Subacute Limb Ischemia Suspected from COVID-19-Related Arterial Thrombosis Presenting with Local Occlusion Site Tenderness.

A 59-year-old man was admitted to our hospital with severe popliteal fossa pain and mild left calf claudication. He had had an episode of pyrexia and dyspnea approximately 3 weeks prior. Contrast-enhanced computed tomography revealed acute occlusion of the left popliteal artery and multiple infiltration shadows with bilateral multifocal parenchymal consolidation of the lungs, suggesting post-coronavirus disease 2019 (COVID-19) pneumonia. As he had no comorbid risk of cardiogenic embolism or atherosclerosis, we diagnosed him with COVID-19-related arterial thrombosis. COVID-19-related arterial thrombosis should be considered a possible cause of acute limb ischemia, even when ischemic symptoms occur several weeks post infection.

A case of endovascular treatment for iatrogenic left vertebral artery injury due to central line catheter placement.

We describe a case of endovascular treatment for an iatrogenic left vertebral artery injury after central line catheter placement in a 68-year-old male patient. The patient had a massive pulmonary embolism, and a Swan-Ganz catheter was required to monitor the patient's circulatory condition. However, the catheter was inserted into the left vertebral artery and passed through the left internal jugular vein. Endovascular treatment was indicated due to the patient's poor general health. Complete hemostasis was achieved, and the postoperative course was uneventful without neurologic deficits.

Validation of the Diagnostic Criteria for IgG4-Related Periaortitis/Periarteritis and Retroperitoneal Fibrosis (IgG4PA/RPF) 2018, and Proposal of a Revised 2023 Version for IgG4-Related Cardiovascular/Retroperitoneal Disease.

BACKGROUND: In 2018, diagnostic criteria were introduced for IgG4-related periaortitis/periarteritis and retroperitoneal fibrosis (PA/RPF). This study assessed the existing criteria and formulated an improved version.Methods and Results: Between August 2022 and January 2023, we retrospectively analyzed 110 Japanese patients diagnosed with IgG4-related disease (IgG4-RD) involving cardiovascular and/or retroperitoneal manifestations, along with 73 non-IgG4-RD patients ("mimickers") identified by experts. Patients were stratified into derivation (n=88) and validation (n=95) groups. Classification as IgG4-RD or non-IgG4-RD was based on the 2018 diagnostic criteria and various revised versions. Sensitivity and specificity were calculated using experts' diagnosis as the gold standard for the diagnosis of true IgG4-RD and mimickers. In the derivation group, the 2018 criteria showed 58.5% sensitivity and 100% specificity. The revised version, incorporating "radiologic findings of pericarditis", "eosinophilic infiltration or lymphoid follicles", and "probable diagnosis of extra-PA/-RPF lesions", improved sensitivity to 69.8% while maintaining 100% specificity. In the validation group, the original and revised criteria had sensitivities of 68.4% and 77.2%, respectively, and specificities of 97.4% and 94.7%, respectively. CONCLUSIONS: Proposed 2023 revised IgG4-related cardiovascular/retroperitoneal disease criteria show significantly enhanced sensitivity while preserving high specificity, achieved through the inclusion of new items in radiologic, pathological, and extra-cardiovascular/retroperitoneal organ categories.

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.

Design Optimization Method for Large-Size Sidewall-Driven Micromixer to Generate Powerful Swirling Flow.

Microfluidic devices, which miniaturize cell culture and chemical experiments from lab-scale to microchip dimensions, have gained significant attention in recent years. Extensive research has been conducted on microfluidic mixers, which facilitate the mixing and agitation of chemicals. The "Sidewall-Driven Micromixer" that we are currently developing employs a unique mechanism; it induces a swirling flow within the main chamber by vibrating the silicone wall situated between the main and driving chambers using pressure fluctuations. In an earlier study, we found that Sidewall-Driven Micromixers of a size suitable for small cells could indeed produce this swirling flow. Furthermore, we successfully established concentration gradients within each mixer. However, when attempting to upscale the mixer while maintaining conventional proportions to accommodate larger cell aggregates such as spheroids, the desired swirling flow was not achieved. To address this challenge, we made adjustments to the wall dimensions, aiming to amplify wall deformation and thereby enhance the mixer's driving force. Concurrently, we modified the mixer's shape to ensure that the increased wall deformation would not hinder the fluid flow. These alterations not only improved the mixer's performance but also provided valuable insights for positioning the mixer's neck channel, considering the extent of wall deformation.

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.

Area reduction of perforation with a small-size sheath technique for iatrogenic femoral artery pseudoaneurysm with a large perforation.

Open surgery for femoral artery pseudoaneurysms is invasive, and complications can be detrimental. Several cases of treatment of iatrogenic femoral artery pseudoaneurysms using percutaneous suture-mediated closure devices have been reported. However, it is difficult to properly deploy the foot of the device to the arterial wall when the perforation area is large. We developed a technique using a double guidewire to partially occupy the perforation with a small-size sheath, which reduces the area of the perforation. This AREPAS (area reduction of perforation with a small-sized sheath) technique might allow for minimally invasive closure of perforations even in patients with large perforation areas.

A case of popliteal artery rupture in an 11-year-old patient with vascular Ehlers-Danlos syndrome.

We have described a case of multiple surgeries for a ruptured popliteal artery in an 11-year-old female patient with vascular Ehlers-Danlos syndrome. She underwent emergency hematoma evacuation and ruptured popliteal artery interposition with the great saphenous vein graft, which was notably fragile during surgery and had ruptured on the seventh postoperative day. We performed another emergency hematoma evacuation and popliteal artery interposition with an expanded polytetrafluoroethylene vascular graft. Despite the early occlusion of the expanded polytetrafluoroethylene graft, she recovered with mild intermittent claudication in the left lower extremity and was discharged on postoperative day 20 after the first surgery.

Popliteal artery aneurysm in a 14-year-old boy with tuberous sclerosis complex.

Tuberous sclerosis complex (TSC) is rarely associated with aneurysms. We have described a patient with a popliteal artery aneurysm that was associated with TSC and occlusion of the right posterior tibial artery. The patient underwent aneurysm resection and vein graft replacement, with an uneventful postoperative course and no recurrence at 11 months of follow-up. Patients with TSC could have aneurysms in areas that will not be recognized on abdominal imaging. Physical examination of the lower extremities should be performed owing to the possibility of a popliteal artery aneurysm, and imaging studies should be performed if an aneurysm is suspected.

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.

Tapered, Twisted Bundled-Tube Locomotive Devices for Stepped Pipe Inspection.

The twisted bundled-tube locomotive device is an elongated soft robot that moves inside a pipe in a helical bending motion. This motion mimics the behavior of microorganisms called spirochetes. This device is inexpensive and easy to miniaturize because of its simple structure, which consists of three inflatable tubes twisted together. It can move in pipes of various diameters without a change in design. Therefore, it has a high capacity for water pipe inspection. However, it has not yet been shown to pass through step parts wherein the diameter of the pipes decreases. In this study, we developed a device that was deformed into a tapered shape by changing the pitch of the spirals at each location. The prototype device was able to move from a pipe with an inside diameter of 52.9 mm to a pipe with an inside diameter of 21.6 mm for horizontally fixed pipes, and from a pipe with an inside diameter of 41.6 mm to a pipe with an inside diameter of 21.6 mm for vertically fixed pipes.

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.

Haemosuccus Pancreaticus Caused by Splenic Artery Aneurysm Derived from Isolated Spontaneous Coeliac Artery Dissection: Two Case Reports.

Objective: Two cases of haemosuccus pancreaticus (HP), a rare cause of gastrointestinal bleeding caused by splenic artery aneurysm derived from isolated spontaneous coeliac artery dissection (ISCAD), are reported. Case report: The first case was a 62-year-old man with a history of hypertension who presented with abdominal pain and melaena. Laboratory tests indicated slight anaemia and a high serum amylase level. Computed tomography (CT) showed coeliac artery dissection and a splenic aneurysm. Endoscopic retrograde cholangiopancreatography suggested a communication between the main pancreatic duct and the aneurysm. A laparoscopic distal pancreatectomy was performed. The second case was a 49-year-old man who had been followed up with coeliac artery dissection and a splenic aneurysm, and developed abdominal pain, haematemesis, and melaena. CT did not show degeneration of the coeliac and splenic lesions, and multiple endoscopies failed to detect the source of bleeding. However, the patient was clinically diagnosed with HP and had a successful transcatheter arterial embolisation. There was no recurrence in either case. Conclusion: HP should be considered in cases with adjacent splenic aneurysms, especially under fragile arterial conditions such as ISCAD.

Sac enlargement due to perigraft seroma and back-bleeding from the remnant wall 11 years after open surgical repair of an infected abdominal aortic aneurysm.

We describe a case of sac enlargement that occurred 11 years after emergent open surgical repair of an infected abdominal aortic aneurysm. The diameter of the sac covering the Dacron graft had gradually expanded to 80 mm, and the flow of contrast medium into the sac was suspected. Elective surgery revealed a perigraft seroma and back-bleeding from the remnant wall. After attaining hemostasis, fibrin glue and oxidized cellulose were applied, and sac plication was performed. Thereafter, the sac has not expanded. Open diagnostic treatment should be a good option for cases of postoperative sac enlargement with an unknown origin.

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.

Pulsation Reduction Using Dual Sidewall-Driven Micropumps.

Single-cell manipulation in microfluidic channels at the micrometer scale has recently become common. However, the current mainstream method using a syringe pump and a piezoelectric actuator is not suitable for long-term experiments. Some methods incorporate a pump mechanism into a microfluidic channel, but they are not suitable for mass production owing to their complex structures. Here, we propose a sidewall-driven micropump integrated into a microfluidic device as well as a method for reducing the pulsation of flow. This sidewall-driven micropump consists of small chambers lined up on both sides along the main flow path, with a wall separating the flow path and each chamber being deformed by air pressure. The chambers are pressurized to make the peristaltic motion of the wall possible, which generates flow in the main flow path. This pump can be created in a single layer, which allows a simplified structure to be achieved, although pulsation can occur when the pump is used alone. We created two types of chips with two micropumps placed in the flow path and attempted to reduce pulsation by driving them in different phases. The proposed dually driven micropump reduced pulsation when compared with the single pump. This device enables precise particle control and is expected to contribute to less costly and easier cell manipulation experiments.