Calf extra-Fascial compartment area affects calf muscle pumping action: an air plethysmography and computed tomography study.

OBJECTIVES: We aimed to elucidate whether lower limb extra-fascial compartment and muscle areas affect the calf muscle pumping action on lower limbs. METHOD: This study included 90 patients (180 limbs) who underwent preoperative air plethysmography (APG) and preoperative non-contrast computed tomography (CT) of the lower limbs for diagnosis of unilateral or bilateral primary varicose veins. A correlation between cross-sectional CT images and preoperative APG was confirmed. Cross-sectional CT was used to measure the extra-fascial compartment and muscle areas of the calf. The lower limbs were divided into two groups: those that were normal and those with primary varicose veins. RESULTS: The extra-fascial compartment area was significantly correlated with the ejection fraction in normal (r = 0.388, n = 53, p = 0.004) and varicose limbs (r = 0.232, n = 91, p = 0.027). CONCLUSIONS: In normal and varicose limbs, evaluation of ejection fraction, an indicator of muscle pumping, requires consideration of the extra-fascial compartment area.

Prediction Models for Two Year Overall Survival and Amputation Free Survival After Revascularisation for Chronic Limb Threatening Ischaemia.

OBJECTIVE: The aim of this study was to create prediction models for two year overall survival (OS) and amputation free survival (AFS) after revascularisation in patients with chronic limb threatening ischaemia (CLTI). METHODS: This was a retrospective analysis of prospectively collected multicentre registry data (JAPAN Critical Limb Ischaemia Database; JCLIMB). Data from 3 505 unique patients with CLTI who had undergone revascularisation from 2013 to 2017 were extracted from the JCLIMB for the analysis. The cohort was randomly divided into development (2 861 patients) and validation cohorts (644 patients). In the development cohort, multivariable risk models were constructed to predict two year OS and AFS using Cox proportional hazard regression analysis. These models were applied to the validation cohort and their performances were evaluated using Harrell's C index and calibration plots. RESULTS: Kaplan-Meier estimates of two year OS and AFS post-revascularisation in the whole cohort were 69% and 62%, respectively. Strong predictors for OS consisted of age, activity, malignant neoplasm, chronic kidney disease (CKD), congestive heart failure (CHF), geriatric nutritional risk index (GNRI), and sex. Strong predictors for AFS included age, activity, malignant neoplasm, CKD, CHF, GNRI, body temperature, white blood cells, urgent revascularisation procedure, and sex. Prediction models for two year OS and AFS showed good discrimination with Harrell's C indexes of 0.73 (95% confidence interval [CI] 0.69 - 0.77) and 0.72 (95% CI 0.68 - 0.76), respectively CONCLUSION: Prediction models for two year OS and AFS post-revascularisation in patients with CLTI were created. They can assist in determining treatment strategies and serve as risk adjustment modalities for quality benchmarking for revascularisation in patients with CLTI at each facility.

Heterogeneity of Age and Its Associated Features in Patients with Critical Limb Ischemia.

Aim: Critical limb ischemia (CLI) has a wide age distribution. We aimed here to reveal age-associated clinical features in CLI patients. Materials and Methods: We analyzed 531 Japanese CLI patients referred to vascular centers. The three-year mortality risk by age was compared to that for the Japanese nationals, derived from Japan's national life table data. Clinical characteristics associated with age in CLI patients were also explored. Results: Mean age was 73±10 years. Whereas 27.9% were aged ≥80 years, 19.2% were aged <65 years. Mortality risk was increased with age, but its risk ratio relative to the same-aged nationals was higher in younger patients. Incidence of major amputation was higher in a younger population. Receiving welfare, smoking, increased body mass index, diabetes with hemoglobin A1c ≥7.0%, non-high density lipoprotein cholesterol ≥190 mg/dL, renal failure, and the Wound, Ischemia, and foot Infection classification stage 4 were associated with younger age, whereas non-ambulation and institutionalization were associated with older age. Conclusion: Patients aged <65 years, belonging to the working-age population, reached almost one fifth of the CLI population. Younger patients had a lower mortality risk in the population, but had a higher risk ratio relative to the same-aged nationals. Socioeconomic disadvantage, poor cardiovascular risk control, and wound severity were associated with younger age.

A Case of Iliac Aneurysm with Persistent Sciatic Artery Treated by Endovascular Aneurysm Repair.

A persistent sciatic artery (PSA) is a rare congenital vascular anomaly that occurs in approximately 0.01 to 0.06% of the population. We encountered a patient with aneurysms in the common iliac-internal iliac artery continuous to an occluded right PSA. The patient was an 85-year-old male in whom intermittent claudication of the right lower limb appeared 3 months ago. The right ankle-brachial index (ABI) was 0.48. On contrast computed tomography, the right PSA was present and was occluded over the popliteal artery. The right superficial femoral artery was hypoplastic. Moreover, abdominal aortic (diameter: 42 mm) and right common-internal iliac (diameter: 46 mm) aneurysms continuous to the PSA were present. For the surgical procedure, endovascular aneurysm repair was selected. First, the right internal iliac artery was embolized, an aortouni-iliac stent graft was placed from the infrarenal aorta down to the left common iliac artery, and left common femoral-right deep femoral artery bypass was performed to achieve revascularization of the right lower limb. Postoperatively, the aneurysms were favorably excluded with stent grafts without endoleak. The right ABI markedly improved to 0.83, and claudication was resolved. There are few reports of iliac aneurysm with a concomitant PSA.

A Case of Patent Ductus Arteriosus in an Elderly Patient Treated by Thoracic Endovascular Aortic Repair.

The patient described herein was a 75-year-old female. Echocardiography showed patent ductus arteriosus (PDA). Heart failure symptoms gradually appeared, and she was referred to our department for treatment. Contrast-enhanced computed tomography (CT) revealed a tubular structure communicating between the aortic arch and pulmonary artery trunk, suggesting adult PDA. Thoracic endovascular aortic repair (TEVAR) was performed to close PDA. Completion angiography confirmed the disappearance of PDA. Post-TEVAR CT revealed no endoleak. The patient was discharged from the hospital on the 11th day after surgery. TEVAR is more useful and less invasive for adult PDA than conventional open surgery.

The prognosis of patients on hemodialysis with foot lesions.

OBJECTIVE: Many studies have shown the high prevalence and incidence of peripheral arterial disease and the marked morbidity and mortality associated with peripheral arterial disease in hemodialysis patients. The purpose of this retrospective study was to clarify the probability of survival and limb salvage in patients with foot lesions and how to manage these patients. METHODS: Data were collected in a retrospectively maintained database for 319 lower limbs with foot lesions in 234 hemodialysis patients treated in a university hospital between 1980 and 2011. Variances influencing survival and limb salvage were compared using log-rank tests and Cox regression analysis. These variables were examined using Kaplan-Meier analysis. Significant factors in bivariate analysis were included in a logistic regression model to determine independent predictors and the probability of failure. RESULTS: The 234 patients (72% men) were a mean age of 65.4 years on admission, and 84% had diabetes. The mean duration of hemodialysis was 6.8 years. During the follow-up period, 171 patients (73%) died. The 1-, 3-, 5-, and 7-year survival rates were 65.2%, 35.5%, 23.4%, and 12.8%, respectively. According to Cox multivariate models, age at admission and ischemic changes on an electrocardiogram independently increased the risk of death (hazard ratios, 1.02 and 1.48, respectively). Conversely, hyperlipidemia independently decreased the risk of death (hazard ratio, 0.56). Critical limb ischemia was present in 247 limbs (77%). Arterial reconstruction was done in 88 limbs (28%), and 119 limbs (37%) required major amputation. The overall 1-, 3-, 5- and 7-year limb salvage rates were 68.9%, 57.2%, 53.8%, and 51.7 %, respectively. According to Cox multivariate models, patent arterial reconstruction and albumin independently decreased the risk of major amputation (hazard ratios, 0.265 and 0.392, respectively). CONCLUSIONS: Hemodialysis patients with foot lesions have a poor prognosis, with high rates of mortality and amputation. Prompt assessments of the severity of systemic conditions, such as cardiac ischemia, and focal wound conditions, such as ischemia and infection, are necessary to treat hemodialysis patients with foot lesions.

Remodeling of proximal neck angulation after endovascular aneurysm repair.

OBJECTIVE: This study investigated the remodeling of proximal neck (PN) angulations of abdominal aortic aneurysms (AAAs) after endovascular aneurysm repair (EVAR). METHODS: A 64-row multidetector computed tomography scan of AAAs treated with EVAR was reviewed, and the PN angulation was measured on a volume-rendered three-dimensional image. The computed tomography scan was examined preoperatively, after EVAR at 1 week, 1 month, 6 months, 1 year, 1.5 years, 2 years, and then yearly. The study enrolled 78 patients, comprising 54 Zenith devices (Cook Medical, Bloomington, Ind) and 24 Excluder devices (W. L. Gore and Associates, Flagstaff, Ariz). RESULTS: PN angulation was 50° ± 20° preoperatively, and after EVAR was 36° ± 14° at 1 week, 32° ± 14° at 1 year, and 28° ± 13° at 3 years. PN angulations ≤ 60° (n = 70, 77%) were 41° ± 13° preoperatively, 31° ± 12° 1 week after EVAR, 28° ± 12° at 1 year, and 26° ± 13° after 3 years. An angulation >60° (n = 18, 23%) was 78° ± 14° preoperatively, 51° ± 11° 1 week after EVAR, 44° ± 11° at 1 year, and 40° ± 12° after 3 years. The greater the preoperative PN angulation, the greater its reduction immediately after EVAR (r = .72, P < .001). The diameter shrinkage of AAAs with a PN angulation >60° was 3 ± 6 mm after 1 year; a significantly smaller shrinkage than with a PN angulation ≤ 60° (7 ± 7 mm, P < .05). AAAs with a PN angulation >60° had a larger angulation reduction and a smaller diameter shrinkage after the EVAR procedure. The PN angulation of the 54 AAAs treated by Zenith was 49° ± 22° preoperatively, 34° ± 14° 1 week after EVAR, and 25° ± 13° after 3 years. The corresponding angulation of the 24 AAAs treated by Excluder devices was 52° ± 17°, 41° ± 14°, and 38° ± 9°, respectively. The PN angulation reduction of Zenith and Excluder was similar 1 week after the EVAR procedure. Unlike Excluder, however, the PN angulation in Zenith continued to reduce for a long period at a slow pace. There were no significant correlations between PN angulation reduction and diameter change and between PN length and diameter change (P = .86 and .18, respectively). CONCLUSIONS: Although the instructions for use of most commercially available stent grafts provide for a PN angulation of ≤ 60°, PN angulation was not a major issue in a midterm follow-up of AAAs with adequate PN length for patients in this series who received a Zenith or Excluder graft.

Partial debranching hybrid stent graft for distal aortic arch aneurysms.

PURPOSE: To evaluate the early outcomes of treating distal aortic arch aneurysms (DAAAs) with a partial debranching hybrid stent graft, and to analyze the morphology of distances among the supra-aortic branches. METHODS: We used this stent graft to treat DAAA in 12 patients, by debranching the left common carotid artery (LCCA) and the left subclavian artery (LSA). With computed tomography (CT) data on the collective total 28 thoracic aortic aneurysms, the distances from the LSA to the LCCA and those from the LSA to the brachiocephalic artery (BA) were measured using multiplanar reconstruction (MPR) and centerline of flow (CLF) methods. RESULTS: All procedures were done in two stages and all stent grafts were deployed in zone-1. The devices used were the TALENT in seven patients and the TAG in five patients. There were no operative deaths, paraplegia, or type-1 or -3 endoleaks. One patient suffered minor cerebral infarction. The distance from the LSA to the BA was longer than that from the LSA to the LCCA by 10 mm in the CLF method and by 13 mm in the MPR method. CONCLUSIONS: It was possible to achieve a longer proximal landing zone by debranching two supra-aortic branches, the LCCA and the LSA. The partial debranching hybrid stent graft was less invasive and more effective for DAAAs.

Stent strut penetration during thoracic endovascular aortic repair: report of a case.

We experienced a serious complication of proximal stent strut penetration (PSSP) during thoracic endovascular aortic repair in a 74-year-old man who underwent two-stage hybrid treatment for a distal arch thoracic aortic aneurysm. First, a debranching right common carotid-left common carotid-left subclavian artery bypass was performed. Second, a TALENT Thoracic Stent Graft (Medtronic, Tokyo, Japan) was inserted at Zone 1 (Ishimaru). At deployment, a proximal bare strut accidentally everted and penetrated the aortic wall vertically. Postoperative computed tomography revealed that one crown of the proximal strut had penetrated the aortic wall vertically and had produced an intramural hematoma around the strut. The patient was observed carefully and discharged from the hospital without any sequelae. Seven months after the procedure, there was no remarkable change and his aneurysm was well excluded. PSSP can cause retrograde type-A aortic dissections. A bare strut tends to cause proximal strut penetration more frequently than a covered strut. More caution should be taken in the deployment of a stent graft with a bare strut.

Huge hemangioma in the chest mimicking a breast tumor: report of a case.

A 35 year-old man first noticed an elastic mass like breast tumor in his left chest 17 years ago. It enlarged to the size of a child's head. Computed tomography showed a well-circumscribed mass in the left chest. Lumpectomy was performed. The mass was located under the thin major pectoralis muscle, covered with a white fibrous capsule. The specimen weighed 1360 g and measured 18 × 14 × 8 cm. Histological examination revealed a cavernous hemangioma. To the best of our knowledge, this is the first reported case of a chest hemangioma arising from connective tissue and located under the major pectoralis muscle.

Mid-term results of endovascular abdominal aortic aneurysm repair: is it possible to predict sac shrinkage?

PURPOSE: To evaluate the mid-term results of endovascular repair of abdominal aortic aneurysms and to predict subsequent sac shrinkage. METHODS: From December 2006 to April 2010, 114 abdominal aortic aneurysms were treated with stent grafts. The intraoperative sac pressure was measured by a microcatheter. Correlations between the diameter change and relevant factors were determined by a logistic regression analysis. RESULTS: Stent grafts were deployed successfully in all patients. Type-2 endoleaks were noted in 25 patients (22%); there were no type-1 or type-3 endoleaks at discharge. The clinical success rate was 99%. The diameter was reduced in 40 patients (56%) but remained unchanged in 32 (44%). There were no aneurysms that increased in diameter. At 2 years after the repair the rate of cumulative survival was 87% and freedom from secondary intervention was 95%. The sac pressure index after stent grafting with a reduced diameter was 0.56 ± 0.11 and that of patients with an unchanged diameter was 0.52 ± 0.14. There were no significant differences between the two groups. Persistent type-2 endoleaks had a slightly negative effect on sac shrinkage (P = 0.052). CONCLUSIONS: The mid-term results of endovascular aneurysm repair were satisfactory. Although it was difficult to predict the fate of a sac after stent grafting, persistent type-2 endoleaks were observed to have a slightly negative impact on sac shrinkage.

Intraoperative sac pressure measurement during endovascular abdominal aortic aneurysm repair.

PURPOSE: Intraoperative sac pressure was measured during endovascular abdominal aortic aneurysm repair (EVAR) to evaluate the clinical significance of sac pressure measurement. METHODS: A microcatheter was placed in an aneurysm sac from the contralateral femoral artery, and sac pressure was measured during EVAR procedures in 47 patients. Aortic blood pressure was measured as a control by a catheter from the left brachial artery. RESULTS: The systolic sac pressure index (SPI) was 0.87 +/- 0.10 after main-body deployment, 0.63 +/- 0.12 after leg deployment (P < 0.01), and 0.56 +/- 0.12 after completion of the procedure (P < 0.01). Pulse pressure was 55 +/- 21 mmHg, 23 +/- 15 mmHg (P < 0.01), and 16 +/- 12 mmHg (P < 0.01), respectively. SPI showed no significant differences between the Zenith and Excluder stent grafts (0.56 +/- 0.13 vs. 0.54 +/- 0.10, NS). Type I endoleak was found in seven patients (15%), and the SPI decreased from 0.62 +/- 0.10 to 0.55 +/- 0.10 (P = 0.10) after fixing procedures. Type II endoleak was found in 12 patients (26%) by completion angiography. The SPI showed no difference between type II endoleak positive and negative (0.58 +/- 0.12 vs. 0.55 +/- 0.12, NS). There were no significant differences between the final SPI of abdominal aortic aneurysms in which the diameter decreased in the follow-up and that of abdominal aortic aneurysms in which the diameter did not change (0.53 +/- 0.12 vs. 0.57 +/- 0.12, NS). CONCLUSIONS: Sac pressure measurement was useful for instant hemodynamic evaluation of the EVAR procedure, especially in type I endoleaks. However, on the basis of this small study, the SPI cannot be used to reliably predict sac growth or regression.

A case of persistent sciatic artery aneurysm accompanied by a persistent sciatic vein.

A persistent sciatic artery is a rare anomaly. On the other hand, a persistent sciatic vein is frequently associated with Klippel-Trenaunay syndrome. In a 71-year-old female with a complete-type persistent sciatic artery aneurysm, we performed aneurysmectomy and right femoropopliteal bypass surgery. The right popliteal vein drained into the femoral vein via a lower-type persistent sciatic vein and the deep femoral vein. The superficial femoral artery and vein were hypoplastic. Since only 4 cases of a coexisting persistent sciatic artery and vein have been reported, we report this extremely rare case.

Endovascular repair for a descending thoracic aortic aneurysm with a stent-graft covering the celiac artery: report of two cases.

An adequate landing zone for fixation and sealing is necessary for endovascular aneurysm repair (EVAR). This report presents two cases of a successful EVAR for thoracic aortic aneurysms (TAA) with a stent-graft covering the celiac artery (CA) to secure a distal landing zone. Case 1 was a 61-year-old man with a chronic traumatic descending TAA 12 mm away from the CA. Case 2 was a 79-year-old man with a descending TAA proximal to the CA. Preoperative angiography and computed tomography (CT) scan revealed a normal visceral blood flow including the peripancreatic arteries. Endovascular aneurysm repair with coverage of the CA was performed in both cases. Angiography after the EVAR demonstrated good blood flow to the CA branches via the peripancreatic arteries and a CT scan showed thrombosed aneurysms. Both patients were discharged without any abdominal symptoms. Endovascular aneurysm repair with a stent-graft covering the CA may therefore be an acceptable endovascular approach in treating selected TAA patients with a limited distal landing zone.

Transcutaneous carbon dioxide tension for the evaluation of limb ischemia.

PURPOSE: Understanding the hemodynamics of critical limb ischemia caused by chronic peripheral arterial occlusive disease is important to evaluate its severity and the efficacy of treatment. We investigated the usefulness of transcutaneous carbon dioxide tension (tcPCO(2)) measurement for evaluating ischemic limbs, in conjunction with the measurement of ankle pressure (AP), toe pressure (TP), skin perfusion pressure (SPP), and transcutaneous oxygen tension (tcPO(2)). METHODS: We measured tcPCO(2) in the dorsum of the foot in 158 patients (304 limbs) with arteriosclerosis obliterans. RESULTS: The tcPCO(2) in normal limbs without any clinical sign or abnormal noninvasive measurement was 43.7 +/- 3.7 mmHg; that in noncritical ischemic limbs was 45.5 +/- 9.0 mmHg, which was not significantly different from that in the normal limbs; and that in critically ischemic limbs was 87.6 +/- 35.5 mmHg, which was significantly different from that in the normal limbs. All limbs with a tcPCO(2) of 100 mmHg or higher, indicative of critical ischemia, had a tcPCO(2) of less than 100 mmHg after revascularization. CONCLUSION: We found tcPCO(2) to be a useful measurement for diagnosing the severity of limb ischemia, and for evaluating the effect of treatment, especially in patients with critically ischemic limbs.

Quantitative assessment of therapeutic effects in the critically ischemic limb using (99m)Tc-diethylene-triamine-pentaacetic acid human serum albumin.

PURPOSE: To investigate the reliability and limitations of a new radioisotope method using (99m)Tc-diethylenetriamine-pentaacetic acid human serum albumin (Tc-99m-DTPA-HSA) and to evaluate the diagnostic ability of isotope infusion for assessing hemodynamic changes in the foot before and after treatment. METHODS: Hemodynamic changes before and after treatment were assessed in 21 limbs with ulcer or gangrene, by analyzing changes in the time-activity curve, the uptake ratio, and the values obtained with noninvasive techniques. RESULTS: There were significant differences between each pair of the three types of time-activity curve and their uptake counts. The uptake ratio was correlated with ankle blood pressure (ABP) and toe blood pressure (TBP), but not with transcutaneous oxygen pressure (tcPO(2)) or skin perfusion pressure (SPP). The hemodynamic change induced by pharmacotherapy was subtle, but that induced by arterial reconstruction was remarkable. Although there was not always a good correlation between the degree of hemodynamic change and the clinical outcome in limbs treated with pharmacotherapy, the hemodynamic change was quantitatively assessed. CONCLUSION: Our study suggests that this isotope technique is a useful quantitative method to evaluate hemodynamic change from a different perspective to conventional noninvasive methods.

Abdominal aortic aneurysm surgery for octogenarians.

PURPOSE: To define the indications for abdominal aortic aneurysm (AAA) surgery in octogenarians. METHODS: We reviewed septuagenarians and octogenarians with a nonspecific AAA diagnosed at our hospital between January, 1990 and June, 2006. RESULTS: Among a total 628 patients seen, 306 were in their 70s (group A) and 108 were in their 80s or older (group B). The mortality rate associated with elective surgery was 1.9% in group A and 7.0% in group B. Of the survivors, 12 (5.7%) of 210 in group A and 8 (15.1%) of 53 in group B died within 2 years. Of the patients who did not undergo surgery, 8 of 53 in group A and 8 of 31 in group B had AAAs greater than 6 cm in diameter. The rupture-free rates of AAAs greater than 6 cm in diameter were 64% at 1 year and 0% at 4 years in group A, and 88% at 1 year and 26% at 3 years in group B. The rupture-free rates of AAAs smaller than 6 cm in diameter were 95% at 3 years and 85% at 5 years in group A, and 100% at 5 years in group B. CONCLUSIONS: We concluded that AAAs over 6 cm in diameter were an appropriate indication for surgery in octogenarians.

Clinical reliability and utility of skin perfusion pressure measurement in ischemic limbs--comparison with other noninvasive diagnostic methods.

PURPOSE: We studied whether the measurement of skin perfusion pressure (SPP) is useful for evaluating ischemic limbs and predicting wound healing. METHODS: Two hundred eleven patients (age range, 45 to 90 years; mean age, 69.6 +/- 9.2 years; 170 men and 41 women), 403 limbs with arteriosclerosis obliterans, were included in this study. Half of the patients had diabetes or were receiving dialysis or both. RESULTS: Significant correlations were found between SPP and ankle blood pressure (ABP), SPP and toe blood pressure (TBP), and SPP and the transcutaneous oxygen pressure (tcPO2) (P < .0001, r = 0.75; P < .0001, r = 0.85; P < .0001, r = 0.62; respectively). In 94 limbs with ulcer or gangrene, wound healing was predicted by the SPP. The mean SPP (mean +/- SD) in the healed-wound group (25 limbs, 48 +/- 20 mm Hg) was greater than that in the unhealed-wound group (69 limbs, 23 +/- 11 mm Hg) (P <.001). According to the receiver operating characteristic (ROC) curve, the cut-off value of SPP was 40 mm Hg (sensitivity, 72%; specificity, 88%). Furthermore, we studied whether the combination of SPP and another measurement could predict wound healing more accurately than could any single variable. There was a strong correlation between SPP, TBP, and the healing rate (P < .001, r = 0.69) and healing could be accurately predicted if the SPP was greater than 40 mm Hg and if the TBP was greater than 30 mm Hg. CONCLUSIONS: Our results suggest that measurement of SPP is an objective method for assessing the severity of peripheral arterial disease or for predicting wound healing.