Positioning for Endovenous Laser Ablation: Comparative Study with Thigh Stripping.

We performed a comparative study of surgical outcomes and venous functions between endovenous laser ablation with a 980-nm diode laser (EV group) and thigh stripping (ST group). There were no severe complications and initial success rates were 100% in both groups. In the EV group, preoperative symptoms improved in 94.3% of cases, the venous occlusion rate was 98%, and endovenous heat induced thrombosis had occurred in 11.9% (Class 3: 0.7%) at 12 months after the operation. Although comparative study of postoperative venous function by air plethysmography showed significant improvement in both groups, there was less recovery of postoperative venous function in the EV than in the ST group. (This article is a translation of J Jpn Coll Angiol 2015; 55: 13-20.).

Long-Term Results of Obturator Bypass.

OBJECTIVE: We evaluated the long-term outcomes of obturator bypass. MATERIAL AND METHODS: A total of 16 patients (13 males and 3 females; 17 limbs) who underwent obturator bypass surgery at our department between April 1995 and March 2008 were included. RESULTS: Their ages ranged from 50 to 90 with a mean of 74 years. Inguinal infections observed in the 16 patients consisted of vascular graft infections in 13 patients, hemostatic device infections following endovascular therapy in two patients, and femoral artery infections following coronary angiography in one patient. The cumulative patency rate was 69% for 3 years and 43% for 5 years. The cumulative survival rate was 64% for 3 years and 55% for 5 years. CONCLUSION: Obturator bypass surgery was successfully performed with favorable results for arterial infections and vascular graft infections in the inguinal region.

Simple Interrupted Suturing for Redo Mitral Valve Replacement.

BACKGROUND: An evaluation was made of the early clinical outcomes and efficacies of simple interrupted suturing (SIS) for redo mitral valve replacement (MVR). METHODS: Among 336 mitral valve surgery patients at the authors' institution between April 2000 and May 2014, a total of 21 redo MVR using SIS (12 women, nine men; mean age 67±11 years; range 32-80 years) participated in the study. Surgical indications for redo MVR were paravalvular leakage (PVL) in 10 patients, prosthetic valve endocarditis in five, mechanical valve thrombosis in three, and structural valve deterioration (SVD) of the bioprosthesis in three. The number of previous surgeries was one in 10 patients, two in seven, and three in four. With regards to surgical technique, sharp dissection was initially performed on one side of the previous prosthetic sewing cuff, and the overall sewing cuff was thereafter completely removed following leaflet detachment. SIS (mean number of sutures 32.5 ± 3.0; range: 28-40 sutures) was performed to implant the new prosthesis, without exposing the rough surface of the previous mitral valve annulus, thereby allowing for eventual implantation of the same-sized or larger-sized prosthesis. RESULTS: The surgical procedure was successfully performed in all patients without any serious complications. Bioprostheses were selected for 11 patients, and mechanical valves for 10. Sixteen patients (76.2%) received a new prosthesis that was the same size as or larger than the previous prosthesis. Operative mortality within 30 days was 4.8%, which was similar to that of primary MVR in the same period (n = 83; 2.4%; p = 0.57). Recurrent PVL was detected in only one patient, who underwent a fourth surgery for SVD of the bioprosthesis. CONCLUSIONS: SIS for redo MVR may allow for the implantation of larger prostheses, and this novel maneuver may achieve acceptable early clinical outcomes.

Optimal timing of clopidogrel discontinuation in Japanese patients: platelet aggregation test using the VerifyNow® system.

OBJECTIVE: The Japanese Circulation Society recommends discontinuation of antiplatelet therapy 7-14 days before major surgery. However, reports on the relationship between the timing of clopidogrel discontinuation and the risk of postoperative bleeding in Japanese subjects are lacking. We assessed the optimal timing of clopidogrel discontinuation before elective surgery using the VerifyNow® P2Y12 assay. In addition, the relationship between preoperative platelet function and risk of postoperative bleeding was evaluated. METHODS: Study 1: Between June 2012 and December 2014, Platelet function was examined by the VerifyNow P2Y12 assay in patients scheduled for cardiac surgery, every other day after clopidogrel cessation. Study 2: We compared the preoperative platelet function, measured by the VerifyNow, with the postoperative bleeding. RESULTS: Study 1: Twenty-four patients were included in this study. The mean P2Y12 reaction units (PRU) on Day-0 was 186, and increased significantly to 283 PRU on Day-7 in a time-dependent manner after clopidogrel discontinuation (p = 0.001). The mean PRU value significantly exceeded the cutoff of 230 on Day-5. Study 2: Correlation between the preoperative aspirin reaction units (ARU) and postoperative bleeding showed a slight inverse correlation in patients undergoing aortic valve replacement (rS = -0.363, p = 0.013), mitral valve plasty (rS = -0.300, p = 0.085) and off-pump coronary artery bypass (rS = -0.176, p = not significant). CONCLUSION: Platelet aggregation had already recovered at 5 days after clopidogrel cessation. Surgeons could consider decreasing the interval from clopidogrel discontinuation to surgery from the recommended 7-14 days. The VerifyNow assay can be used to predict the risk of perioperative bleeding.

Bypass vs. Endovascular Therapy of Infrapopliteal Lesions for Critical Limb Ischemia.

OBJECTIVE: This study was conducted to determine whether to perform endovascular intervention or bypass surgery as a treatment option for critical limb ischemia (CLI) with lesions in the popliteal artery or below. SUBJECTS AND METHODS: A total of 150 patients (164 limbs) with CLI underwent endovascular intervention or bypass surgery for lesions in the popliteal artery or below at our department between May 1995 and June 2011. Therapeutic outcomes were examined by surgical technique. An indication for endovascular intervention was established with the combination of (1) poor general condition, and (2) a stenotic or occlusive lesion ≤5 cm. RESULTS: The bypass group (group B) comprised 119 patients (99 males, 20 females) with 131 affected limbs at 46 to 89 years of age (mean: 70 years). The endovascular intervention group (group E) comprised 31 patients (25 males, 6 females) with 33 affected limbs at 47 to 89 years of age (mean: 72 years). There was no significant difference in patient demography between the two groups. Regarding preoperative complications, hypertension was observed in 54% and 61% of the subjects in groups B and E, respectively, diabetes in 36% and 55%, renal dysfunction in 29% and 58%, ischemic heart disease in 27% and 32%, and cerebrovascular disorder in 18% and 23%; renal dysfunction accounted for a significantly higher percentage in group E. As for early postoperative complications, subjects in group B experienced wound infections (6 patients), hemorrhage (2), thrombosis (2), pneumonia (1), and another complication (1), and those in group E experienced wound infections (1) and another complication (1). The hospital mortality rate was 0.8% (1 patient) for group B and 0% for group E. The 3-year cumulative primary patency rate was 72% for group B and 54% for group E; the rate was significantly higher for group B. The 3-year secondary patency rate was 82% for group B and 60% for group E. The 3-year limb salvage rate was 86% for group B and 82% for group E; there was no significant difference between the two groups. The 5-year survival rate was 57% for group B and 42% for group E; the survival rate was significantly lower for group E. CONCLUSION: For the study population of CLI patients with lesions in the popliteal artery or below, the patency rate was higher for the bypass group than for the endovascular intervention group, whereas there was no difference in the limb salvage rate. Based on the findings in prognosis for survival, the indication for endovascular intervention at our department is believed to be appropriate. (English translation of Jpn J Vasc Surg 2013; 22: 715-718).

Assessment of the characteristics and detectability of skin perfusion pressure measured using a thermostatic heating probe.

OBJECTIVES: To assess the characteristics of skin perfusion pressure (SPP) measured using a thermostatic heating probe and whether a thermostatic heating probe improves SPP detection. METHODS: We studied 8 feet of healthy young subjects and 31 feet of elderly patients suspected to have severe limb ischemia. We measured SPP at the dorsum and plantar aspects of each foot using a plain laser Doppler probe and a thermostatic heating probe heated at 44°C. Results were expressed as median. Comparisons were analyzed using a non-parametric test. RESULTS: In the healthy subjects, the SPP values at both the dorsum and the plantar aspect were not significantly different after heating. The thermostatic heating probe did not improve the SPP detection rates. In the patients with ischemic limb, the SPP values at both the dorsum and the plantar aspect significantly increased after heating (p <0.001 for both). The SPP detection rate at the dorsum remained at 96.8%; however, it was improved from 87.1% to 100% at the plantar aspect after heating. CONCLUSION: The thermostatic heating probe was shown to be useful for improving the detectability of SPP in the ischemic limbs. An SPP increase after heating may be considered as a parameter of limb ischemia.

Early outcomes of chordal reconstruction for posterior mitral leaflet prolapse.

We retrospectively reviewed 16 patients (7 men and 9 women, aged 36 to 77 years) who underwent mitral valve repair with chordal reconstruction for isolated posterior mitral leaflet prolapse. Preoperative echocardiography demonstrated moderate mitral regurgitation in 1, and severe regurgitation in 15. We routinely used expanded polytetrafluoroethylene sutures as artificial chords, and ring annuloplasty was performed in all cases (mean ring size, 30 ± 2 mm). After implanting the ring, the length of the artificial chords was adjusted repeatedly using saline solution. Early postoperative echocardiography at 7.1 ± 1.1 days after surgery showed mitral regurgitation grades reduced to none or trivial in 15/16 patients. One required reoperation for recurrent mitral regurgitation 1.5 years after surgery. In the other patients, intermediate-term echocardiography at 9.1 ± 10.1 months after surgery demonstrated that residual mitral regurgitation was less than mild. We concluded that chordal reconstruction is an effective and highly reproducible procedure for the repair of isolated posterior mitral leaflet prolapse. Artificial chords for the posterior mitral leaflet should not be too long, to avoid systolic anterior motion or recurrent mitral regurgitation after surgery.

Intrapericardial diaphragmatic hernia after coronary artery bypass grafting using the right gastroepiploic artery graft: report of a case.

Surgeons should be aware of diaphragmatic hernia in obese patients who have undergone coronary artery bypass grafting (CABG) using a gastroepiploic artery graft (GEA), even if the antegastric route is utilized.We report a case of diaphragmatic hernia, which occurred 88 months after initial CABG. A 64-year-old obese man underwent surgical repair of a diaphragmatic hernia. At initial surgery, the diaphragm was incised vertically and re-sutured, leaving a route for GEA graft. Both the stomach and the lateral segment of the liver were dislocated in the pericardial space. The diaphragmatic defect was closed with a polytetrafluoroethylene patch.

En bloc resection and extended replacement of the infected aortic arch.

We present the technical details of en bloc resection and extended replacement of an infected aortic arch. A 74-year-old man underwent emergent surgery under a diagnosis of impending rupture of an infected aortic arch aneurysm. The patient's chest was entered through a median sternotomy with a left thoracotomy at the fourth intercostal space. After dissection of the left phrenic and left recurrent nerves, the infected aortic arch was widely excised en bloc under circulatory arrest with selective cerebral perfusion. It was replaced with a rifampicin-bonded prosthetic graft. The prosthesis and anastomoses were covered with a harvested omental flap. Although an appropriate approach and supportive therapy are indispensable, en bloc resection of the infected tissue is an important technique when treating infected aortic aneurysms.

Two-stage Surgery for Double Infected Aneurysms in the Infrarenal Abdominal and Descending Thoracic Aorta.

A 61-year-old man complaining of lumbago and high-grade fever was admitted to our institution. Computed tomography (CT) revealed a saccular aneurysm in the infrarenal abdominal aorta and blood culture results were positive for Streptococcus pneumoniae. He was diagnosed with infected abdominal aortic aneurysm, and antibiotic therapy was initiated. Follow-up CT demonstrated a rapidly-enlarging abdominal aortic aneurysm and a newly-developed descending thoracic aortic aneurysm. For this case, two-stage surgery consisting of extra-anatomical bypass and in-situ reconstruction using rifampicin-soaked Dacron graft was performed after an interval of 37 days. The patient was discharged 14 days after the second surgery without any complications.