saphenofemoral junction (SFJ) is controversial. EVLA using 980 nm diode laser was performed on 215 legs in patients with great saphenous vein insufficiency. They were divided into two groups; group L with SFJ 10–20 mm, group S with SFJ <10 mm. The follow-up results using duplex ultrasound were compared between the groups. The median follow-up period was 12 months in both groups. Laser power (9.6±0.6 W vs 9.2±0.6 W, p<0.001) and linear endovenous energy density (79±8 J/cm vs 75±9 J/cm, p<0.001) were significantly greater in group L. The incidence of endovenous heat-induced thrombosis (class 0: 87% vs 89%, p=0.642), the rate of recanalization (1% vs 1%, p=0.999) or reoperation (1% vs 0%, p=0.999) were similar in both groups. In 6 legs with SFJ>15 mm, the SFJ diameter (16.5±1.5 mm) significantly (p<0.001) decreased to less than 10 mm (6.5±0.8 mm) postoperatively. EVLA without concomitant high ligation for dilated SFJ (<20 mm) is feasible with relatively high energy ablation.
A 65-year-old woman with Takayasu arteritis had the chief complaint of a pulsatile mass in the right lower abdomen. As the result of the detailed examinations, the diagnosis was an anastomotic aneurysm at the external iliac artery–axillary artery bypass graft anastomotic site. The graft had occluded 26 years ago. An endovascular repair was performed successfully. As Takayasu’s arteritis is associated with low age of morbidity and favorable long term prognosis under treatment, long-term observation is necessary. The risk of an anastomotic aneurysm increases with time, and monitoring of the anastomosis is needed even if the bypass is occluded.