Prognosis of arterial aneurysm after surgery in patients with Behçet's disease.

AIM: Despite improvements in therapeutic modalities, the treatment of arterial aneurysms complicating Behçet's disease (BD) is still challenging. This study examined the long-term prognosis after surgery for arterial aneurysms in BD. METHODS: This study included 9 patients with BD (8 men and 1 woman) who underwent surgery for arterial aneurysms between 1989 and 2008. The outcomes after the surgical intervention were assessed, including procedure-related complications and survival. RESULTS: The initial surgical procedures were performed for aortic or iliac aneurysms in 5 patients and for lower-extremity aneurysms in 4 patients. There was no operative mortality. The mean follow-up period was 135±69 months, ranging from 53 to 259 months. Patients with aortic or iliac aneurysms underwent graft interposition with Dacron prostheses. Their postoperative courses were uneventful, and all patients were alive during the follow-up with no procedure-related complications. Those treated for lower-extremity aneurysms tended to show perioperative and postoperative complications, including aneurysmal degeneration of the autogenous vein graft in 2 patients. One patient who initially underwent surgery for a popliteal artery aneurysm died due to the rupture of a dissecting aortic aneurysm after serial surgical interventions for multiple aneurysms. Concomitant aortic or iliac aneurysms in 2 patients were followed up without any change in size under medical treatment using colchicine and corticosteroids. CONCLUSION: Although we cannot draw a firm conclusion because of the small number of cases in the present series, graft interposition can lead to a favorable prognosis in BD patients with aortic or iliac aneurysms, whereas surgical treatment of BD-related lower-extremity aneurysms is frequently associated with short- and long-term postoperative complications. Immunosuppressive therapy might possibly improve treatment outcomes.

Fate of the asymptomatic contralateral limb after initial intervention for ipsilateral critical limb ischemia.

AIM: In Trans-Atlantic Inter-Society Concensus (TASC) II, patients at risk for critical limb ischemia (CLI) without symptoms are termed "chronic subclinical ische mia," but research are still lacking. The objective was to find out whether clinically asymptomatic contralateral limbs at the time of treatment for ipsilateral CLI could be regarded as "chronic subclinical ischemia". METHODS: Ninety-six patients with CLI who had no symptoms in the contralateral limb were retrospectively reviewed. The symptoms of the contralateral limb after initial intervention for the ipsilateral limb were surveyed. Risk factors for developing CLI and tissue loss were then analyzed. RESULTS: Five patients (5.2%) became claudicants, 37 patients (38.5%) had symptoms of CLI, and 14 (14.6%) experienced tissue loss during the follow-up period. The overall CLI-free rates at 12, 36, and 60 months were 79.2%, 55.2%, and 45.8%, respectively, while the tissue loss-free rates at 12, 36, and 60 months were 91.3%, 78.8%, and 78.8%, respectively. Risk factor for developing CLI on the contralateral limb was having skin perfusion pressure (SPP) <40 mmHg at the surgery for ipsilateral limb. The presence of SPP <40 mmHg and end stage renal failure with hemodialysis resulted in a significantly high probability of tissue loss. CONCLUSION: Patients with CLI with an asymptomatic contralateral limb with an SPP value <40 mmHg are at a high risk of developing CLI and tissue loss during the follow-up period. Information on the contralateral limb at initial surgery may help to speculate the fate of the asymptomatic contralateral limb.

Ibudilast, a phosphodiesterase inhibitor, in combination with low-dose aspirin potently inhibits guinea pig carotid artery thrombosis without extending bleeding time and causing gastric mucosal injury.

A combination of low-dose aspirin (ASA) and a phosphodiesterase inhibitor has been clinically tried for the secondary prevention of atherothrombotic diseases. The in vivo antithrombotic property of ibudilast (CAS 50847-11-5), a phosphodiesterase 4 (PDE4) inhibitor, was evaluated in a photochemically-induced guinea pig carotid artery thrombosis model in combination with low-dose ASA. The time required to decrease the carotid artery blood flow to the reading "zero" was defined as the time to occlusion (TTO) of the artery through thrombogenesis. Each independent use of ASA (300 mg/kg, p.o.) and ibudilast (3 and 10 mg/kg, p.o.) significantly prolonged the TTO, and ASA (300 mg/kg) significantly increased bleeding time (BT) and gastric mucosal injury. A selective PDE4 inhibitor rolipram (1 and 5 mg/kg, p.o.) tended to prolong the TTO without extending BT. ASA (100 mg/kg) plus ibudilast (3 mg/kg) and ASA (100 mg/kg) plus rolipram (5 mg/kg) markedly prolonged the TTO compared with each agent alone. Interestingly, ASA (100 mg/kg) plus ibudilast (3 mg/kg) caused a longer TTO than ASA (300 mg/kg) alone, without significant extension of BT and gastric mucosal injury as observed in ASA (300 mg/kg). These results indicate that the combination of low-dose ASA and ibudilast has a more potent antithrombotic effect than ASA alone without increasing bleeding tendency and gastric mucosal injury. The potent in vivo antithrombotic effect of this combination may be brought about by an action that is associated with PDE4 inhibition of ibudilast.

Outcomes after open surgery and endovascular aneurysm repair for abdominal aortic aneurysm in patients with massive neck atheroma.

OBJECTIVE: We retrospectively analysed surgically treated abdominal aortic aneurysm (AAA) in patients with massive atheroma in the aneurysmal neck and compared the outcomes of endovascular aneurysm repair (EVAR) and open surgery (OS) to determine an appropriate strategy for massive neck atheroma cases. METHODS: A retrospective study was performed in 326 consecutive patients who underwent EVAR and in 247 patients who underwent OS. We defined massive neck atheromas if the following characteristics were observed: (1) thickness ≥ 5 mm; (2) the circumference of the infrarenal aorta ≥ 75%; and (3) length ≥ 5 mm. Twenty-eight patients (8.5%) in the EVAR group and 22 (8.9%) in the OS group met these criteria. We modified the previously published reporting standards on the basis of the selection of systemic and embolisation-related complications. RESULTS: Patients in the EVAR group had less intra-operative blood loss, shorter operation time, and shorter hospital stays after the operation (P < 0.01). No perioperative deaths were observed in either group. Major complications were categorised as early (in-hospital) or late (outpatient, within 6 months). Five and three patients in the OS and EVAR groups had early complications, but the difference was not statistically significant. In contrast, 7 patients in the EVAR group had late complications, compared to no patients in the OS group (P = 0.01). Kaplan-Meier analysis revealed a significantly higher survival rate in the OS group (P = 0.011). Two of the 4 patients with suprarenal clamping developed major complications. Mild eosinophilia was observed in 10 patients in the EVAR group. Proteinuria occurred or worsened in 5 EVAR patients and 1 OS patient. CONCLUSION: Compared to OS patients, EVAR patients with massive neck atheroma tend to develop late-phase complications possibly related to cholesterol crystal embolisation. The clinical features of massive neck atheroma patients receiving EVAR should be carefully monitored even after hospital discharge.

Middle-term results of endovascular aneurysm repair in Japan: does intraoperative endovascular management against the hostile aneurysmal neck prevent the proximal type I endoleak?

AIM: Endovascular aneurysm repair (EVAR) was first approved in Japan in 2007. In order to avoid the learning curve generally seen in the initial stages of implementation, we have aimed for procedural perfection. As the proximal type I endoleak (EL) is associated with a higher risk of late conversion and rupture, so we have treated the intraoperative type I EL scrupulously. The hostile neck, which is known to be a risk for perigraft leakage, is the focus of this study. We showed both the middle-term results of EVAR in our country and the possible necessity of intraoperative management for the hostile neck. METHODS: From a consecutive series of 134 patients who underwent EVAR of abdominal aortic aneurysms, 129 cases in which contrast agent was used intraoperatively were selected. All cases had at least 12-month follow-up postoperatively (12-40 months). Of the 129 selected cases, 49 cases (37%) that did not fulfill the commercially recommended criteria of the aneurysmal neck (length <15 mm and angle >60° of the aneurysm or >45° of the suprarenal aorta) were assigned to the off-label group. The other 80 cases were assigned to the on-label group. We carefully observed the completion angiography and when we found or suspected a type I EL, we performed a re-touch up, changed to a non-compliant balloon, and used a supportive device, such as a PalmazTM stent or aortic cuffs, in sequence. RESULTS: No postoperative type I ELs were detected within the follow-up period. Intraoperative type I ELs were detected more frequently in the off-label group (51%) than the on-label group (20%) (P<0.01). The rate of type I EL in the off-label group in terms of the neck length criteria (11/14 cases) was higher than that in the on-label group (30/115 cases) (P<0.01). In terms of the neck angle, patients in the off-label group had a greater tendency to develop the type I EL than those in the on-label group (18/42 vs. 23/87 cases) (P=0.06). CONCLUSION: Off-label usage regarding aneurysmal neck length and angle tends to be incomplete without additional procedures. Conversely, various techniques, including non-compliant balloon usage and aortic stenting or cuffs, produce good results for the intraoperative type I EL. We found a relationship between the neck condition and the intraoperative type I EL, and showed the importance of strictly obeying our simple algorithm against the proximal type I EL.

Surgical treatment of patients with congenital vascular malformation-associated aneurysms.

OBJECTIVES: Aneurysms associated with congenital vascular malformation (CVM) comprise critical complication. We review our experience with extracranial CVM-associated aneurysms and attempt to clarify their clinical features. PATIENTS AND METHODS: The prevalence, site, size and morphology of the accompanying aneurysms of 48 consecutive CVM patients, who were managed at our hospital from 1999 to 2008, were evaluated. After diagnosis or treatment, the patients were followed up, and the recurrence of aneurysms and patient survival were assessed. RESULTS: CVM-associated aneurysms were found in 14 patients (29%). CVMs were classified according to the Hamburg classification. The patients were classified into groups as follows: four (31%), in the 'predominantly arteriovenous (AV) shunting defect type'; eight (47%), 'combined vascular defects + predominantly AV shunting defects type'; and two (11%), 'combined vascular defects type'. All aneurysms except one situated at the CVM were saccular, whereas nine were fusiform aneurysms; all the ruptured aneurysms and seven out of the nine enlarging aneurysms were saccular. Surgical treatment was performed 8 times in six patients. During the postoperative follow-up period, recurrence and an aneurysm rupture were encountered in one patient each. CONCLUSION: Aneurysm is not a rare complication of CVM. It is important to treat CVM before the emergency presents. In addition to the treatment for malformation, regular screening for and proper management of the aneurysms in CVM patients are indispensable.

A retrospective study of intravascular ultrasound use in patients undergoing endovascular aneurysm repair: its usefulness and a description of the procedure.

OBJECTIVES: To verify the usefulness and limitation of intravascular ultrasound (IVUS) in endovascular aneurysm repair (EVAR). METHODS: A total of 112 consecutive patients, who underwent EVAR to treat abdominal aortic aneurysms, were examined retrospectively. Of these, 33 patients were assigned to the IVUS group because of renal failure, a suspected allergy to contrast agents or anatomical difficulties; the remaining 79 patients were assigned to the non-IVUS group. RESULTS: Patients in the IVUS group required fewer intra-arterial contrast agents (IACAs) than those in the non-IVUS group (67±34ml vs. 123±50ml; p<0.01). Blood loss and operation time were comparable between the two groups. No patients died within 30 days of the operation. Three major renal complications occurred in the non-IVUS group. Renal deterioration evaluated by chronic kidney disease (CKD) stage was found to a greater extent in the non-IVUS group. CONCLUSIONS: IVUS is a powerful auxiliary method in EVAR for reducing the required volume of contrast agents. The combination of IVUS and IACA usage showed good overall performance; thus, we propose the routine use of IVUS in EVAR procedures.

Current status of the medical expenses for the treatment of arteriosclerosis obliterans in Japan.

AIM: We aimed to determine the current status of the medical expenses for the treatment of arteriosclerosis obliterans (ASO) and evaluate the cost effectiveness of the medical practices employed in ASO treatment in Japan. METHODS: We performed a prospective observational study using 140 ASO patients. The cost of the medical practices comprised the costs of outpatient treatment, pharmacological agents, and hospitalization. To compare the average monthly costs, the patients were divided into preintervention, postintervention, or conservative-therapy groups. To compare the total costs and effectiveness of each treatment, the patients who had first visited our division during the study period were classified into surgery, endovascular-revascularization (EVR), or conservative-therapy groups. The adverse reactions of the 4 most popular agents for ASO were investigated, and bleeding events were assessed specifically. RESULTS: The average monthly costs for outpatient treatment and pharmacological agents were yen 168,002 in conservative cases, yen 149,871 in preoperation cases, and yen 128,527 in postoperation cases. The mean total costs were yen 5,407,950 in conservative cases, yen 7,375,290 in surgical cases, and yen 2,631,650 in EVR cases. The average change of the gauge in clinical status was 0.57 in conservative cases, 2.13 in surgical cases, and 2.25 in EVR cases. Warfarin induced more bleeding complications than the other agents. CONCLUSION: The costs of pharmacological agents represented much of the medical costs in any treatment groups.

Hemodynamic influence of peripheral vascular occlusive disease on abdominal aortic aneurysms.

AIM: Clinical evidence indicates that hemodynamic conditions such as peripheral vascular occlusive disease (PVOD) influence abdominal aortic aneurysm (AAA) disease. METHODS: We retrospectively analyzed 406 operated cases of AAA at our institute over the last 15 years, and compared 39 patients with PVOD to those without, to examine hemodynamic effects and risk factors. Aneurysm size at operation, rupture, shape, expansion rate and several preoperative risk factors were compared. RESULTS: Mean aortic diameter in the AAA with PVOD patients (56.8+/-17.8 mm) showed no significant difference to that in the AAA without PVOD group (60.4+/-14.8 mm). However, the subgroup of AAA with PVOD in whom the aneurysm was found prior to PVOD diagnosis (67.8+/-18.1 mm) (n=19) showed a larger mean AAA diameter compared to the AAA (not followed up until operative indication/prior to operation) without PVOD group (60.4+/-14.8 mm), (n=340), (p=0.04). Smoking was the only preoperative risk factor to show a difference between AAA patients with and without PVOD. The aneurysm expansion rate was determined retrospectively in 13 patients with PVOD who had been followed for at least 1 year by CT scan and 17 patients without PVOD. The rate in the PVOD group was 8.1 mm/year, which was significantly faster than that in PVOD-free patients (4.6 mm/year), (p=0.03). CONCLUSIONS: The findings of a large diameter and fast expansion rate in AAA patients with concomitant PVOD suggest that the hemodynamic effects of PVOD have a great influence on AAA development.

Selective isolation of eae-positive strains of shiga toxin-producing Escherichia coli.

Culture on cefixime, tellurite, and sorbitol-MacConkey agar after HCl treatment facilitated the growth of 410 (94%) of 436 eae-positive Shiga toxin-producing Escherichia coli (STEC) strains and 17 (16%) of 107 eae-negative STEC strains. This selectivity was closely related to acid resistance in E. coli and tellurite resistance in eae-positive STEC strains.

[Ineffective and recurrent cases of thoracoscopic sympathectomy for hyperhidrosis and intractable pain].

We reported the cases of thoracoscopic sympathectomy, that is, six cases of hyperhidrosis, three of post herpetic neuralgia, and four of reflex sympathetic dystrophy, including recurrent or incompletely resected or ineffective ones. Recently this procedure for hyperhidrosis had been performed frequently because of its effectiveness, less pain, early discharge and cosmetic aspect. For an ineffective case of hyperhidrosis abdominal respiration which emphasized the exhalation and using an upper abdomen decreased the sweating. The balance of autonomic nerve system, toward parasympathetic dominant, was thought to be improved by conscious respiration. The decrease of sweating right after the operation in a case of incomplete resection indicated that intraoperative maneuver could restrict the sympathetic nerve. This procedure for a pain control could be less effective than that for hyperhidrosis, so an adequate preoperative informed consent was thought to be necessary.

Long-term survival of shiga toxin-producing Escherichia coli O26, O111, and O157 in bovine feces.

Cattle are an important reservoir of Shiga toxin-producing Escherichia coli (STEC) O26, O111, and O157. The fate of these pathogens in bovine feces at 5, 15, and 25 degrees C was examined. The feces of a cow naturally infected with STEC O26:H11 and two STEC-free cows were studied. STEC O26, O111, and O157 were inoculated into bovine feces at 10(1), 10(3), and 10(5) CFU/g. All three pathogens survived at 5 and 25 degrees C for 1 to 4 weeks and at 15 degrees C for 1 to 8 weeks when inoculated at the low concentration. On samples inoculated with the middle and high concentrations, O26, O111, and O157 survived at 25 degrees C for 3 to 12 weeks, at 15 degrees C for 1 to 18 weeks, and at 5 degrees C for 2 to 14 weeks, respectively. Therefore, these pathogens can survive in feces for a long time, especially at 15 degrees C. The surprising long-term survival of STEC O26, O111, and O157 in bovine feces shows that such feces are a potential vehicle for transmitting not only O157 but also O26 and O111 to cattle, food, and the environment. Appropriate handling of bovine feces is emphasized.

[A case of spontaneous hemopneumothorax associated with uncontrolled massive bleeding after inserting thorathic drain].

A 31-year-old man admitted to our hospital complaining of right chest pain. Chest X-ray on admission revealed a collapsed lung and an air fluid line in the right thorax. A chest tube drainage was carried out, but hemorrhagic pleural fluid was drainaged. Forty minutes later, an anemia developed and chest X-ray showed increased massive right pleural collection. Therefore, emergent surgery was performed. An operation under thoracoscopic guidance was converted into thoracotomy because of massive blood clots and fresh bleeding. A bleeding originating from the branch of 1st intercostal artery and a bulla on upper lobes were noted. The artery was coagulated with electrocoutary and ligated using Endo-loop. This artery is not congenital abnormal one but collateral expanded one of which the elastic lamina is thickened. Spontaneous hemopneumothorax is life-threatening, emergent operation should be undergone.

Three generations of hereditary chronic pancreatitis.

The patient was a 22 year-old male. Hereditary chronic pancreatitis was suspected as a diagnosis since his mother's uncle had been operated on for chronic pancreatitis 14 years previously at the age of 64 years and his mother had been operated on for chronic pancreatitis with calculi 5 years previously at the age of 40 years. Surgery was needed, since: 1) he had experienced abdominal pain for 8 years; 2) endoscopic retrograde cholangiopancreatography (ERCP) revealed a marked irregular dilatation in the main pancreatic duct and a marked irregular dilatation and protein plugs in the ductule of the tail of the pancreas; and, 3) pancreatic functional diagnostic (PFD) test examination showed a 75% decrease in exocrine function. If a surgical procedure had not been performed, the patient would likely have experienced calculi formation in the pancreas and a further decrease in exocrine function. Since the patient was very young and had many protein plugs in the dilated ductule of the tail of the pancreas, we decided to perform a spleen-preserving Puestow's procedure with removal of the tail of the pancreas. Clinical and pathological findings of hereditary pancreatitis are reviewed.

Minimization of the number of pregnant women to be treated with preventive procedure against GBS infection by means of antibody measurement. GBS Infection Group.

To study preventive strategies, it is essential to screen pregnant women having group B Streptococcus (GBS) infection in the birth canal. For the purpose of studying preventive measures against this infection, nationwide multicenter research was performed in GBS-carrying pregnant women. Of a total of 10,267 pregnant women, 1860 cases (18.1%) had GBS. The most common serotypes of detected GBS were type NT6 and JM9, followed by type III, type Ia and then type Ib. Type-specific antibody titer was below the cut-off point of 10 units/mL in 30.9% of Ia carriers, 58.5% of Ib carriers, 45.9% of II carriers and 32.9% of III carriers. Fortunately, no neonatal GBS infection occurred during this research. We concluded that 18.1% of studied pregnant women were GBS carriers and one-third of these GBS carriers required preventive procedures with antibody measurement.