The Effect of Severe Femoropopliteal Arterial Calcification on the Treatment Outcome of Femoropopliteal Intervention in Patients with Ischemic Tissue Loss

Purpose@#We investigated the effect of severe calcification of the femoropopliteal artery on intervention outcomes in patients with ischemic tissue loss. @*Materials and Methods@#A retrospective review of the first endovascular treatment of the femoropopliteal artery for ischemic tissue loss between May 2010 and February 2018 was performed. The calcification of femoropopliteal lesions was estimated by the Compliance 360° score, and lesions with a score of 4 were defined as severe calcification lesions. @*Results@#Overall, 135 first femoropopliteal endovascular procedures on 135 limbs from 112 patients were included in this study. Among the 135 limbs that received treatement of the femoropopliteal arteries, 74 limbs had Trans-Atlantic Inter Society Consensus (TASC) A or B lesions and 61 limbs had TASC C or D lesions. Among 61 cases of TASC C or D lesions, 21 limbs (34.4%) had severe calcification; there was no statistically significant difference in limb salvage (P=0.75), and amputationfree survival (P=0.11) based on the degree of calcification. However, the survival rate in TASC C or D lesions was significantly different between the two groups (non-severe calcification group vs severe calcification group at 1-year, 2-years, and 3-years: 88.6%, 79.7%, and 61.0% vs 70.0%, 56.0%, and 28.0%, respectively, P=0.01). In multivariate analysis of influencing factors for poor survival in TASC C or D using the Cox proportional hazards model, severe calcification (hazard ratio, 2.362; 95% confidence interval, 1.035-5.391; P=0.041) was a statistically significant risk factor. @*Conclusion@#Severe femoropopliteal artery calcification was associated with poor survival, especially in TASC C or D lesions.

The Mass Infection of COVID-19 in Daegu City of Korea: Vascular Surgeons’ Perspective

Since February 18, 2020, the number of patients with COVID-19 has increased rapidly after the infection was initially confirmed in Daegu. Daegu city subsequently became the largest epicenter of the coronavirus outside China. In the early days of the outbreak of mass infection, Daegu citizens were in various difficult circumstances. Vascular surgery in Daegu was also affected as much as other medical field. Most of elective schedule were canceled, and the vascular surgeons cooperated to utilize the limited medical resources in Daegu region. Fortunately, the citizens of Daegu city could overcome the first crisis because of matured citizenship, sufficient medical resources and the timely-supplied surplus bed for patient isolation. Now all humanity today is interdependent and we are all one community in the pandemic. To overcome pandemic, it is necessary to respect and share experiences in various places at the beginning of the crisis.

The Mass Infection of COVID-19 in Daegu City of Korea: Vascular Surgeons’ Perspective

Since February 18, 2020, the number of patients with COVID-19 has increased rapidly after the infection was initially confirmed in Daegu. Daegu city subsequently became the largest epicenter of the coronavirus outside China. In the early days of the outbreak of mass infection, Daegu citizens were in various difficult circumstances. Vascular surgery in Daegu was also affected as much as other medical field. Most of elective schedule were canceled, and the vascular surgeons cooperated to utilize the limited medical resources in Daegu region. Fortunately, the citizens of Daegu city could overcome the first crisis because of matured citizenship, sufficient medical resources and the timely-supplied surplus bed for patient isolation. Now all humanity today is interdependent and we are all one community in the pandemic. To overcome pandemic, it is necessary to respect and share experiences in various places at the beginning of the crisis.

Results of Infrainguinal Bypass with a Composite Graft Combining Polytetrafluoroethylene and Vein Graft in Absence of Appropriate Saphenous Vein Graft

PURPOSE: Use of a composite graft combining a polytetrafluoroethylene graft with an autogenous vein is an option for limb salvage in the absence of an adequate single segment vein graft. We aimed to investigate the results of infrainguinal bypass with a composite graft. MATERIALS AND METHODS: We retrospectively reviewed 11 infrainguinal arterial bypasses on 11 limbs which underwent surgery from March 2012 to November 2016. RESULTS: Critical limb ischemia was common (63.6%) indication of bypass surgery and most (90.9%) of the patients had history of failed previous treatment including endovascular treatment (36.4%) and bypass surgery (72.7%). At the 2 years after graft implantations, primary patency and amputation-free survival of below-knee bypasses using composite graft were 73% and 76%, respectively. CONCLUSION: Infrainguinal arterial bypasses with composite graft had an acceptable patency. In patients without other alternative conduits for revascularization, bypass with a composite graft can be an option.

Influencing Factors Affecting Successful Organ Donation and Families' Consent to Donate after Drain Death / 대한이식학회지

BACKGROUND: This study was conducted to identify the factors influencing successful organ donation and families' consent to donate after brain death. METHODS: Medical records and data regarding organ donation counseling with the families of 107 brain-dead potential donors between September 2012 and March 2016 at a single tertiary medical center were retrospectively reviewed. RESULTS: The final consent rate was 57.9% (62/107), and successful donation was performed in 40.2% (43/107) of cases. Univariate and multivariate analyses revealed that the independent factors associated with successful organ donation were age <60 years (odds ratio [OR], 3.384; 95% confidence interval [CI], 1.350 to 8.484; P=0.009), systolic blood pressure ≥90 mmHg (OR, 6.261; 95% CI, 1.418 to 27.653; P=0.015), and serum sodium level ≥150 mEq (OR, 4.215; 95% CI, 1.655 to 10.733; P=0.003). Family's consent to donate was significantly associated with head trauma (OR, 3.538; 95% CI, 1.104 to 11.334; P=0.033) and serum sodium level ≥150 mEq (OR, 3.392; 95% CI, 1.404 to 8.194; P=0.007). CONCLUSIONS: Successful organ donation was associated with patient age, systolic blood pressure and serum sodium level. Family's consent to donate was associated with head trauma and serum sodium level.

Thrombolytic Therapy Using Urokinase for Management of Central Venous Catheter Thrombosis

PURPOSE: The management of central venous catheters (CVCs) and catheter thrombosis vary among centers, and the efficacy of the methods of management of catheter thrombosis in CVCs is rarely reported. We investigated the efficacy of bedside thrombolysis with urokinase for the management of catheter thrombosis. MATERIALS AND METHODS: We retrospectively reviewed data from patients who had undergone CVC insertion by a single surgeon in a single center between April 2012 and June 2014. We used a protocol for the management of CVCs and when catheter thrombosis was confirmed, 5,000 U urokinase was infused into the catheter. RESULTS: A total of 137 CVCs were inserted in 126 patients. The most common catheter-related complication was thrombosis (12, 8.8%) followed by infection (8, 5.8%). Nine of the 12 patients (75%) with catheter thrombosis were recanalized successfully with urokinase. The rate of CVC recanalization was higher in the peripherally inserted central catheter (PICC) group (87.5%) than the chemoport group (50%). Reintervention for catheter-related thrombosis was needed in only 2.2% of patients when thrombolytic therapy using urokinase was applied. Age <60 years (P=0.035), PICC group (P=0.037) and location of the catheter tip above the superior vena cava (P=0.044) were confirmed as independent risk factors for catheter thrombosis. CONCLUSION: Thrombolysis therapy using urokinase could successfully manage CVC thrombosis. Reintervention was rarely needed when a protocol using urokinase was applied for the management of CVC thromboses.

Upper Extremity Replantation for Patients with Major Amputation Injury: Follow-up Results of 11 Patients / 대한혈관외과학회지

PURPOSE: To report follow-up data on upper extremity (UE) macroreplantation in patients with traumatic amputation injuries. METHODS: Between 1996 and 2003, 11 patients underwent UE macroreplantation at a single institution. All patients had an open fracture (n=9; upper arm, 5; forearm, 4) or an open dislocation of the elbow (n=2), combined with neurovascular and soft tissue transection injuries. The replantation procedures were performed on an emergency basis by a multi-departmental team. The mean warm ischemic time was 328 minutes (range, 165 to 480 minutes). Functional recovery of the replanted UE was evaluated with Chen's classification system, and patient satisfaction was determined using Russell's questionnaire; periodic examinations were conducted over a minimum follow-up period of 2 years. RESULTS: Early complications consisted of 2 arterial thromboses, 1 soft tissue infection resulting in sepsis, and 1 episode of acute renal failure; UE reamputation was required in 2 patients. As a result, limb salvage was achieved in 82% of patients (9/11). A functional extremity, defined as grades I and II using Chen's criteria, was preserved in 33.3% of patients with successfully replanted limbs. Despite the objectively poor rate of function preservation, 89% of patients who had successful replantation procedures were satisfied with the results. CONCLUSION: Even though the functional recovery rate was low, UE macroreplantation resulted in acceptable limb salvage rates and good patient satisfaction.

Clinical Experience of Symptomatic Spontaneous Isolated Splanchnic Artery Dissection / 대한혈관외과학회지

PURPOSE: Symptomatic spontaneous isolated splanchnic artery dissection (SSISAD) is a rare disease entity. The treatment guideline for SSISAD has not been established. Isolated dissection of splanchnic artery can be clinically asymptomatic or symptomatic. Symptomatic dissection is more important because it can indicate ischemia of abdominal organ. METHODS: A retrospective study was conducted on 15 consecutive patients (mean age, 47.0 years; male, 87%) with SSISAD from January 2006 to July 2013. Each patient had acute onset abdominal pain and was diagnosed with SSISAD by abdominal-pelvic computed tomography. RESULTS: Median follow-up duration was 14.5+/-27.7 months (range, 1 to 79 months). Splanchnic arterial dissection involved celiac artery in three patients and superior mesentery artery in 12 patients. Conservative management (including bowel rest, hypertension medication, anticoagulation, and prophylactic antibiotics) was done in 14 patients. Endovascular treatment with stent insertion was performed in one patient. We experienced favorable clinical outcomes with SSISAD, even though one case needed endovascular treatment. CONCLUSION: Conservative management and selective revascularization could be a treatment option in patients with SSISAD.

Renal and abdominal visceral complications after open aortic surgery requiring supra-renal aortic cross clamping / 대한외과학회지

PURPOSE: The aim of this study was to assess renal or abdominal visceral complications after open aortic surgery (OAS) requiring supra-renal aortic cross clamping (SRACC). METHODS: We retrospectively reviewed the medical records of 66 patients who underwent SRACC. Among them, 17 followed supra-celiac aortic cross clamping (SCACC) procedure, 42 supra-renal, and 7 inter-renal aorta. Postoperative renal, hepatic or pancreatic complications were investigated by reviewing levels of serum creatinine and hepatic and pancreatic enzymes. Preoperative clinical and operative variables were analyzed to determine risk factors for postoperative renal insufficiency (PORI). RESULTS: Indications for SRACC were 25 juxta-renal aortic occlusion and 41 aortic aneurysms (24 juxta-renal, 12 supra-renal and 5 type IV thoraco-abdominal). The mean duration of renal ischemic time (RIT) was 30.1 +/- 22.2 minutes (range, 3 to 120 minutes). PORI developed in 21% of patients, including four patients requiring hemodialysis (HD). However, chronic HD was required for only one patient (1.5%) who had preoperative renal insufficiency. RIT > or = 25 minutes and SCACC were significant risk factors for PORI development by univariate analysis, but not by multivariate analysis. Serum pancreatic and hepatic enzyme was elevated in 41% and 53% of the 17 patients who underwent SCACC, respectively. CONCLUSION: Though postoperative renal or abdominal visceral complications developed often after SRACC, we found that most of those complications resolved spontaneously unless there was preexisting renal disease or the aortic clamping time was exceptionally long.

A hybrid operation in a patient with complex right subclavian artery aneurysm / 대한외과학회지

We report a hybrid surgery including endovascular aneurysm repair and debranching procedures to treat a patient with a complex right subclavian artery aneurysm. The patient was a 70-year-old woman who presented with dry cough and hoarseness. The aneurysm was characterized by the absence of a proximal neck, and involvement of the origin of the right vertebral artery. She underwent carotid-vertebral artery bypass, stent graft from the innomiate artery to the common carotid artery and carotid-axillary artery bypass. Great saphenous vein was used for the carotid-vertebral artery bypass and 7 mm reinforced polytetrafluoroethylene graft was used for the carotid-axillary artery bypass. The postoperative course was uneventful.

Risk factors for delayed recanalization of calf vein thrombosis / 대한외과학회지

PURPOSE: To determine the risk factors of delayed recanalization of isolated calf vein thrombosis (CVT). METHODS: One hundred fifty limbs of 110 patients with CVT between September 2007 and April 2010 were enrolled. We used ultrasonography for the diagnosis and follow-up examinations of CVT. We calculated recanalization rates at 1 and 3 months after initial diagnosis and analyzed the risk factors associated with delayed recanalization of CVT. RESULTS: CVTs were located in the muscular calf vein in 110 (73.3%), in the deep calf vein in 18 (12%), and in both in 22 cases (14.7%). Among all CVTs, 94 limbs (63%) were symptomatic. Major risk factors for CVT were orthopedic surgery (87.3%), malignancy (21.3%), and immobilization (15.3%). Sixty-seven patients (60.9%) were treated with oral anticoagulation therapy, while 43 patients by low molecular weight heparin (n = 19) or by conservative methods including elastic compression stockings and ambulation (n = 21). The cumulative recanalization rate at 1 and 3 months was 23% and 82% and it was significantly higher in patients who underwent oral anticoagulation therapy compared with patients without oral anticoagulation therapy (84% vs. 65%, P = 0.008 by log-rank test). Malignancy (odds ratio [OR], 2.789; P = 0.043) and immobilization (OR, 4.191; P = 0.029) were independent risk factors for delayed recanalization of CVT and oral anticoagulation (OR, 0.300; P = 0.020) was an independent factor in promoting recanalization in multivariate analysis. CONCLUSION: For patients with isolated CVT, no oral anticoagulation resulted in higher rates of delayed recanalization compared to oral anticoagulation treatment. Immobilization and having malignancy were independent risk factors for delayed recanalization.

Prevalence of Asymptomatic Carotid Stenosis in Korea Based on Health Screening Population

We attempted to investigate the prevalence and risk factors of carotid artery stenosis in Korea. Twenty thousand seven hundred twelve individuals who underwent carotid artery ultrasonography for health screening between March 2005 and March 2010 were retrospectively evaluated. The population was divided into four groups, according to the degree of stenosis, as Group A, below 29%; Group B, 30% to 49%; Group C, 50% to 74%; Group D, above 75%. The medical records of the individuals were investigated, and Fisher's exact test, chi-square tests, Kruskal-Wallis tests and a binary logistic regression model were used for statistical analysis. The prevalence of carotid stenosis was Group B, 5.5%; Group C, 0.9%; Group D, 0.1%. Old age, male gender, hypertension, diabetes mellitus and ischemic heart disease were significantly higher in Groups C and D (P = 0.001, 0.001, 0.001, 0.048, and 0.001, respectively). Among the males aged over 65 yr, the prevalence of carotid stenosis > or = 50% and > or = 30% were 4.0% and 18.2%, respectively. Asymptomatic carotid stenosis is not uncommon in Korea. Carotid ultrasonography is necessary for people with above-listed risk factors.

Comparative Results of Combined Coronary Artery Bypass Grafting and Carotid Endarterectomy versus Staged Operation

PURPOSE: Between combined and staged operations of carotid endarterectomy (CEA) and coronary artery bypass grafting (CABG) for patients with concurrent coronary and carotid disease, each treatment strategy has its own advantages and disadvantages. We attempted to compare early surgical results between the two operations. METHODS: We retrospectively reviewed medical records of 71 patients who underwent either combined CEA & CABG (n=37) or staged CABG & CEA (n=34) in a single institute between January 2001 and March 2010. After comparing patients' demographics and preoperative neurologic and cardiac status, we compared early (<1 month) postoperative cardiac or neurologic complications and surgical mortality between the 2 groups. RESULTS: There was no significant difference in patients' demographics and indications for operation the between 2 groups. There were 2 (5.4%) cases of postoperative stroke in combined groups and 1 (2.9%) in staged group. However, there was no myocardial infarction or death. In staged operation group, during the interval time between the two operations, 5 cases (14.7%) of stroke developed, of which, all patients recovered without any sequelae by anticoagulation. CONCLUSION: After experiencing low postoperative cardiac or neurologic morbidity or mortality after combined CABG and CEA, we conclude that combined CABG and CEA was a safe and feasible treatment option for patients with neurologic symptoms and in stable cardiac status. In the staged operation group of patients, we observed development of neurologic events during the interval period between CABG and CEA. To attain optimal treatment strategy in asymptomatic patients, further prospective study would be required.

Indications and Short-term Results of Open Surgical Repair of Abdominal Aortic Aneurysm in an Endovascular Era

PURPOSE: To assess the role of OR in treatment of AAA patients, we reviewed the indications and our current results of OR of AAA. METHODS: We retrospectively investigated the database of 366 patients (mean age, 68.3+/-8.7 years, male 86%) who underwent open surgical (n=291, 80%) or endovascular treatments (n=75, 20%) of AAA in a tertiary referral center between Sep. 2003 to Aug. 2010. Treatment-related morbidities and mortality rates within 30 days were investigated according to the indications for treatment, clinical features, anatomic location, and underlying causes of AAA. RESULTS: According to the location of AAA, we treated 343 (94%) infrarenal, 17 (5%) juxtarenal and 6 (2%) suprarenal AAAs. Underlying causes of AAA were degenerative (90%), infected (3%), inflammatory (3%), Marfan's syndrome (2%), and vasculitis (0.5%). Clinically, 338 (92%) were non-ruptured and 28 (8%) were ruptured AAAs. 75% of patients were treated with OR after the inception of reimbursement of aortic device while 25% of patients were treated with EVARs. The operative mortality rates of OR was 0.4% in patients with non-ruptured infrarenal AAA, 0% in patients with non-ruptured juxta- and suprarenal AAA and 21.4% in ruptured AAA patients. CONCLUSION: In an era of endovascular treatment of AAA, we have experienced excellent surgical results after OR in patients with non-ruptured AAA with various clinical features. Though EVAR is rapidly replacing OR in treatment of infrarenal AAAs, OR has its own role in treatment of AAA patients with unfavorable conditions for EVAR. The role of OR should not be underestimated.

The Prevalence of Abdominal Cystic Lesion in Patients with Vascular Disease

PURPOSE: This study evaluated the prevalence of cystic disease in the intra-abdominal organs in a normal population and a group of patients with vascular disease. METHODS: We reviewed the medical records and computed tomography scans of the vascular disease group and the control group. Vascular disease group (n=586) were patients who suffered with abdominal aortic aneurysm (AAA), aorto-iliac occlusive disease (AOD) and peripheral arterial occlusive disease (PAOD) and who were treated in our institute. The control group (n=424) were patients who visited the health promotion center in our institute during the same period. RESULTS: The prevalence of abdominal cysts in the control group and the vascular disease group was 41.7% and 65.2%, respectively. The vascular disease group showed a higher prevalence of abdominal cystic lesion for all the specific vascular diseases. However, when the two groups were stratified according to age, the vascular disease group displayed no significant difference in the prevalence of abdominal cyst compared to that of the control group. CONCLUSION: Abdominal cystic lesions are common in patients with vascular disease, including AAA, AOD, and PAOD. But this high prevalence of abdominal cystic lesions seems to be associated with the advanced age of vascular disease patients. Further molecular-based research is needed to clarify the pathogenetic relationship between vascular disease and abdominal cystic lesions.

Analysis of Anatomy and Hemodynamics of Carotid and Vertebral Artery in a Healthy Korean Population

PURPOSE: The duplex scan is recommended for initial assessment of carotid artery disease as a non-invasive diagnostic method. However, the guidelines for diagnosis of carotid stenosis are based on Western guidelines. Therefore, we studied the anatomy and hemodynamics of the carotid and vertebral arteries in a healthy Korean population. METHODS: The study was performed with 421 healthy adults, aged 20 to 69 years (219 men, 202 women; mean age of all patients, 44.32+/-14.33 years). The flow velocities and luminal diameters of the common, external and internal carotid arteries and the vertebral arteries were examined using a duplex scan. RESULTS: The luminal diameters of the carotid and vertebral arteries increased significantly with increased age, height and weight and were significantly larger in men than in women. The flow velocities of the carotid and vertebral arteries decreased significantly with increased age. The flow velocities of carotid arteries were significantly faster in men than in women. The flow velocities of the carotid and vertebral arteries varied according to height and weight. CONCLUSION: Our results from a healthy Korean population might be used as reference values for diagnosis of carotid and vertebral arterial disease in Koreans.

The Indications and Outcomes of Major Venous Reconstructions

PURPOSE: We wanted to review our indications and the results of venous reconstructions. METHOD: We retrospectively investigated the medical records of 64 patients who underwent vein reconstructions between Jan 1992 and Oct 2006 at 2 university hospitals. The clinical outcomes of venous reconstruction were analyzed according to the sites of venous reconstruction, the indications and the venous patency. RESULT: The indications for venous reconstructions were traumatic vein injury (58%), malignant tumor (28%), Nut-cracker syndrome (9%) and others (5%). The venous reconstruction procedure included graft interposition (48%, 24 vein grafts and 7 prosthetic grafts), lateral venorrhaphy (19%), end-to-end anastomosis (16%), patch angioplasty (6%), vein transposition (9%) and 1 case (2%) of vein bypass. 10 forearm replantations were included among the venous reconstructions. There were 4 mortalities and 4 limb amputations after venous reconstructions. According to the method of venous reconstructions, early venous thrombosis occurred in 3.6%, 7.1% and 37.5% of the patients after venorrhaphy, reconstruction with autologous vein and prosthetic graft, respectively. CONCLUSION: After venous reconstructions for various indications, we found that the clinical significance was related with an early venous patency, but not with the late patency.

The Indications and Outcomes of Major Venous Reconstructions

PURPOSE: We wanted to review our indications and the results of venous reconstructions. METHOD: We retrospectively investigated the medical records of 64 patients who underwent vein reconstructions between Jan 1992 and Oct 2006 at 2 university hospitals. The clinical outcomes of venous reconstruction were analyzed according to the sites of venous reconstruction, the indications and the venous patency. RESULT: The indications for venous reconstructions were traumatic vein injury (58%), malignant tumor (28%), Nut-cracker syndrome (9%) and others (5%). The venous reconstruction procedure included graft interposition (48%, 24 vein grafts and 7 prosthetic grafts), lateral venorrhaphy (19%), end-to-end anastomosis (16%), patch angioplasty (6%), vein transposition (9%) and 1 case (2%) of vein bypass. 10 forearm replantations were included among the venous reconstructions. There were 4 mortalities and 4 limb amputations after venous reconstructions. According to the method of venous reconstructions, early venous thrombosis occurred in 3.6%, 7.1% and 37.5% of the patients after venorrhaphy, reconstruction with autologous vein and prosthetic graft, respectively. CONCLUSION: After venous reconstructions for various indications, we found that the clinical significance was related with an early venous patency, but not with the late patency.

Management of a Bleeding Pseudoaneurysm after Pancreaticoduodenectomy: 27 cases experience in single-center

PURPOSE: Delayed massive hemorrhages from pseudoaneurysm rupture of the peripancreatic large arteries, after pancreaticoduodenectomy, are fatal. We reviewed the clinical course and outcome of bleeding pseudoaneurysms after pancreaticoduodenectomy. METHOD: The medical records of 905 consecutive patients who underwent pancreaticoduodenectomies between October 1994 and February 2007 were reviewed retrospectively. In 27 cases with hemorrhagic complications, pseudoaneurysms were diagnosed as the main cause of bleeding. The clinical characteristics, course, management, and outcomes were reviewed. RESULT: In 27 cases (3.0%) of the 905, the bleeding pseudoaneurysms were diagnosed by angiography, during surgery or clinically. In 11 cases, the hemorrhage was from the pseudoaneurysm on the ligated gastroduodenal artery-stump, in five it was from the right hepatic artery, in four from the proper hepatic artery or common hepatic artery, and two from the right gastric artery. Twelve cases had pancreatic leakage. Sentinel bleedings were observed in 21 cases, there were 11 cases of bleeding from the surgical drains, eight cases from the GI tract, and in two cases from both. In 23 cases, arterial embolization was attempted and 18 cases were successful. Four cases had secondary pseudoaneurysmal bleeding. After embolization at the common or proper hepatic artery, six cases had liver abscess or infarction and there was one case of hepatic failure. CONCLUSION: Delayed massive hemorrhage after pancreaticoduodenectomy should be ruled out to determine whether it is associated with an arterial pseudoaneurysm rupture. Transcatheter arterial embolization is an effective modality for control of the bleeding from an arterial pseudoaneurysm.