Anterior Tibial Artery Angioplasty and Stenting by Retrograde Pedal Artery Approach in Diabetic Patient with Critical Limb Ischemia: A Case Report / 대한혈관외과학회지

Endovascular therapy of critical limb ischemia is indicated in high risk patients, especially the diabetics. The ipsilateral antegrade femoral approach is the most common access site. When this approach fails, the retrograde pedal artery percutaneous approach can be considered. A 51-year-old diabetic male patient was presented with severe rest pain and gangrene on his right 4th toe. Computed tomography angiography showed multilevel calcific arterial occlusive disease, involving the popliteal and proximal anterior tibial arteries. Below knee angioplasty and stenting of the right leg was done through ipsilateral antegrade femoral approach and retrograde pedal artery approach. The C-arm guided retrograde pedal approach for calcific artery was useful for recanalization of the occluded anterior tibial artery when antegrade approach failed.

CO2 Angiography-2: CO2 Inferior Vena Cavograohy / 대한혈관외과학회지

CO2 has been used increasingly as a contrast agent in both the arterial and venous circulations. CO2 was firstly used as an intravenous contrast medium in the early 1950s for diagnosing pericardial effusion. In the 1970s Cho and Hawkins pioneered the intraarterial use of CO2. CO2 can be used very safely particularly not only in patients with contrast allergies and renal failure, but also in patients undergoing routine angiographic evaluations and many interventional procedures. In venous circulations, CO2 is used for imaging large veins, including the inferior vena cava (IVC), superior vena cava, central veins of the upper extremity, iliac veins, and hepatic and portal veins. Familiarity with the physical properties of carbon dioxide, avoidance of air contamination, catheterization techniques, vascular anatomy, physiologic monitoring, and radiation safety is essential for the safe and effective performance of carbon dioxide angiography. Recently, CO2 has been reported as a "black blood" contrast agent for magnetic resonance angiography. Today, carbon dioxide is used worldwide as a contrast agent for numerous vascular and nonvascular procedures in various organs and arterial circulation below the diagram, as well as in the venous circulation including IVC for various indications, including filter insertion. With the advent of very safe and inexpensive plastic bag delivery system, the safety and ease of gas delivery has been improved.

Predictors of Postoperative Mortality of Ruptured Abdominal Aortic Aneurysm: A Retrospective Clinical Study

PURPOSE: Despite significant improvements in surgery, anesthesia, and postoperative critical care, the postoperative mortality rate of ruptured abdominal aortic aneurysm (RAAA) has remained at 40% to 50% for several decades. Therefore, we evaluated factors associated with the postoperative mortality of RAAA. MATERIALS AND METHODS: From January 1999 to December 2008, a retrospective study was performed with 34 patients who underwent open repair of RAAA. The preoperative factors included age, sex, smoking, comorbidities, serum creatinine, hemoglobin, shock, pulse rate, and time from emergency room to operation room. The intraoperative factors included blood loss, transfusion, aortic clamping site and time, aneurysmal characteristics, rupture type, graft type, hourly urine output (HUO), and operative time. The postoperative factors included inotropic support, renal replacement therapy (RRT), reoperation, bowel ischemia, multiple organ failure (MOF), and intensive care unit stay. The 2-day and the 30-day mortality rates were analyzed separately. RESULTS: The 2-day and the 30-day mortality rates were 14.7% and 41.2%, respectively. On univariate analysis, shock, transfusion, HUO, inotropic support and MOF for the 2-day mortality and serum creatinine, transfusion, aortic clamping site, HUO, inotropic support, RRT and MOF for the 30-day mortality were statistically significant. On multivariate analysis, shock, inotropic support and MOF for the 2-day mortality and aortic clamping site, RRT and MOF for the 30-day mortality were statistically significant. CONCLUSION: To decrease the postoperative mortality rate of RAAA, prevention of massive hemorrhage and acute renal failure with infrarenal aortic clamping, as well as prompt operative control of bleeding and maintenance of systemic perfusion are important.

A Clinical Consideration of Abdominal Aortic Aneurysm Rupture / 대한혈관외과학회지

PURPOSE: With current advances in surgical technique, the prognosis for elective open repair of abdominal aortic aneurysm (AAA) has improved, but the mortality rate for ruptured AAA remains high. The aim of this study was to define the risk factors of AAA rupture. METHODS: We performed a retrospective analysis of 169 AAA patients who underwent open surgical repair between March 2000 and October 2010. According to the rupture, the patients were divided into 2 groups: 'ruptured' (n=41), 'non-ruptured' (n=128). To define the risk factor of ruptured AAA, we compared following variables between the 2 groups: clinical co-morbidities (hypertension, diabetes mellitus, ischemic heart disease, malignancies), diameter (maximal diameter of AAA), location of rupture, gender, and previous abdominal surgery history. RESULTS: Mean patient-age was 68.4+/-4.4 years (range: 32 to 86 years); the majority of patients were males, 135 (79.8%). Mean diameter of AAA was 6.67+/-2.0 cm (range: 4 to 15 cm); 'non-ruptured': 6.3+/-1.6 cm, 'ruptured': 7.8+/-2.6 cm. The risk of AAA rupture was statistically significantly increased with increased diameter of the AAA (P=0.007). On multivariateanalysis, the only statistically significant risk factor for AAA rupture was diameter of AAA (P=0.004). CONCLUSION: The only significant risk factor for AAA rupture found in this study is the diameter of AAA. To minimize the rupture rate of the AAA patients, we will have to closely monitor the size of AAA diameter.

CO2 Angiography-1 / 대한혈관외과학회지

CO2 was firstly used as an intravenous contrast medium in the early 1950s for diagnosing pericardial effusion. In the 1970s Cho and Hawkins pioneered the intraarterial use of CO2. In 1980, with the appearance of digital subtraction angiography (DSA), excellent imaging of "low density" contrast material was available. CO2 can be used very safely not only in patients with contrast allergies and renal failure, but also in patients undergoing routine angiographic evaluations and many interventional procedures. Nowadays, conventional invasive vascular imaging is being replaced by high-technology imaging modalities, including ultrasound, computed tomography, and magnetic resonance angiography (MRA): however, angiography continues to be the gold common procedure. Gadodiamide has been proposed to replace iodinated contrast material in high-risk patients with contrast allergy and renal insuffieciency. Neither nonionic iodinated contrast medium nor gadolinium-based contrast medium is safe, because these contrast medium may cause allergic reactions or nephrotoxicity. In recent years, its gadolinium-containing contrast agents have been shown to cause nephrogenic systemic fibrosis in patients with end-stage renal disease. Therefore, the use of carbon dioxide as a contrast agent has increased significantly with its wide clinical applications, including the use of carbon dioxide during peripheral vascular stenting and abdominal aortic stent graft placement. Familiarity with the physical properties of carbon dioxide, avoidance of air contamination, catheterization techniques, vascular anatomy, physiologic monitoring, and radiation safety is essential for the safe and effective performance of carbon dioxide angiography. Recently, CO2 has been reported as a "black blood" contrast agent for MRA. Today, carbon dioxide is used worldwide as a contrast agent for numerous vascular and nonvascular procedures in various organs and arterial circulation below the diagram, as well as in the venous circulation. There are over 200 publications proving that CO2 is not nephrotoxic and is without any kind of allergy. For safe and reliable utilization, one must understand the principles of CO2 delivery in the vascular system. A very safe and inexpensive plastic bag delivery system (CO2 Plastic Bag Delivery System(TM), AngioDynamics, Inc., USA) has been used during the over past 20 years. High-resolution DSA 1024x1024 systems with high frame rates have produce images nearly comparable to those with iodinated contrast material.

Effect of Intermittent Pneumatic Compression on the Hemodynamics of Lower Extremity Artery

Better understanding of the hemodynamic role of foot and calf pump not only in enhancing the return of lower-limb venous blood, but in fibrinolysis of thrombus motivated the development of intermittent pneumatic compression (IPC) system for limb venous insufficiency. Additionally, IPC treatment have also been investigated with respect to their effect on distal arterial flow in patients with peripheral arterial disease. Some studies investigated the direct effect of IPC on popliteal artery hemodynamics not only in normal individuals, but also in patients with peripheral arterial insufficiency. There are several mechanisms by which a positive effect on the lower limb tissue perfusion is conferred by the use of IPC. These include emptying of the plantar venous plexus, reduction of the venous leg pressure, increase of the arterio-venous pressure gradients in dependent patients, increase of arterial flow, release of vasodilators (nitric oxide - NO, prostacycline), reductin of local vascular resistance, and transient suspension of the arterio-venous reflex. The use of IPC for the treatment of peripheral arterial disease appears to be promosing and may be used in patients with severe peripheral arterial disease (PAD) who are not candidates for revascularization using percutaneous angioplasty or surgey.

Palma-Dale Operation for Chronic Ilio-femoral Vein Thrombosis

PURPOSE: Deep vein thrombosis is usually managed conservatively or with radiologic intervention. Yet deep vein reconstruction is of value as one of the treatments for a small group of patients who present with significant chronic venous insufficiency due to hypoplastic, absent or occluded deep venous outflow such as occurs because of chronic ilio-femoral vein thrombosis. Therefore, we evaluate the improvement of symptoms and graft patency after a Palma-Dale operation as a treatment modality for chronic ilio-femoral vein thrombosis. METHODS: From January 2001 to August 2008, a retrospective study was performed on 15 patients with chronic ilio-femoral vein thrombosis that was treated with a Palma-Dale operation. RESULTS: The mean age of the patients was 51.1+/-15.9 years. The ratio of males to females was 8 to 7. All the patients had lower limb swelling. A Palma-Dale operation was performed on all the patients. Simultaneous thrombectomy was done for 1 patient and arteriovenous fistulas were used to improve graft patency in four patients. The mean follow-up period was 36.3+/-24.0 months. Postoperatively, there was improvement of symptoms in all the patients. However, there was recurrence of symptoms in three patients after two or three months. The rate of graft patency was 84.1% at one year after surgery. CONCLUSION: The Palma-Dale operation has the possibility of recurrence of deep vein thrombosis and postoperative complications. Yet in patients with significant chronic venous insufficiency due to chronic ilio-femoral vein thrombosis, this type of surgery is obviously of value with respect to improvement of symptoms and an acceptable graft patency rate.

The Anatomical Relationship of the Aortic Bifurcation and the Iliocaval Junction to the Lumbar Vertebrae in a Korean Population

PURPOSE: The objective of this study was to determine the anatomic significance and the level of the abdominal aortic bifurcation and the iliocaval junction in relation to the lumbar spine. METHOD: We conducted a retrospective study of 79 patients who underwent prosthetic replacement of an intervertebral disc by the anterior approach. The location of the aortic bifurcation and iliocaval junction and the size of the aorta and IVC were evaluated using CT angiography. The levels of the aortic bifurcation and iliocaval junction were recorded in relation to the upper or lower half of the adjacent vertebral body or intervertebral disc. RESULT: The aorta was bifurcated at the lower half of the L4 vertebral body in 35.4% of the cases. The iliocaval junction was between L4 and L5, and it was most often at the upper half of L5 (43.0%). CONCLUSION: The variability of the aortic bifurcation and iliocaval junction is high and an accurate description may be useful for using the various retroperitoneal approaches for not only aortic and venacaval surgery, but also for the anterior approach for spinal surgery.

Surgical Treatments for Takayasu's Arteritis

PURPOSE: Takayasu's arteritis (TA) is a chronic inflammatory, stenotic or aneurysmal disease of an unknown etiology. TA occurs worldwide, but it disproportionately affects young females of Asian descent. TA is known to affect a variety of vessels, but the subclavian artery, axillary artery, carotid arteries and infraabdominal aorta are most frequently affected. In this article, we evaluated surgical treatment as a modality for the management for TA. METHOD: We retrospectively reviewed 20 patients with TA and who were operated on from January 1994 to December 2007. RESULT: The ages of patients were ranged from 12 to 56 years. The ratio of males to females was 1 to 19. The main affected vessels were the subclavian artery (n=10), the common carotid artery (n=10), the abdominal aorta (n=4) and the renal artery (n=4). 20 patients with TA were operated on. 17 of them underwent arterioarterial bypass, and 5 patients received angioplasty. There were 8 cases of reoperation due to the effect on other arteries, or due the stenosis or occlusion of the previous bypass graft. Angioplasty and stenting can be used in the treatment of shorter stenoses such as those encountered in the renal arteries. CONCLUSION: Symptomatic patients who have Takayasu's arteritis can be operated on. Our surgical experiences have showed low mortality and the surgical procedures relieved the symptoms. Surgical therapy for Takayasu's arteritis was safe and it showed good results.

Fenestration of the Common Femoral Artery in Patients with Acute Aortic Dissection Combined with Lower Limb Ischemia

Acute aortic dissection is a catastrophic event. Nowadays, the management of aortic dissection can be challenging with performing procedures such as aortic fenestration, stenting and endovascular treatment. While most cases of acute Stanford type A dissection are managed surgically, many cases of acute Stanford type B dissection are treated medically, although open surgery or stent-graft placement is sometimes performed. Patients with Stanford type B dissection may develop vascular complications such as mesenteric or peripheral ischemia, which cannot be managed medically. Fenestration is a procedure for decompressing the hypertensive false lumen by creating a hole in the distal part of the dissection flap and this allows outflow from the false lumen, it relieves branch vessel obstruction, it restores the flow to the ischemic organ and it reduces the risk of extension or rupture of the dissection. Urgent revascularization is required to correct mesenteric and renal ischemia and to restore distal perfusion if there is rest pain and ischemia signs at the lower extremity. We report here on a case of successful surgical fenestration of an acute aortic dissection for relief of lower limb ischemia, and we utilized a transfemoral artery to puncture the obstructed intimal flap.

The Difference of Akt Phosphorylation with Different Strengths of Hemodynamic Forces on the Endothelial Cell

PURPOSE: Mechanical forces including shear stress (SS) and cyclic strain (CS) trigger signal transducing events and modulate gene expression in vascular endothelial cells (ECs). However, differences in intracellular events and gene expression depend on the intensity of the forces, which remain unknown. We attempted to clarify the effect of different strengths of SS and CS by determination of the Akt phosphorylation of ECs. METHOD: ECs were exposed to the arterial level of orbital SS with an orbital shaker (210 rpm) or laminar SS (14 dyne/cm2) with a parallel plate or CS (10%) at a frequency of 60 cycles/min. Akt phosphorylation was assessed by immunocytochemical staining and Western blotting with specific antibodies against the phosphorylated Akt. RESULT: Akt demonstrated a time-dependent stimulation of Akt phosphorylation by mechanical forces with a maximal increase up to 2.5-fold after 30 minutes of orbital SS exposure, 3-fold after 2 minutes of laminar SS exposure and 2.3-fold after 30 minutes of CS exposure. Akt phosphorylation in the periphery of the membrane was significantly increased, compared to at the center of the membrane. It was up to 1.4-fold after 30 minutes of orbital SS and up to 2.4-fold after 30 minutes of CS (P<0.05). CONCLUSION: Our results demonstrate that all types of hemodynamic forces phosphorylated Akt in a time-dependent manner and different types of SS may have different effects on the ECs. In addition, the phosphorylation of Akt is dependent on the intensity of the mechanical forces on ECs.

Overexpression of Estrogen Receptor in Female Patients with Varicose Vein of Lower Extremities

PURPOSE: The high frequency of varicose veins in female suggests the involvement of female sex hormone in pathophysiology of varicose vein. We investigated the presence of estrogen receptor in the wall of normal and varicose veins, and compared their expression between male and female. METHODS: Twenty normal veins were obtained from patient undergoing peripheral artery bypass surgery. Forty varicose segment and non-varicose segment of varicose veins in same patients were obtained from patient during operation. Using immunohistochemistry, we measured estrogen receptor expression rate and compared the estrogen receptor expression of varicose vein with that of normal vein. RESULTS: There is no difference on estrogen receptor expression between normal vein and varicose vein. The positive rate of estrogen receptor expression was higher in varicose segment of varicose vein than in non-varicose segment of varicose vein (P=0.039). In varicose segments in female, estrogen receptor positive rate was higher than non-varicose segment (P=0.022), and than normal vein (P=0.017). The estrogen receptor positive rate of varicose segment in varicose vein was higher in female than male (P=0.008). But there is no statistical significance for the estrogen receptor positive rate of non-varicose segment in varicose vein between male and female. CONCLUSION: The gender difference may be related to hormonal action. Also, these finding suggested the involvement of female sex hormone in varicosity and provides a basis for the finding of causes of primary varicose veins.

Abdominal Aortic Aneurysm in Marfan's Syndrome: Two Cases

Marfan syndrome is an inherited autosomal dominant disorder of the connective tissues, and the afflicted patients present with abnormalities of the skeletal, ocular, and cardiovascular system. The progressive dilatation of the proximal aorta leading to dissection and rupture is the typical feature and this can be a lethal complication of this disease. The incidence of Marfan syndrome is estimated to be 1 in 10,000 in most racial and ethnic groups. We experienced two cases of aortic aneurysm in Marfan syndrome. The first case was 32-year-old woman. She was admitted because of sudden onset of a painful abdominal mass for 2 days. Aortic aneurysm was diagnosed by CT and an echocardiogram showed severe mitral regurgitation (area ratio: 13/15). She underwent successful abdominal aortic aneurysm (AAA) repair and was discharged on postoperative 14th day; she was then prepared for open cardiac surgery for mitral valve replacement. The second case was 19- year-old woman. She was admitted with a known abdominal aortic aneurysm that she'd had for 1.5 years. She also underwent abdominal aortic aneurysm (AAA) repair that was technically successful, but she died on postoperative 10th day due to sudden cardiac arrest.

A Case of Aberrant Right Subclavian Artery with Aneurysmal Change

An aberrant right subclavian artery is the most common arch anomaly, and it occurs in approximately 1.0% of the population. It is caused by obliteration of the right fourth aortic arch during the early embryologic development. Aberrant right subclavian artery originates from a diverticulum; this was originally described by Kommerell. Aneurysms arising in an aberrant subclavian artery are rare, but they constitute a potentially lethal condition that can be treated successfully when this is appropriately identified. The presence of an aneurysm of the artery or Kommerell's diverticulum at its aortic origin is more likely to produce symptoms from the esophageal compression. Virtually all these patients have a superior mediastinal mass that may be asymptomatic, but such patients usually have symptoms of dysphagia, chest pain, or shortness of breath. The presence of an aneurysm of an anomalous subclavian artery is an indication for surgical resection. Resection of the aneurysm may be approached through either a right or left thoracotomy. We present here a case of an aberrant origin of the right subclavian artery together with a review of the literature.

Report of Nation-wide Questionnaire Survey for Abdominal Aortic Aneurysm Treatment in Korea

While endovascular aneurysm repair (EVAR) is prevailing for the treatment of abdominal aortic aneurysm (AAA) in modern vascular practice, PURPOSE: we conducted nationwide questionnaire survey to investigate the current status of AAA treatment and their results in Korea. METHOD: We reviewed the replies from 28 hospitals (33 departments) to the questionnaire inquiring annual number, clinical features, mode of treatment and results of AAA patients during the period from Jan. 2000 to Jul. 2004. Results: 980 AAA patients were reported including 292 ruptured AAA (29.8%) and 688 non-ruptured AAA (70.2%). For treatment of AAA, 834 (85.1%) surgical repairs (SRs) and 111 (11.3%) endovascualr aneurysm repairs (EVARs) were performed while 35 patients (3.6%) died of AAA rupture before operation. The locations of AAA were infrarenal in 889 (90.7%), juxtarenal in 62 (6.3%), and suprarenal in 29 patients (3.0%). Among 834 patients undergoing SR, 577 patients (69.2%) had non-ruptured AAAs and 257 patients (30.8%) had ruptured AAAs. Mean operative mortality rate was 4.1% after elective SRs, 30.7% after SR for ruptured AAAs, and 2.3% after EVARs. The reported brand name of stent graft devices were various including domestic custom-made in 56 (50.5%), imported brand in 18 (16.2%) while 37 (33.3%) stent grafts were not reported their brand name. The frequencies of type I and III endoleaks after EVAR were reported 5.8% and 5.8% respectively in 86 patients with an available data. CONCLUSION: SR has been used as a major treatment option in Korea for the treatment of AAA patients while EVAR is increasing. The mortality rate of SR of AAA was comparable to western multi-center trial reports but mortality or morbidity rates of EVAR were unable to know in this questionnaire survey.

Expression of HER-2/neu in Gastric Adenocarcinoma

PURPOSE: The HER-2 oncogene plays a role in cellular oncogenic transformation, and is related to the aggressive tumor behaviour. Several studies have addressed the prognostic and predictive roles of the HER-2 status in gastric cancer; however, the HER-2 gene has not been used as a therapeutic target, as the opinions relating to its prognostic role are controversial. METHODS: Between January 1994 and December 1997 (1995 group), 192 patients who underwent a curative resection for a gastric adenocarcinoma at St. Mary's Hospital, College of Medicine, The Catholic University of Korea, were retrospectively reviewed from their paraffin embedded tissues and medical records. One hundred and twenty-seven patients, with the same characteristics and operated on between January and December 2002 (2000 group) were compared. The expression of HER-2 was analyzed by means of immunohistochemistry, with regard to the clinicopathological features and survival rate. RESULTS: The average ages of patients in the 1995 and 2000 groups were 56.3 and 59.1 years, respectively. In the 1995 group, 40.1, 26.5, 24.0 and 9.4%, had stage I, II, III and IV diseases, Whereas, in the 2000 group, these figures were 57.5, 18.1, 19.7, and 4.7%, respectively. The expression of HER-2 was positive in 12/192 patients (6.3%) in the 1995 group, and in 7/127 (5.5%) in the 2000 group. There was no relation between the overexpression of HER-2 and the pathological findings. However, the 5-year survival rates of patients with negative and positive HER-2 expression were 91.7 and 75.0%, in stage I and II gastric cancers, respectively. There was a significant difference in the survival rates between the two groups (P=0.010). CONCLUSION: HER-2 overexpression is an early event in gastric cancers, appearing at all stages of the disease, and is related to the poor prognosis of stage I, and II diseases. This fact is thought to be the basis of monoclonal antibody treatment and chemotherapy following a surgical operation for early gastric cancer.

Buerger's Disease in Korea

PURPOSE: Buerger's disease (Thromboangiitis obliterans, TAO) is characterized by non- atheromatous inflammatory disease, and segmental inflammatory thrombotic occlusions of the small & middle-sized arteries and veins of the upper or lower extremities. Any epidemiological study of Buerger's disease in Korea has not been carried out until now. This study was undertaken to investigate the incidence of Buerger's disease in Korea among the patients suffering with arterial disease. METHODS: We collected and analyzed the data on 11,128 patients who were admitted to or visited the participating 22 hospitals for chronic arterial diseases throughout the major region of the South Korea from January 1986 to December 2003. The clinical diagnostic inclusion criteria for Buerger's disease were the followings: (1) a history of smoking or tobacco abuse; (2) an age of onset less than 50 years; (3) infrapopliteal, segmental arterial occlusions with sparing of the proximal vasculature; (4) frequent distal upper extremity arterial involvement (Raynaud's syndrome or digital ulceration) or-superficial phlebitis; and (5) the absence of arteriosclerotic risk factors other than smoking. RESULTS: The incidence rate of Buerger's disease among the arterial disease (11,128 patients) was 93 patients (0.83%) when the strict criteria of Shionoya was applied. 699 male-patients (6.55%) and 30 female patients (4.12%) who met the less strict criteria (the extended clinical diagnostic criteria group) were also reviewed. The 4th and 5th decades were the most common ages with-249 patients (34.2%) and 222 patients (30.5%) respectively, being found at these ages. The mean age was 40.4+/-1.6 years (age range: 16~83 years) and this was similar in both the strict criteria group and the less strict criteria group. CONCLUSIONS: This study suggests there was a low incidence of Buerger's disease in Korea among the patients who visited the participating hospitals when the strict diagnostic criteria were used. The incidence was lower than expected even when the less strict criteria were used. The more accurate incidence of Buerger's disease among the general population can be obtained by performing careful prospective study that is participated in by not only vascular surgeons, but also the other medical specialists with utilizing the strict diagnostic criteria.

Laparoscopic-assisted Aortic Surgery

Since the initial success and widespread acceptance of laparoscopic cholecystectomy (1), the application of this laparoscopic technique to vascular surgery has been somewhat limited. However, after laparoscopic techniques were first applied to vascular surgery in 1993 (2), many technological developments for this procedure have been accepted. Laparoscopy confers three major benefits: better visualization of the aorta, less bowel manipulation, and avoidance of hypothermia. However, advanced total laparoscopic surgery can be difficult and time-consuming, and its benefits are not yet readily apparent. Laparoscopic-assisted aortic surgery enables the surgeon to use a smaller incision and this reduces surgical trauma when compared with the conventional surgical techniques (3). The use of the HandPort device enables the surgeon to use their hands while maintaining the pneumoperitoneum; this allows the vascular surgeon to maintain the sense of touch, and to perform the aortoprosthetic anastomosis safely with use of a MultiTool instrument. Our two case reports illustrate the feasibility of laparoscopic-assisted aortic surgery via minilaparotomy.

Inhibitory Effect of Inducible Nitric Oxide Synthase Gene Transfer on Intimal Hyperplasia and Fibronectin Expression Induced by Carotid Artery Denudation

PURPOSE: Intimal hyperplasia is a pathologic condition that is commonly observed with the atherosclerotic change of blood vessels; this condition is usually observed after arterial operation and interventions such as angioplasty, endaterectomy and bypass grafting, and it remains a major cause for hindering for arterial patency. It is a multiple processes that includes smooth muscle cell migration, proliferation, and expression of extracellular matrix proteins, such as fibronectin. Nitric oxide (NO) has been found to possess many different vasoprotective properties: inhibition of platelet aggregation and adherence, inhibition of leukocyte chemotaxis, inhibition of vascular smooth muscle cell proliferation and migration, inhibition of endothelial cell apoptosis and stimulation of endothelial cell growth. Overexpression of nitric oxide synthase (NOS) in the vascular wall has been used to regulate vasomotor function, prevent neointimal formation after balloon injury or vein grafting, and to prevent transplant vasculopathy. NOS gene transfer to the vascular wall holds great promise as a means of controlling local vascular function. METHOD: We investigated whether the inducible NOS (iNOS) gene transfer to the arterial wall has an inhibitory effect on intimal hyperplasia after endothelial denudation and on the change of the level of extracellular matrix fibronectin expression in the rabbit common carotid artery. Rabbits were divided into three groups: the saline only (without injury) normal group, the injury + saline intima injury group, and the injury + recombinant adenoviral vector encording human iNOS (AdiNOS) gene transfer group (n=5 per group). AdiNOS (1.6x10(10) plaque-forming units [pfu]) were used for the iNOS gene delivery and the virus was intraluminally infected to the balloon-injured common carotid arterial wall for 20 minutes. The NO levels were assessed in the blood of all the animals at the three time point: before-, 1 hr after-, and 14 days after the surgical procedures. The left common carotid arteries were harvested from the animals at 14 days after balloon injury and they were then assessed for fibronectin expression and intimal hyperplasia. RESULT: 14 days after AdiNOS infection, the NO levels were increased 67% in the gene transfer group compared with those levels obtained before the gene transfer (333.5+/-11.5 vs. 557.4+/-72.1, respectively, P<0.05), and the intima/intima+media ratio and the FN expression were reduced by 60% and 50%, respectively, in the gene transfer group compared with the intima injury group (41.5+/-5.6 vs. 16.6+/-2.8, respectively, P<0.05 and 307.9+/-38.3 vs. 154.3+/-20.2, respectively, P<0.05). CONCLUSION: Our results show that iNOS gene transfer to the arterial wall resulted in increased NO levels in the blood, and the procedure greatly inhibited intimal hyperplasia and it reduced fibronectin expression in the arteriaql wall.

Nicardipine Hydrochloride Injectable Phase IV Clinical Trial-Study on the antihypertensive effect and safety of nicardipine for acute aortic dissection / 대한흉부외과학회지

BACKGROUND: We performed a phase IV clinical trial to examine the usefulness of a continuous infusion of nicardipine hydrochloride to control hypertension in patients with acute aortic dissection. MATERIAL AND METHOD: Systolic/diastolic blood pressure, and heart rate were monitored before and after the intravenous administration of nicardipine in 31 patients with aortic diseases. The period of nicardipine administration in each patient was from 3 to 14 days. Efficacy was evaluated by determining the average amount of blood pressure reduction on the 3rd day of drug administration. The dosage of another antihypertensive agent was slowly tapered down, and ultimately replaced by the test drug. RESULT: 28 patients were diagnosed as acute aortic dissection, 2 patients as rupture of the aortic arch aneurysm, and 1 patient as traumatic aortic rupture. Mean age was 53.9 +/- 14.9(29~89) years, and 21 patients(67.7%) were male. 14 patients(32.3%) had complications associated with underlying aortic disease: aortic insufficiency in 7, hemopericardium in 6, acute renal failure in 1, paraplegia in 1, lower extremity ischemia in 1, and hemothorax in 1. The time needed to reach the target blood pressure was within 15 minutes in 16, from 15 to 30 minutes in 10, from 30 to 45 minutes in 3 and from 45 to 60 minutes in 2, and their baseline average systolic, diastolic, and mean arterial blood pressures(mmHg) were 147 +/- 23, 82.3 +/- 18.6, and 104 +/- 18, respectively. Average systolic, diastolic, and mean arterial blood pressures(mmHg) on the third day of nicardipine infusion were 119 +/- 12, 69 +/- 9, and 86 +/- 8, and they all showed statistically significant decrease(p < 0.05). The average systolic, diastolic, and meanarterial blood pressure(mmHg) after the discontinuation of the nicardipine infusion were 119 +/- 15, 71 +/- 14, and 86 +/- 13, respectively. No significant difference was observed between the average pressures measured on the third day and those measured after the discontinuation of the nicardipine infusion, and no definite side effects were observed during the study period. CONCLUSION: Nicardipine hydrochloride was both effective and safe at controlling blood pressure in patients with acute aortic dissection.