We introduce our surgical technique for carotid endarterectomy (CEA) and our use of vocal fold electromyography to prevent perioperative complications. Between 2006 and 2015, 243 CEA procedures were performed (186 symptomatic CEAs and 57 asymptomatic CEAs). All patients were screened preoperatively by cardiologists for congestive and/or ischemic heart disease. If coronary artery stenosis was found, it was treated before CEA was performed. In this series, CEA was done under general anesthesia with a neurosurgical microscope, and we used arterial patch grafts with or without shunting, depending on a number of intraoperative parameters. This procedure requires careful attention to technical details, and specific principles must be followed to achieve a consistently favorable outcome. For high-risk patients with a higher carotid bifurcation, we exposed the distal internal carotid artery (ICA) beyond the hypoglossal nerve under microsurgery. It is important to adequately expose the distal ICA to permit direct visualization of the entire atherosclerotic plaque. Of the 186 patients with symptomatic CEAs, perioperative stroke occurred in 3 (minor stroke in 1 and major stroke in 2). The surgical morbidity and mortality rate were 1.2% and 0%, respectively. Among the 57 patients with asymptomatic CEAs, there was no surgical morbidity or mortality. Vagus nerve palsy is the most commonly recognized complication of CEA, but there are others such as stroke and cardiac events. Injury to the vagus nerve or one of its branches during CEA can result in vocal fold paralysis (VFP), but the exact mechanisms responsible for VFP are unclear. Therefore, we monitored vocal fold electromyograms during CEA. Sudden loss of the vocal fold electromyogram signals was noted in 3 patients (during plaque removal in 2 and during arterial wall suture in 1). In these patients, the cause of vagus nerve injury may have been traction on the nerve at the time of distal ICA manipulation. We examined vocal fold movements postoperatively with a nasolaryngoscope and detected VFP in 11 patients (9%). Monitoring vocal fold electromyograms may be useful for elucidating the mechanism of vagus nerve injury related to CEA. During long-term follow up (32 months), minor ipsilateral stroke occurred in 2 patients, and 10 patients died of causes other than stroke, including 1 death from myocardial infarction and 7 from malignancies. The incidence of adverse events (all-cause death, stroke, myocardial infarction) at 30 days after CEA was 1.2%, which seemed to be acceptable compared with other reports. CEA effectively prevents stroke (even in high-risk patients) if performed according to a consistent treatment strategy and with appropriate technical support.
Adeno-associated virus (AAV) vectors are widely used for retinal gene transfer, and they are undergoing various clinical trials. Their popularity is due to the non-pathogenic nature of AAVs and their versatility in basic research and clinical applications; the excellent transduction efficiency of AAV vectors has boosted basic research and has facilitated the development of various technical innovation systems, such as AAV vector serotypes, self-complementary AAV vectors, tyrosine mutated AAV vectors and the routes of vector administration. However, while the transduction efficiency of intravitreal injections has increased markedly in rodents, it is still low in non-human primates. We have recently developed a new technique of intravitreal administration in macaque monkeys. In this review, we outline and discuss strategies for developing AAV vector systems and advancing intravitreal administration.
A 72-year-old Japanese woman presented in July 2012 with a 5-year history of depigmented areas on the face. On physical examination, she had multiple well-demarcated depigmented areas on the face and neck. She had also experienced increased thirst for the past 3 years. A blood sample was positive for antinuclear and anti-SS-A antibodies. A biopsied specimen from the lower lip showed dense focal lymphoid infiltration in the minor salivary glands. The patient was diagnosed with vitiligo vulgaris associated with Sjögren syndrome. Internal treatment with L-cysteine, tocopherol nicotinate and topical tacrolimus was of limited efficacy. Subsequent excimer light irradiation together with topical vitamin D3 administration led to repigmentation around the hair follicles without causing photodermatosis. These treatments appear to be effective for patients with vitiligo vulgaris associated with Sjögren syndrome who have no past history of photosensitivity.