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 the outcomes of 292 ASO patients who had had critical limb ischemia between May 1995 and July 2009. The 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 the P 3 risk scores and measured the transcutaneous oxygen pressure (tcPO2) and the 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 3 risk 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 5 years 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 P 3 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.
Objectives: The management of intractable foot ulcers requires a team approach which includes vascular surgeons and plastic surgeons. We retrospectively reviewed the results of the management of intractable foot 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 foot ulcers.
Purpose: The increasing incidence of diabetes and dialysis patients is leading to a rise in the number of patients with critical limb ischemia. Despite recent increasing indications for distal bypass, endovascular revascularization and therapeutic neovascularization, a considerable number of patients must undergo major amputation when wounds of the foot or lower leg do not heal. In these patients, combined aggressive revascularization with a free flap transfer is applied in our hospital to cover on the defect, yielding limb salvage with good functional results. The purpose of this study was to evaluate the results of combined simultaneous arterial revascularization and free flap transfer in patients with critical limb ischemia. Patients and Methods: Between February 2004 and April 2010, 7 patients with arteriosclerosis obliterans (ASO) underwent a combination of arterial revascularization by means of saphenous vein grafting and free flap transfer. The mean age of patients was 67 years (range, 44–77 years). Of the 7 patients, 6 had diabetes mellitus and 4 patients had hemodialysis-dependent renal failure. The latissimus dorsi muscle was used as the donor muscle in all patients except 2 cases in the early stage. Results: Limb salvage failed in 1 patient due to ischemia of the free flap, requiring below-the-knee amputation. Limb salvage was successful in the remaining 6 patients. Of these, 4 achieved independent ambulation and 1 could walk with a short leg brace. Conclusion: Combined arterial revascularization and free flap transfer can save not only almost the full length of the limb, but also retain walking ability in many cases of critical limb ischemia. This combined technique provides immediate soft tissue coverage, allowing the possibility of early rehabilitation.
Exercise conditioning for peripheral arterial disease, despite being the treatment of choice for patients with intermittent claudication, is not commonly employed in Japan, in contrast with the extensive use of invasive treatment. Furthermore, vascular rehabilitation (VR) for patients with chronic critical limb ischemia (CLI) is rarely performed. In this study, 10 patients with CLI after vascular reconstruction (REC: bypass surgery or percutaneous peripheral intervention) who were enrolled in a 12-week comprehensive VR program (supervised treadmill exercise or alternative walking exercise, physical therapy, and consultation regarding daily activities), were compared with 10 patients with CLI who were treated with REC but did not receive VR. The patency rate and limb salvage rate did not differ between the VR group and the REC group, but improvements in walking ability, SF-36 health survey scores and B-type natriuretic peptide levels were greater in the VR group than in the REC group. This suggests that VR is an essential treatment for CLI patients in order to obtain improvement in their quality of life.
The surgical treatment of acute aortic dissection in a patient with idiopathic dilated cardiomyopathy is rare. We present a case of a 70-year-old man with a diagnosis of idiopathic dilated cardiomyopathy and a left ventricular ejection fraction of 0.26 on echocardiography, in whom type A acute aortic dissection developed. We performed emergency surgery, consisting of ascending aortic dissection and cardiac tamponade. We then performed ascending aorta replacement, and coronary artery bypass grafting and intra-aortic balloon pumping were necessary due to stenosis of the right coronary ostium. Postoperatively, mediastinitis occurred on postoperative day 13, and therefore the patient needed intensive care for an extended period and was eventually discharged on postoperative day 97.
Cystic adventitial degeneration of the popliteal artery is a rare cause of lower extremity occlusive disease. In this disease, a cystoma which originates in the adventitia compresses the popliteal artery. This disease mainly affects relatively young men who have not experienced trauma in the lower extremities are mainly affected by this disease. We encountered a case of cystic adventitial degeneration of the popliteal artery which spontaneously remitted. The patient was a 41-year-old man who complained of intermittent exertional claudication but with no history of trauma in his lower extremities. On his first visit to our outpatient clinic, computed tomography (CT) showed a homogenous scimitar-shaped cystic lesion of 19 mm in width and 48 mm in length around the left popliteal artery. We diagnosed cystic adventitial disease of the popliteal artery and scheduled ultrasound-guided fine-needle aspiration of the cyst under local anesthesia. However, his symptoms improved before the scheduled procedure date and CT images obtained after the disappearance of his symptoms showed reduction of the cyst to 13 mm by 38 mm, with dilation of the lumen of the popliteal artery. We therefore decided to follow up this patient without treatment. Although this disease is very rare, it occurs in a highly active group of patients, and we can therefore expect considerable improvement in activities of daily living after treatment. This disease must be considered in cases of ischemic symptoms in the lower extremities.
A 37-year-old man visited our hospital with a principal complaint of severe abdominal pain. He had received immunosuppressive therapy since age 31 due to aplastic anemia. At the age of 36, he had undergone computed tomography (CT) due to intermittent claudication, and peripheral arterial disease had been diagnosed. However, his abdominal aorta at that time was 22 mm × 23 mm, and irregularities were observed only in the arterial wall. On CT images obtained at the current presentation (at age 37), the abdominal aorta was 44 mm × 47 mm, showing a rapid enlargement of 24 mm within the previous 18 months. With a diagnosis of impending rupture of an abdominal aortic aneurysm, an urgent Y-type blood vessel prosthesis implantation was performed. Histopathological examination showed the aneurysm to be arteriosclerotic. The possibility that cyclosporine and anabolic steroids were involved in the shape of the aneurysm and its expansion was considered. We report a case of an arteriosclerotic abdominal aortic aneurysm, of which impending rupture appeared to be imminent, in a young man who had been receiving immunosuppressive therapy for aplastic anemia.
A 54-year-old man underwent emergency total arch graft replacement for acute aortic dissection. On the 2nd postoperative day, he showed signs of acute mesenteric ischemia and abdominal computed tomography showed severe stenosis of the superior mesenteric artery (SMA). We performed emergency laparotomy and angioplasty of the SMA. His blood flow to the SMA improved, and the operation was completed without bowel resection. After a period of stay in intensive care, he began eating from the 35th postoperative day and was discharged on the 89th postoperative day.
An aortoenteric fistula (AEF) is a complication of an untreated inflammatory abdominal aortic aneurysm (AAA) which can cause life-threatening gastrointestinal (GI) bleeding. We successfully treated a patient with an AEF, and report this case. A 65-year-old man was referred to us because of massive melena and loss of consciousness. Emergency gastroduodenal fiberscopic examination revealed a bleeding focus at a site opposite the papilla of Vater. Intravenous contrast-enhanced abdominal computed tomography (CT) scans were performed. We diagnosed AEF and the patient underwent emergency surgery. Intraoperatively, we confirmed the presence of an aortoenteric fistula between an abdominal aortic aneurysm and the duodenum. We performed an en-bloc resection of the duodenum and abdominal aortic aneurysm wall, followed by in-situ aortic reconstruction. In order to reduce the risk of infectious complications such as a graft infection, a pedicled omentum was used to cover the prosthetic graft. His postoperative course was uneventful, he was discharged 36 days later, and there has been no evidence of infection during the following 18 months. In conclusion, early diagnosis and prompt surgical treatment is essential in such cases of aortoenteric fistula.
Mid-aortic syndrome (MAS) is a rare disease found in children and young adults. This syndrome is characterized by the segmental narrowing of the descending thoracic and the proximal abdominal aorta and is often accompanied by ostial stenosis of its major branches. We present a case of a 4-year-old boy with abdominal aortic obstruction which progressed from MAS. At 1 month of age he underwent evaluation for a continuous murmur and hypertension of the upper body. Magnetic resonance angiography and aortography showed stenosis in the descending thoracic and abdominal aortas, proximal to the origin of the celiac artery. However, his hypertension was not controlled by the administration of anti-hypertensive agents. At 3 years of age, aortography and computed tomography (CT) revealed an aortic obstruction proximal to the celiac artery. Therefore, we performed an extra-anatomical bypass from the ascending aorta to the abdominal aorta with an 8-mm ring-supported ePTFE graft. After surgery, the difference in blood pressure between the upper and lower limbs resolved and postoperative CT images showed good graft patency.
A 59-year-old woman who had undergone aortic valve replacement for infected endocarditis at 47 years old and repair for pseudoaneurysm at the site of a prior aortotomy 2 years previously was transferred to our hospital. Follow-up computed tomographic (CT) images demonstrated a recurrent pseudoaneurysm of the ascending aorta. Aortic graft replacement was performed using cardiopulmonary bypass under hypothermic circulatory arrest. Postoperatively, the patient suffered from cerebral infarction and therefore, we initiated edaravone administration with rehabilitation. She recovered without palsy, and postoperative CT images showed that the pseudoaneurysm had completely disappeared.