Late events and mid-term results after endovascular aneurysm repair.

PURPOSE: To evaluate the late events and mid-term results after endovascular aneurysm repair (EVAR). METHODS: Between December 2006 and May 2012, 175 abdominal aortic aneurysms were treated by EVAR. Aneurysm-related events were analyzed. RESULTS: The complications that occurred during the EVAR procedure were renal artery occlusion in two patients, access artery injury in two, delivery failure in one, retrograde aortic dissection in one, and death from hepatic failure in one patient. Five adverse endoleaks (four type I, one type III) remained at discharge, and the technical success rate was 97 %. On follow-up, limb occlusion had occurred in five patients. Unilateral renal atrophy was found in three patients, but none of the patients required new hemodialysis. Sac enlargement (≥5 mm) developed in ten patients. Their culprit endoleaks were type Ia in one, II in eight, and V in one patient. Transarterial embolization was performed for three out of the eight type II endoleaks. The rate of freedom from secondary re-intervention was 93 % at 3 and 5 years, respectively. The survival and freedom from aneurysm-related events rates were 74 % at 3 years and 47 % at 5 years. CONCLUSIONS: The mid-term results of EVAR were excellent with a low rate of aneurysm-related deaths, although there were relatively high aneurysm-related event rates. Sac re-enlargement from type II endoleaks was the most common major issue at the mid-term follow-up.

Anatomical evaluation of facial nerve pathways and dissection of "premasseter space" for rhytidectomy in Asians.

BACKGROUND: Partial detachment of the superficial musculoaponeurotic system (SMAS) by dissection of the premasseter space (PMS) is an option for enhancing the effectiveness of SMAS-based rhytidectomy. The aim of this study was to identify the underlying cause of the potential risk of motor nerve impairment sometimes caused by PMS dissection and to consider the effective use of PMS dissection, especially in Asians. METHODS: Detailed dissection was carried out on six fixed Japanese cadavers to evaluate facial nerve pathways around the PMS. RESULTS: The anterior wall of the PMS was opaque because each face exhibited fibers of various thicknesses within and around the anterior border of the masseter. The ascending ramifications of the buccal trunk ran through the fibers, outside the anterior border of the masseter in some faces but within it in others. CONCLUSIONS: This study revealed the presence of a danger zone when dissecting the PMS in Asians. Severing the fibers that fix the SMAS to the masseter fascia around the anterior border of the masseter is sometimes unavoidable to attain good mobility of the SMAS. Surgeons must be mindful of the fibers near the anterior border of the masseter because they may be outside the PMS and contain buccal trunk ramifications; the anterior wall of the PMS tends to be opaque in Asians. Nonetheless, the extent of PMS dissection should be determined on an individual basis. The present findings may help to reduce relevant risks in Asian patients and standardize procedures for effective rhytidectomy. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these evidence-based medicine ratings, please refer to the table of contents or the online instructions to authors at www.springer.com/00266.

Development of a device to determine the stiffness of elastic garments and bandages.

OBJECTIVE: To evaluate the reliability of a newly developed stiffness-determining device, composed of a leg mannequin and air-pack type analyser, for measuring the interface pressure. METHOD: The correlation of stiffness values obtained employing the Hohenstein method and this new method was investigated using 17 different brands of medical elastic compression stocking. RESULTS: A significant correlation in stiffness values using the two methods was obtained (P < 0.01). When this new method was applied to the bandages, the stiffness was significantly correlated with the initial pressure when assessing both short-stretch and long-stretch bandages. On the comparison of stiffness values between elastic stockings and bandages with the same initial pressure, the short-stretch bandages showed a predominantly higher value than long-stretch bandages and stockings (P < 0.01). CONCLUSION: The reliability of this new method, which can be easily applied to not only elastic stockings but also elastic bandages, was verified. In clinical practice, the compression pressure should be selected in consideration of the prospective stiffness.

IFNß-1b may severely exacerbate Japanese optic-spinal MS in neuromyelitis optica spectrum.

BACKGROUND: Interferon-ß-1b (IFNß-1b) has been used to prevent exacerbation of relapsing-remitting multiple sclerosis (RRMS) including optic-spinal multiple sclerosis (OSMS) in Japan. We encountered 2 patients with OSMS with unexpectedly severe exacerbation soon after the initiation of IFNß-1b therapy. The experience urged us to retrospectively review the patients with RRMS who had been treated with IFNß-1b to identify similar cases. METHODS: At neurologic departments of 9 hospitals, the medical records of 56 patients with RRMS were reviewed to identify those who showed severe exacerbation soon after the initiation of IFNß-1b therapy. RESULTS: Of 56 patients with RRMS, we identified 7 who experienced severe exacerbation (exacerbation with increased scores of Expanded Disability Status Scale ≧7.0) within 90 days of the initiation of IFNß-1b therapy. In all 7 patients, the exacerbations after the initiation of IFNß-1b therapy were more severe than those experienced by the individual patients before the use of IFNß-1b, and seemed to have occurred unexpectedly in a short time after the initiation of INFß-1b therapy. A retrospective analysis revealed that all 7 patients had antibodies toward aquaporin 4, and the clinical features of all 7 patients after the exacerbation were consistent with those of neuromyelitis optica (NMO) spectrum. CONCLUSIONS: Our study suggests that IFNß-1b may trigger severe exacerbation in patients with the NMO spectrum. In INFß-1b therapy, cases in NMO spectrum should be carefully excluded.

Comparison of stiffness and interface pressure during rest and exercise among various arm sleeves.

OBJECTIVES: To compare the interface pressure during rest and exercise among various kinds of arm sleeves. METHODS: The interface pressure underneath nine different arm sleeves was measured during 10 maximal opening and closing movements of fingers using a pressure transducer (Air Pack Type Analyser) in 16 healthy volunteers. Furthermore, in order to evaluate the characteristics of each arm sleeve, the extensibility, stiffness and thickness were determined in vitro by several apparatuses. RESULTS: There was a significant correlation between stiffness and extensibility. The stiffness was significantly correlated with the pressure difference between muscle contraction and relaxation during exercise. The higher the value of stiffness, the greater the pressure amplitude during exercise. CONCLUSION: Short-stretch arm sleeves characterized with a high level stiffness, including thick round- and flat-knitted arm sleeves, are more beneficial for the augmentation of muscle pumping than long-stretch arm sleeves, in the same way as short-stretch bandages or stockings applied to the leg.

Conservative treatment for patients with intermittent claudication.

AIM: The effect of pharmacotherapy or supervised exercise training on patients with intermittent claudication was assessed. METHODS: One hundred patients with stable intermittent claudication due to arteriosclerosis obliterans were analyzed. We divided the patients into 2 groups: patients treated by pharmacotherapy alone (Group A: 39 claudicants) and patients treated by supervised exercise training and pharmacotherapy (Group B: 61 claudicants). The changes in ankle-brachial pressure index (ABI) and recovery time of ABI after a 40-m walk (RT(40)) and absolute claudication distance (ACD) on a treadmill before and after each treatment were assessed. RESULTS: In Group A, RT(40) decreased from 9.5 +/- 5.8 min at the baseline to 6.4 +/- 3.5 min after 6 months (P=0.0002). In Group B, it decreased from 9.7+/-5.2 min at the baseline to 6.3+/-4.2 min after 3 weeks (P<0.0001). In Group A, ACD increased from 249+/-177 m at the baseline to 317+/-168 m after 6 months (P=0.0003). In Group B, it increased from 143+/-90 m at the baseline to 257+/-161 m after 3 weeks (P<0.0001). CONCLUSION: Hemodynamics and walking ability were improved by either short-term supervised exercise training or midterm pharmacotherapy. RT(40) may be useful for predicting the effect of conservative treatment on intermittent claudication. Greater increases in ACD after treatment can be achieved in claudicants with a shorter RT(40) before conservative treatment.

A case of an infected abdominal aortic aneurysm caused by infectious spondylitis.

An 82-year-old female was admitted with a diagnosis of infectious spondylitis.The culturing of vertebral body biopsy specimens yielded a non-tuberculous acid-fast bacterium (Mycobacterium intracellulare). CT disclosed a saccular mass in the abdominal aorta in contact with the collapsed vertebral bodies (L2-3), and a diagnosis of infected abdominal aortic aneurysm was made. Axillofemoral bypass, resection of the infected abdominal aortic aneurysm, vertebrectomy (L2-3) and reconstruction with a fibular graft, and packing with the greater omentum were performed. An acid fast bacterium was detected from the thrombus in the aneurysm. The clinical course suggested that this patient developed an infected abdominal aortic aneurysm due to Mycobacterium intracellulare transmitted from infectious spondylitis.

A comparison of interface pressure and stiffness between elastic stockings and bandages.

OBJECTIVES: To compare the interface pressure during posture changes and exercise between elastic stockings and bandages. METHODS: Using a pressure transducer (air pack-type analyzer), the interface pressures associated with three different elastic stockings and three different elastic bandages were measured during supine resting, standing and exercise in 15 healthy volunteers. RESULTS: Short-stretch bandages showed a significantly higher static stiffness index value, which is defined as the pressure difference between lying and standing, than long-stretch bandages and short-stretch stockings (P < 0.001). Furthermore, short-stretch bandages showed a significantly greater pressure difference between muscle contraction and relaxation in both tip-toe and knee-bending exercises than long-stretch bandages and short-stretch stockings (P < 0.001). CONCLUSION: Short-stretch bandages can be expected to have more pronounced benefits for augmenting muscle pump than long-stretch bandages and short-stretch stockings.

Heparin-induced thrombocytopenia complicated with massive thrombosis of the inferior vena cava after filter placement.

A 45-year-old man presented with deep vein thrombosis of the right leg and bilateral pulmonary embolism. Heparin was administered on the initial one and a half days. On the 3rd day, an inferior vena cava (IVC) filter was placed with a heparin flush, after which massive IVC thrombosis developed. The platelet count was 221000/mm3, decreased 42% from the initial level, but remained within the normal range. Heparin was replaced by argatroban on the 13th day. The platelet count increased to 355000/mm3 on the 15th day. The patient was positive for antibody against complexes of heparin and platelet factor 4, and was diagnosed as heparin-induced thrombocytopenia with thrombosis syndrome (HITTS). When thrombosis develops during heparin treatment, it is important to suspect HITTs and to assay for the associated antibodies, regardless of the actual platelet count.

Gluteal compartment syndrome after abdominal aortic aneurysm repair.

A 66-year-old man underwent emergency surgery for a ruptured abdominal aortic aneurysm associated with right common and internal iliac aneurysms. Postoperatively, his right buttock was distended and tender to compression. A CT scan revealed an extremely swollen right gluteus maximus with decreased density. Macromyoglobinuria was noted, and creatine kinase and myoglobin were elevated: 87,800 IU/l and 144,300 ng/ml, respectively. Renal function had deteriorated and he was treated with hemodialysis until the 15th postoperative day. The patient recovered without any discomfort to the buttock or intermittent claudication. To our knowledge this is the first documented case of gluteal compartment syndrome after the repair of an abdominal aortic aneurysm.

Disappearance of M(r) 25,000 protein, a new protein kinase substrate, in parallel with a kind of serpin during embryogenesis.

M(r) 25,000 protein (pp25) is a protein kinase substrate detected recently in Xenopus laevis oocytes [Hashimoto, E. et al. (1995) J. Biochem. 118, 453-460], but the physiological role of this protein remains to be determined. In order to elucidate some characteristics of pp25, a polyclonal antibody was raised against it and the distribution and quantitative changes of this protein were examined using various tissues and biological systems. In Western blot analysis, pp25 was detected only in Xenopus oocytes and not in other frog tissues when the heat-stable cytosolic fraction from each tissue was examined. Although the amount of pp25 apparently did not change during oocyte maturation induced by progesterone, pp25 disappeared in embryos around Nieuwkoop/Faber stages 45-48 in parallel with the change of pNiXa (a kind of serpin). These results suggest that pp25 plays some specific role(s) in Xenopus oocytes and that the level of pp25 changes dramatically during embryonic development.

Detecting odorous materials in water using quartz crystal microbalance sensors.

Water drawn from rivers into purification plants must be checked for the presence of odorous materials because oil or organic-solvent contamination of the water may occur. If the detection of odorous materials in water is untimely or fails, the consequences can be serious. Therefore, the water must be checked continuously. We have developed a water-monitoring system that uses a highly sensitive electronic nose consisting of quartz crystal microbalance sensors to detect odorous materials in water. The nose is sensitive enough to detect petroleum hydrocarbons without water vapor at a low-ppb level. However, the nose is very sensitive to humidity and temperature. We have thus developed a method for accurately maintaining the humidity and temperature in the sensor cell. Experimental results show that the developed system can quickly detect contaminated water that was mixed with gasoline, kerosene, or benzene (concentration: several hundred ppb level), and we should be able to classify the pollutant by using pattern recognition of the dynamic sensor response.

Indications for and limitations of exercise training in patients with intermittent claudication.

BACKGROUND: The selection of candidates for exercise training among patients with intermittent claudication is still a matter of debate. PATIENTS AND METHODS: Forty-nine patients with intermittent claudication due to arteriosclerosis obliterans were tested. Forty-six patients were men and 3 were women, with an average age of 65 years (range, 46 to 76 years). The patients walked on a treadmill at 2.4 km/h on a 12% upgrade followed by an appropriate period of rest for 30 minutes twice a day during a 3-week hospitalization. Programs were individualized for each patient. Four parameters were assessed after exercise training: (1) Ankle-brachial index (ABI) at rest, (2) Fall in ABI after 40 m of treadmill walking (ABI Fall 40), (3) the recovery time (RT 40) required for the ABI to return to resting levels after 40 m of walking, and (4) the maximal walking distance (MWD) on the treadmill. RESULTS: The average ABI at rest before the 3-week training period was 0.60 +/- 0.02 (mean +/- SE), and after training it was 0.62 +/- 0.02. There was a small although not statistically significant increase in the ABI after training. This increase in the ABI did not exceed 0.21. The average ABI Fall 40 before training was 0.36 +/- 0.01, and after training it was 0.30 +/- 0.02. The average RT 40 before training was 9.9 +/- 0.8 min, and after training it was 6.2 +/- 0.6 min. There were significant decreases in the ABI Fall 40 and RT 40 after training (p < 0.01 and p < 0.001, respectively). The MWD increased after training in 48 of the 49 patients. The average MWD increased from 134 +/- 13 m to 226 +/- 32 m after training (p < 0.001). The occlusion levels did not influence the results as training effects and hemodynamic parameters. Fourteen of 49 patients desired arterial reconstruction after exercise training. CONCLUSIONS: Patients with shorter RT 40's before training achieved greater increases in the MWD after training. In patients with an RT 40 under 12 min, exercise training is indicated. However, there is some discrepancy between the increase in MWD and the degree of satisfaction in individual patients.

Treatment for aortic graft infection.

Nine patients with an aortic graft infection presented after undergoing aortic grafting. Seven of 9 patients underwent an initial aortic reconstruction in our hospital. The incidence of aortic graft infection was 1.5% (7/456). There were 6 cases of paraprosthetic infection and 3 cases of aortointestinal fistulas. The treatments consisted of a complete graft excision and an axillofemoral bypass in 6 patients, a complete graft excision alone, a partial graft excision and a femorofemoral bypass, and the preservation of the graft with omental wrapping and irrigation in 1 each. Broad-spectrum antibiotics were intravenously administered to all patients and were then replaced by selective antibiotics for the responsible organisms. All surviving patients received antibiotics orally for 3-6 months. The early postoperative mortality rate was 11.1%. Aortoduodenal fistula occurred in 1 patient with graft excision alone. Graft thrombosis occurred in 2 patients with an axillofemoral bypass. No late graft infection or stump blowout occurred in any patient. We believe that a complete excision of the infected graft as well as the maintenance of distal tissue perfusion is necessary. However, based on the condition of the patient, the appearance of the operating field, and the difficulty of a repeat operation, we would like to stress the importance of selecting the best and safest treatment plan for each case.

A serpin with M(r) 43,000 is a binding protein of M(r) 25,000 protein, a substrate for protein ser/thr kinase detected in Xenopus laevis oocytes.

In an attempt to get some clue as to the function of M(r) 25,000 protein, a protein Ser/Thr kinase substrate detected in Xenopus laevis oocytes [Hashimoto, E. et al. (1995) J. Biochem. 118, 453-460], the binding protein was surveyed using the (32)P-labeled protein by casein kinase II as a screening probe. When the cytosolic proteins from oocytes were transferred to a polyvinylidene fluoride membrane and incubated with the labeled protein, only one protein with M(r) 43,000 was visualized on autoradiography. This protein was purified to a nearly homogeneous state through several column chromatography steps. The amino acid sequence of the amino-terminal region of this protein identified it as a kind of serine protease inhibitor (serpin) [Holland, L.J. et al. (1992) J. Biol. Chem. 267, 7053-7059]. However, the M(r) 25,000 protein did not have any effect on the inhibitory action of this serpin on alpha-chymotrypsin. In addition, several binding proteins were also detected in the particulate fraction of oocytes, although the exact identity of these proteins is not clear at this time. These results suggest that the M(r) 25,000 protein may play some role(s) by interacting with these binding proteins in Xenopus oocytes.

Algal-lytic activities encoded by Chlorella virus CVK2.

Using a halo assay with E. coli lysates expressing Chlorella virus CVK2 genes on a cosmid contig, two different algal-lytic activities against Chlorella strain NC64A cells were found to be encoded on the CVK2 genome. The gene for vAL-1, one of the two activities, encoded a 349-aa ORF, which was homologous to PBCV-1 A215L and CVN1 CL-2. The vAL-1 gene was expressed at relatively early stages of the virus life cycle; transcripts and translation products appeared at 60 and 90 min postinfection, respectively. The vAL-1 protein was not incorporated into the viral particles but remained in the cell lysate, suggesting a role in the digestion of the cell wall before viral release at the final stage of infection. Cell wall materials isolated from Chlorella strain NC64A cells were digested by vAL-1 and degradation products were detected on TLC. In addition to Chlorella strain NC64A, vAL-1 lysed cells of four C. vulgaris strains as well as Chlorella sp. SAG-241-80.

Usefulness of HMG-CoA reductase inhibitor in Japanese hyperlipidemic women within seven years of menopause.

OBJECTIVE: To assess the therapeutic value of treatment with an HMG-CoA reductase inhibitor in women with hypoestrogenic hyperlipidemia caused by menopause. DESIGN: Fifty-six women with total cholesterol (TC) levels of 220 mg/dl or more who were within 7 years of menopause were randomly assigned to receive an HMG-CoA reductase inhibitor (pravastatin 10 mg/day; treated group, 26 patients) or no medical treatment (nontreated group, 30 patients) in this 6-month nonblinded prospective trial. RESULTS: In the treated group, the mean (SD) TC levels decreased significantly from 254.5+/-22.3 mg/dl at baseline to 204.7+/-22.2 mg/dl (19.6%), and the mean low-density lipoprotein cholesterol (LDL-C) level decreased significantly from 146.7+/-30.5 to 104.3+/-22.5 mg/dl (28.9%); the mean arteriosclerotic index decreased significantly from 2.98 to 2.08 (30.2%). There were no significant changes in either triglyceride levels or high-density lipoprotein cholesterol (HDL-C) levels. In the nontreated group, there were no significant changes in the TC, HDL-C, LDL-C, or triglyceride levels; there was also no change in the arteriosclerotic index. After 6 months, the TC level, LDL-C level, and arteriosclerotic index were significantly lower in the treated group compared with the nontreated group (p<0.01). CONCLUSIONS: The results indicate that the HMG-CoA reductase inhibitor lowered TC and LDL-C levels and was useful in the treatment of hypoestrogenic hyperlipidemia for periods of at least 6 months.

[Surgical treatment for infective endocarditis with multiple embolic complications].

A 59-year-old man was transferred to our hospital because of severe right leg pain, dyspnea and anuria. Due to severe cyanosis of the legs below the knees and severe hyperkalemia, he had undergone embolectomy of the right femoral artery and hemodialysis. Medical treatment for infective endocarditis was started after the first operation, because transesophageal echo cardiography revealed severe aortic regurgitation and massive vegetation of the aortic valve. Amputation of the right leg below the knee and of the left leg below the Lisfranc joint was performed after 19 days and aortic valve replacement with patch closure of a perivalvular abscess was performed one month after the first operation. The post-operative course was uneventful. He was weaned from hemodialysis and the follow-up echocardiographic study revealed no vegetation.

Synthesis of pyrimidine 2'-deoxy ribonucleosides branched at the 2'-position via radical atom-transfer cyclization reaction with a vinylsilyl group as a radical-acceptor tether.

Recently, we developed a regio- and stereoselective method for introducing a vinyl group at the position beta to a hydroxyl group in halohydrins or alpha-phenylselenoalkanols via a radical atom-transfer cyclization reaction with a vinylsilyl group as a temporary connecting radical-acceptor tether. The synthesis of 2'-deoxy-2'-C-vinyl- and 2'-deoxy-2'-C-hydroxymethyluridines (7 and 8, respectively) and the corresponding 2'-deoxycytidine congeners (10 and 11, respectively), which were designed as potential antitumor and/or antiviral agents, was achieved using this radical atom-transfer cyclization as the key step. When the 2'-deoxy-2'-iodo-5'-O-monomethoxytrityl (MMTr) uridine derivative 19a, bearing a vinylsilyl group at the 3'-hydroxyl group, was heated with (Me(3)Sn)(2) and AIBN in benzene, the corresponding radical atom-transfer product was generated, which in turn was successively treated with tetrabutylammonium fluoride and TBSCl/imidazole to give the desired 2'-deoxy-5'-O-MMTr-3'-O-TBS-2'-C-vinyluridine (25). Compound 25 was successfully converted into the target 2'-deoxy-2'-branched pyrimidine ribonucleosides 7, 8, 10, and 11.

(-)-Epigallocatechin gallate inhibits mos activation-mediated xenopus oocyte maturation induced by progesterone.

(-)-Epigallocatechin gallate (EGCG), one of the constituents of green tea known to have a tumor preventing effect, inhibited maturation of Xenopus laevis oocytes induced by progesterone when this polyphenol was microinjected into oocytes at a final concentration of about 1 mM. Western blot and activity measurement analyses showed that Mos translation and the subsequent activations of mitogen-activated protein kinase and p90(rsk), probably by protein phosphorylation, seemed to have been inhibited by the microinjection of EGCG. These results suggest that EGCG may have the ability to control Xenopus oocyte maturation at least during the stage of Mos activation.