Poor Limb Prognosis of Patients with Chronic Limb-Threatening Ischemia on Hemodialysis: A Retrospective Observational Study Based on the Global Limb Anatomic Staging System.

BACKGROUND: The Global Limb Anatomic Staging System (GLASS) has been widely used to evaluate patients with chronic limb-threatening ischemia (CLTI). As end-stage kidney disease (ESKD) is a well-known CLTI risk factor, we aimed to determine whether patients on hemodialysis (HD) have a worse limb prognosis than those without ESKD, considering the same GLASS background. METHODS: The data of 445 patients who underwent surgical and/or endovascular revascularization procedures for lower extremity ischemia were retrospectively collected in our division between 2005 and 2018. The major amputation rate and amputation-free survival (AFS) were compared between HD and non-HD patients. RESULTS: Among the 215 (48%) patients receiving HD, 58 limbs required major amputation (27% limb loss rate). Among the non-HD group, the limb loss rate was 13% (P < 0.0001). The overall AFS was significantly worse in patients receiving HD than those not (P < 0.0001). The AFS was significantly worse in HD patients when comparing GLASS-standardized subgroups. CONCLUSIONS: Patients with CLTI who were receiving HD had a worse limb prognosis than those not receiving, even when considering the same GLASS classification. Furthermore, there is a need for an ideal guideline focused on ESKD-directed peripheral artery disease.

Motion capture device reveals a quick learning curve in vascular anastomosis training.

PURPOSE: Surgical procedures are often evaluated subjectively, and an objective evaluation has been considered difficult to make and rarely reported, especially in open surgery, where the range of motion is wide. This study evaluated the effectiveness of surgical suturing training as an educational tool using the Leap Motion Controller (LMC), which can capture hand movements and reproduce them as data comprising parametric elements. METHODS: We developed an off-the-job training system (Off-JT) in our department, mainly using prosthetic grafts and various anastomotic methodologies with graded difficulty levels. We recruited 50 medical students (novice group) and 6 vascular surgeons (expert group) for the study. We evaluated four parameters for intraoperative skills: suturing time, slope of the roll, smoothness, and rate of excess motion. RESULTS: All 4 parameters distinguished the skill of the novice group at 1 and 10 h off-JT. After 10 h of off-JT, all 4 parameters of the novices were comparable to those of the expert group. CONCLUSION: Our education system using the LMC is relatively inexpensive and easy to set up, with a free application for analyses, serving as an effective and ubiquitous educational tool for young surgeons.

Giant Coeliac Artery Aneurysm Treated with a Hybrid Approach: A Case Report.

Introduction: Coeliac artery aneurysms are rare and have a high mortality rate when ruptured. Although they are often asymptomatic, treatment is recommended for patients with true coeliac aneurysms >2.5 cm, noted enlargement, or associated symptoms. Less invasive endovascular treatment is predominantly performed for coeliac artery aneurysms, while open surgery is preferred for patients with compression symptoms. Here, a case of symptomatic giant coeliac artery aneurysm that was successfully treated with hybrid surgery is reported. Report: A 73 year old man was referred with continuous epigastric discomfort and loss of appetite for two weeks. Abdominal ultrasound and computed tomography revealed a 12 cm aneurysm of the coeliac artery. The splenic and common hepatic arteries were severely distorted and compressed by the aneurysm, making their origins unclear. Considering the risk of rupture, semi-urgent surgery was performed with interruption of the inflow and outflow arteries using open and endovascular techniques together with aneurysmorrhaphy. Vascular reconstruction was omitted because abundant collateral flow to the liver and spleen was confirmed on angiography. Discussion: With the hybrid approach, aneurysmorrhaphy was performed safely with minimal incision and dissection. Short term outcomes were satisfactory, with complete resolution of compression symptoms and remarkable sac shrinkage at 12 months. Owing to the possibility of the pancreaticoduodenal arcade developing as a collateral pathway, periodic surveillance for de novo aneurysms is warranted.

Risk Factors for Incisional Hernia After Open Abdominal Aortic Aneurysm Repair.

BACKGROUND/AIM: Incisional hernia is among the most prevalent complications associated with open abdominal aortic aneurysm repair. However, risk factors for incisional hernias in patients with abdominal aortic aneurysm are multifactorial. Therefore, this study evaluated the risk factors of incisional hernia after open abdominal aortic aneurysm repair, including surgical factors. PATIENTS AND METHODS: We retrospectively extracted data from patients with incisional hernias after abdominal aortic aneurysm repair between 2012 and 2019 and investigated their perioperative characteristics and wound closure techniques. RESULTS: The mean follow-up periods were 41.5±30.3 months, and 30 of 131 (22.9%) patients suffered an incisional hernia. Regarding the underlying disease, only diabetes mellitus was significantly more common in the incisional hernia group (11 of 30 patients, 36.6%), and no significant differences were found in the patients' perioperative data. Interrupted sutures were used in all 30 patients in the hernia group. Moreover, in 8 of the 101 remaining cases, barbed sutures were used, and no incisional hernia occurred in any of these cases. CONCLUSION: In addition to diabetes mellitus, abdominal aortic aneurysm is a significant risk factor for incisional hernia after abdominal aortic aneurysm repair. Therefore, employing the barbed suture technique may effectively prevent incisional hernias after abdominal aortic aneurysm repair.

Midterm outcomes of AFX2 endografts used in combination with aortic cuffs.

OBJECTIVE: Type III endoleaks after endovascular aneurysm repair (EVAR) of abdominal aortic aneurysms (AAAs) with the Endologix unibody endograft remain a major concern, despite fabric, system, and instructional updates. The purpose of this study was to examine real-world outcomes of repairing AAAs using the current version of the AFX2 main body in combination with an aortic cuff, specifically focusing on type III endoleaks and morphological changes of the endograft. METHODS: We recruited facilities in Japan that used AFX2 combined with an aortic cuff for at least five cases between April 2017 and March 2018. A total of 175 cases in 24 facilities were analyzed. Patients' background information, including anatomic factors, operative findings, device component variations, and midterm outcomes at 3 years after the EVAR were collected. The data on computed tomography scans from cases registered as types I and III endoleaks and migration from each institute were sent to our department for verification. RESULTS: The mean patient age was 74.6 ± 8.1 years, and 48 cases (27%) were saccular aneurysms. The mean fusiform and saccular AAA diameters were 50.5 ± 5.8 mm and 43.5 ± 8.9 mm, respectively. No in-hospital deaths occurred. Data at 3 years, including computed tomography images, of 128 cases were analyzed. Overall survival, freedom from aneurysm-related mortality, and freedom from reintervention rates at 3 years were 85.8%, 99.3%, and 87.3%, respectively. There were three, one, and three cases of types I, IIIa, and IIIb endoleaks without sac dilatations, respectively. Among five migration cases, one case of aortic cuff migration presented as a type Ia endoleak, and four cases demonstrated sideways displacement, one of which presented as a type IIIa endoleak. The sac regression and enlargement rates at 3 years were 41.4% and 20.5% in the fusiform group and 44.2% and 16.7% in the saccular group, respectively. The proximal neck diameter slightly increased from 20.8 ± 2.7 mm before the EVAR to 22.2 ± 4.6 mm after the repair. CONCLUSIONS: Midterm outcomes of the AFX2 used in combination with an aortic cuff were acceptable, considering the rates of types I and III endoleaks. However, there were cases of sideways displacement that could cause future type IIIa endoleaks. When the AFX2 is used in combination with an aortic cuff, close surveillance for endograft deformations and subsequent adverse events, including type III endoleaks, is needed.

Volumetric computed tomography analysis for gastroduodenal and pancreaticoduodenal artery aneurysm formation: A retrospective single-center study.

ABSTRACT: Gastroduodenal artery aneurysms (GDAA) and pancreaticoduodenal artery aneurysms (PDAA) are rare, have high rupture risks, and are located in the arcade between the celiac artery and the superior mesenteric artery. Pancreaticoduodenal artery aneurysms are associated with celiac artery stenosis, and it is hypothesized that these celiac lesions might contribute to the formation of aneurysms. In contrast, a few studies have reported an association between a gastroduodenal artery aneurysm and celiac lesions. This study aimed to investigate the potential differences between patients with gastroduodenal and pancreaticoduodenal artery aneurysms and better understand their pathogenesis.We selected patients with GDAA and PDAA who were admitted to our department between January 2010 and December 2020. Aortic wall volume, aortic wall calcification, and pancreaticoduodenal arcade volume of computed tomography images were calculated semi-manually using Horos 3.3.5.Eight GDAAs and 11 PDAAs were analyzed. Celiac lesions were found in all PDAA patients, with none in GDAA cases. Volumetry demonstrated that aortic wall volume and calcification were more prominent in the GDAA group than in the PDAA group (P = .026 and P = .049, respectively). The pancreaticoduodenal arcade volume was larger in the PDAA group (P = .002).In our study, celiac artery lesions were strongly correlated with PDAA. The volume of the pancreaticoduodenal arcade was larger in the PDAA group, and aortic wall volume and calcification were larger in the GDAA group.

Motion analysis of suturing technique with Leap Motion ControllerTM. Proof-of-concept.

PURPOSE: Leap Motion Controller is a device that can capture hand gestures and reproduce these as data comprising several parametric elements. We analyzed surgical suture motion using this device and investigated the optical methodology for clinical applications. METHODS: We recruited medical students and residents (novice group) and vascular surgeons (specialist group). The operators applied sutures once on a prosthetic graft, and the captured motion was analyzed. RESULTS: Ten novices, who each received procedural instruction for at least 2 h, and 10 specialists were recruited. The hand gesture consisted of four elements (roll, pitch, yaw, and wrist angle). Since "roll" was the only element in this simple suture movement that showed some difference between the two groups, we analyzed three parameters: (1) the suturing time, (2) the difference in the degree between two piercing points, and (3) slope of the roll. We found that the specialist group demonstrated significantly shorter suturing times and a larger degree of the slope. CONCLUSION: Leap Motion Controller analysis with the roll revealed that the novices could use the roll motion after only 2 h of instruction; however, the suturing speed and smoothness were secondary to those of the specialists.

Specific Features of Patients Under 40 Years Old With Small-to-Medium-Sized Arterial Deterioration.

Background: Arterial deterioration is mostly caused by atherosclerosis, which progresses with age. However, we have observed serious backgrounds or etiologies in younger patients with non-atherosclerotic diseases and deterioration of small-to-medium-sized arterial lesions. Therefore, we aimed to identify the specific features of patients aged <40 years with deterioration of small-to-medium-sized arteries. Methods: We selected patients who were admitted to our department from 1995 to 2019 with deterioration of small-to-medium-sized arteries (aneurysms, dissection, rupture, or arterial injury/damage) and focused on the cohort aged <40 years. We examined the backgrounds or etiologies of the patients including genetic and inflammatory diseases, which might have caused the arterial deterioration. Results: Consequently, more than half (54.1%) of the patients aged <40 years had non-atherosclerotic comorbid diseases. However, the number of deteriorated arterial lesions was higher in patients aged <40 years than in patients aged ≥40 years (3.13 vs. 1.33 lesion/patient; P = 0.011). Furthermore, the data analysis of patients with multiple arterial lesions (≥3) revealed that the younger population tended to have more specific backgrounds or etiologies, notably Ehlers-Danlos syndrome and Behçet's disease. There were no differences in the all-cause mortality and cardiovascular disease-related mortality between patients aged <40 and ≥40 years (P = 0.89 and 0.29, respectively). Conclusions: Over 50% of patients aged <40 years with deterioration of small-to-medium-sized arteries had non-atherosclerotic, specific clinical backgrounds or etiologies, including genetic and inflammatory diseases. In addition, they exhibited more arterial lesions than older patients.

Ten-Hour Simulation Training Improved the Suturing Performance of Medical Students.

PURPOSE: We evaluated the effectiveness of an original simulation training system in improving the suturing performance of medical students using a previously developed web application for scoring suturing performance. METHODS: Medical students were recruited for this study and trained on vascular graft anastomosis. Prosthetic grafts were anastomosed and evaluated after orientation, and after 1 hr and 10 hr after training. Vascular surgeons were recruited as controls. Using a previously developed web application, suturing performance was evaluated on the basis of procedural time, coefficient of variation of bite (length of a stitch across the graft), coefficient of variation of pitch (interval between stitches), and skewness (symmetry of the angles between stitches). RESULTS: Forty-eight medical students and 10 vascular surgeons were recruited. After 1 hr of training, only the students' procedural time improved. After 10 hr of training, all scores improved compared with those in the first trial, and all students' scores except procedural time were statistically similar to those of the vascular surgeons. CONCLUSIONS: Ten-hour training improved all factors, including bite, pitch, skewness, and time. Our simple and inexpensive training system and web application for calculating anastomosis scores can be a useful open educational resource.

A comparison of subjective clinical and objective judgement of abdominal aortic aneurysm morphology.

BACKGROUND: We compared the subjective, clinical judgement of "saccular" morphology with the objective judgement of mechanical structural analysis. METHODS: Using structural analysis with the finite element method, we previously created a simple model of abdominal aortic aneurysm (AAA) that visualized the distribution of the maximum principal stress (MPS) in the aortic wall and identified the area of prominent stress. AAA "saccular" morphology was determined according to the area showing MPS>0.03 MPa. AAAs with low aspect ratio (horizontally long AAA sac) and small fillet radius were defined as "saccular." Twelve vascular surgeons were recruited. First, they judged the AAA as saccular or fusiform with 3-dimensional images at their clinical impression (subjective "eyeball" judgement). Second, they applied the deformable figure tools on the simple AAA-shaped sagittal view in the application model for 30 AAA cases. From the data of the tools applied, the mechanical structural analysis was performed semi-automatically and the morphology was judged with the objective "simple application." RESULTS: The structural analysis revealed that only one case was judged as saccular by 11 out of 12 surgeons and the other 29 AAAs were judged as fusiform by two-thirds or more of the surgeons. In contrast, 5 cases were subjectively judged as saccular by eight and more of the surgeons. CONCLUSIONS: The clinical judgement of AAA saccular morphology by the vascular surgeons was different from the judgement derived from the mechanical structural analysis using the application model. The saccular morphology may be theoretically rare in AAAs.

High aneurysm wall enhancement values are associated with late sac shrinkage after endovascular repair of abdominal aortic aneurysms.

ABSTRACT: To analyze the correlation between aneurysm wall enhancement (AWE) values and early and late sac shrinkage after endovascular aneurysm repair (EVAR).We retrospectively analyzed 28 patients who underwent EVAR for abdominal aortic aneurysms (AAA) using a bifurcated main body stent graft. The value of AWE in the slice of the maximum AAA diameter was measured using a volumetric analysis of computed tomography images. Sac measurements before EVAR and more than 10 months after EVAR were compared, and the maximum sac shrinkage rate was calculated.The AWE value immediately after (4 to 7 days) EVAR correlated positively with the sac shrinkage rate (R2 = 0.0139). The AWE value at 6 months after EVAR was also strongly correlated with the sac shrinkage rate (R2 = 0.4982).Higher AWE values at 6 months after EVAR were strongly associated with the sac volume shrinkage rate. High AWE values may be a predictive factor for sac shrinkage and may aid in the selection of the appropriate clinical strategy after EVAR.

Comparison of utilisation and fermentation of highly cross-linked phosphate starches produced from two different plant origins, potato and tapioca in rats and humans.

The utilisation and fermentation of highly cross-linked phosphate starches made from two different origins, potato (HXL-P) and tapioca (HXL-T) were investigated in rats and humans. HXL-P and HXL-T were highly resistant to digestion by carbohydrate enzymes and were also resistant to fermentation by gut microbiota in rats. The postprandial blood glucose scarcely increased after administration of HXL-P or HXL-T in healthy humans. Incremental AUC of both HXL-P and HXL-T for 180 min was significantly lower than that of glucose (p < .05). Breath hydrogen excretion was very low after oral administration of HXL-P or HXL-T, and AUCs of breath hydrogen excretion for 13 h after administration were significantly lower than that of fructooligosaccharide as a reference of fermentation (p < .05). These results show that HXL-P and HXL-T were hardly digested and were highly resistant to fermentation. In conclusion, HXL-P and HXL-T could be good low-energy bulking ingredients to replace wheat flour.

Development of a Web Application That Evaluates Suture Performance in Off-the-Job Training.

Objective: To create a web application that can evaluate suture performance and assess its quality. Material and Methods: We developed the web application using a few cloud computing systems, servers, database, and computing languages. We used 20 anastomosed graft samples for optimizing the application. The images of the anastomosed grafts were captured two-dimensionally. Five vascular surgeons utilized the application to compute the objective score and rank the score of the anastomoses subjectively. Results: Steps for using the application include uploading a two-dimensional image of sutures, tracing the stitch line manually, and pushing the button to have the score displayed. After using this system for more than 1,000 times without server issues or failures, we confirmed its stability and easy accessibility. The system calculated the score within several seconds. The score of the three factors (bite, pitch, and skewness of angle) ranged from 0.25 to 0.76. The error range of the application was acceptable. The interclass correlation coefficient (ICC (2,1)) of the three factors was 0.92. Conclusion: The quality of the application was acceptable considering the low range of interoperator variations in the scores.

Hemodynamic Simulation of Pancreaticoduodenal Artery Aneurysm Formation Using an Electronic Circuit Model and a Case Series Analysis.

Objective: To assess mechanisms underlying aneurysm formation using a simple electronic circuit model. Materials and Methods: We created a simple circuit model connecting the celiac artery (CA) to the superior mesenteric artery via the pancreaticoduodenal arcade. We retrospectively reviewed 12 patients with true pancreaticoduodenal artery aneurysms (PDAAs) who received open or endovascular treatment between 2004 and 2017. We set the resistance of each artery and organ voltage and calculated flow volume and rate in response to degrees of simulated CA stenosis from 0% to 99.9%. Results: Flow volume rates of the anterior pancreaticoduodenal artery and posterior pancreaticoduodenal artery decreased to zero when CA stenosis increased from 0% to 50% and then increased drastically, at which point flow direction reverted and the flow was up to three times the initial rate. The gastroduodenal artery (GDA) also showed reversed flow with severe CA stenosis. In 12 patients with PDAA, eight presented with a CA lesion, and the other patients presented with comorbidities causing the arteries to be pathologically fragile, such as Marfan syndrome, Behçet's disease, and segmental arterial mediolysis. All four GDA aneurysms were not accompanied by CA lesions. Conclusion: The mechanism underlying CA-lesion-associated PDAA formation may be partially explained using our model.

Computational simulation of flow-induced arterial remodeling of the pancreaticoduodenal arcade associated with celiac artery stenosis.

Arterial remodeling of the pancreaticoduodenal arcade, which enables collateral flow to the liver, spleen, and stomach, is a well-recognized clinical sign of celiac artery (CA) stenosis. However, the hemodynamic changes due to remodeling are poorly understood, despite their importance in surgical procedures such as pancreaticoduodenectomy. In this study, a framework to simulate remodeling of the arterial network following pathological flow alterations was developed and applied to investigate the hemodynamic characteristics of patients with CA stenosis. A one-dimensional-zero-dimensional cardiovascular model was used for blood flow simulation. After introducing CA stenosis into the normal network, arterial remodeling was simulated by iteratively changing the diameter of each artery until time-averaged wall shear stress reached its value under normal conditions. A representative case was simulated to validate the present framework, followed by simulation cases to investigate the impact of stenosis severity on remodeling outcome. A markedly dilated arcade was observed whose diameter agreed well with the corresponding values measured in subjects with CA stenosis, confirming the ability of the framework to predict arterial remodeling. A series of simulations clarified how the geometry and hemodynamics after remodeling change with stenosis severity. In particular, the arterial remodeling and resulting blood flow redistribution were found to maintain adequate organ blood supply regardless of stenosis severity. Furthermore, it was suggested that flow conditions in patients with CA stenosis could be estimated from geometric factors, namely, stenosis severity and arcade diameter, which can be preoperatively and non-invasively measured using diagnostic medical images.

Geometric analysis of ruptured and nonruptured abdominal aortic aneurysms.

OBJECTIVE: The objective of this study was to use parameters to determine the geometric differences between ruptured abdominal aortic aneurysms (AAAs) and nonruptured AAAs. METHODS: Computed tomography data of 38 ruptured AAAs and 215 electively repaired (nonruptured) AAAs were collected from multiple institutes. We compared the ruptured AAA group and nonruptured AAA group with 1:1 matching by using the Mahalanobis distance, which was calculated using the patient's age, sex, and AAA diameter. We selected the longitudinal AAA image in multiplanar reconstruction view, placed a hypothetical ellipse on the aneurysm's protruded curve, and placed a circle on the portion connecting the aneurysm and the aorta. We then measured the aspect ratio (the vertical diameter divided by the horizontal diameter) and fillet radius (the radius of arc). RESULTS: The aspect ratio was significantly lower in the ruptured group than in the nonruptured group (2.02 ± 0.53 vs 2.60 ± 1.02; P = .002), as was the fillet radius (0.28 ± 0.18 vs 0.81 ± 0.44; P < .001). Receiver operating characteristic analysis revealed that the area under the curve of the aspect ratio was 0.688, and the optimal cutoff point was 2.23, with sensitivity and specificity of 0.55 and 0.76, respectively. The area under the curve of the fillet radius was 0.933, and the optimal cutoff was 0.347, with sensitivity and specificity of 0.97 and 0.87, respectively. CONCLUSIONS: The geometric analysis performed in this study revealed that ruptured AAAs had a smaller fillet radius and smaller aspect ratio than nonruptured AAAs did.

Proresolving Lipid Mediators Resolvin D1 and Protectin D1 Isomer Attenuate Neointimal Hyperplasia in the Rat Carotid Artery Balloon Injury Model.

BACKGROUND: Specialized proresolving mediators from ω-3 polyunsaturated fatty acid may control resolution of inflammation. We evaluated the influence of two specialized proresolving mediators, resolvin D1 (RvD1) and protectin D1 isomer (PD1 iso) on neointimal hyperplasia after balloon injury. MATERIALS AND METHODS: Sprague Dawley male rats at 12-14 wk of age were injured as a model of balloon angioplasty. Then, 1 µg/rat of RvD1 or PD1 iso was administered intravenously via the tail vein immediately and 2 d after angioplasty. The proliferation of injured artery and the infiltration of leukocytes, monocytes, and macrophages at 3 d after injury were evaluated by immunostaining. The activity of the inflammatory transcription factor nuclear factor kappa-light-chain-enhancer of activated B cells (NFκB) in the injured artery at 3 d after injury was evaluated using an enzyme-linked immuno sorbent assay kit. The proliferation of the neointima was evaluated by calculating the ratio of the neointimal and medial areas using specimens at 14 d after injury. RESULTS: RvD1 and PD1 iso attenuated proliferation of medial cells (P < 0.05) and infiltration of leukocytes (P < 0.05) and monocytes/macrophages (P < 0.01). Although both RvD1 and PD1 iso mitigated NFκB activity (P < 0.01), RvD1 attenuated this activity more strongly (P < 0.01). RvD1 decreased neointimal hyperplasia by 37.3% (P < 0.01), whereas PD1 iso decreased neointimal hyperplasia by 31.8% (P < 0.05) (RvD1 versus PD1 iso: P = 0.51). CONCLUSIONS: RvD1 and PD1 iso reduced the activity of inflammatory transcription factor NFκB within the injured artery and attenuated inflammatory cell infiltration, leading to a reduction in early inflammation and subsequent neointimal hyperplasia.

Original Homebuilt Off-the-Job Training System for Vascular Surgeons: System Analysis and Assessment.

Objective: We assessed the effectiveness and appropriateness of our original off-the-job training (Off JT) system using data acquired from recruited medical students and doctors. Materials and Methods: We presented our original homebuilt Off JT system, which is simple and inexpensive. In our unique system, we performed anastomosis at the bottom of a plastic pot, which mimics the actual open surgical procedure at a deep site. There were four evaluation points: (A) operating time, (B) performance of anastomosis by semi-automatically analyzing the image with the coefficient of variation (standard deviation/length) of the "bite" and the "pitch," (C) scoring of the total surgical skill evaluated by the trainers according to the Operative Performance Rating System (OPRS), and (D) the relationship of these three factors (A, B, and C). Results: The procedural time and coefficient of variation of the bite and pitch decreased and the OPRS score increased after training. There was a strong correlation between procedural time, anastomotic performance, and OPRS score. Conclusion: The effectiveness of our original homebuilt system was shown by reduced procedural time, improved anastomotic quality, and increased OPRS score.