Iatrogenic acute limb ischemia with complete traumatic rupture of the popliteal artery associated with total knee arthroplasty.

Acute limb ischemia (ALI) related to total knee arthroplasty (TKA) is rare. Most occlusions are caused by thrombus formation in the popliteal artery (PA). Currently such cases are revascularized using less invasive approaches such as endovascular therapy or Fogarty thrombectomy. We report a case of ALI in a 65-year-old woman with complete rupture of the PA due to a TKA procedure. She had resting pain and motor paralysis in her right lower extremity after TKA. Contrast-enhanced computed tomography showed occlusion of the right femoropopliteal artery. Subsequently, she was referred to our hospital with a diagnosis of ALI. Initially, a less invasive revascularization procedure was unsuccessfully attempted. Therefore, we performed an emergency distal bypass and succeeded in revascularization. Intraoperative examination revealed a complete rupture of the PA. Postoperatively, the patient exhibited no signs of myonephropathic metabolic syndrome. Although there was significant motor impairment, the affected limbs were successfully salvaged. ALI with complete rupture of the PA associated with TKA has not been reported previously. In cases of iatrogenic ALI after TKA, it would be essential to consider diagnostic and revascularization methods that account for the possibility of severe injury to the PA. Learning objective: Acute limb ischemia after total knee arthroplasty is a rare and life- and limb-threatening condition. The underlying pathological mechanism is often thrombus occlusion due to mechanical stimuli of the popliteal artery (PA). There are no established treatments for this condition, and less invasive approaches such as endovascular procedures and Fogarty thrombectomy are often used. However, in cases involving severe damage to the PA, bypass surgery may be necessary, and revascularization procedures should be considered accordingly.

Poor short-term outcomes for prognostic high-risk patients with chronic limb-threatening ischemia undergoing endovascular therapy.

BACKGROUND: The prognosis of chronic limb-threatening ischemia (CLTI) is poor, with an expected life expectancy of 2 or more years, which significantly influences treatment decisions. However, death may occur at the early stages of treatment for wound healing, and aggressive treatment may limit the quality of life of such patients. In patients with CLTI undergoing endovascular therapy (EVT), the Wound, Ischemia, and foot Infection (WIfI) clinical stage, male sex, older age, non-ambulatory status, low body mass index, and dialysis have been reported as predictors of mortality risk. However, most studies have not fully investigated the WIFI clinical stage as a prognostic predictor of CLTI. This study aimed to evaluate short-term prognosis and wound healing rates using the prognostic predictors (PPs) indicated above in risk-stratified patients with CLTI who underwent EVT. METHODS: This retrospective single-center observational study included 61 CLTI patients undergoing EVT from April 2020 to October 2022. The patients were divided into a high-risk group (PPs ≥ 4, n = 20) and low-risk group (PPs ≤ 3, n = 41) according to the number of PPs. Survival and wound healing rates within one year were compared between these two groups. RESULTS: The mean age of the patients was 74.7 ± 1.6 years, and 42 (68.9%) were male. Among these patients, the high-risk group compared with the low-risk group had a significantly worse survival rate within one year (46.4% vs. 84.7%, log-rank p < 0.001). Fifteen patients died within one year. Of these, seven deaths were cardiovascular deaths and six were deaths from infectious diseases. Cox proportional hazards analysis showed that WIfI clinical stage 4 (p = 0.043, hazard ratio [HR] = 4.85) and the male sex (p = 0.037, HR = 6.34) influenced the prognosis of this population. The high-risk group tended to have a worse wound healing rate within one year than that had by the low-risk group (55.4% vs. 83.0%, log-rank p = 0.086). CONCLUSIONS: The assessment of short-term prognosis and wound healing rates using PPs may be useful. Discussing the results of short-term clinical outcome assessments with patients should be considered when determining their individualized treatment plans.

Right atrial appendage detected by intravascular ultrasound.

A 70-year-old woman with a history of type 2 diabetes mellitus was transferred to our hospital due to inferior ST-segment elevation myocardial infarction. An emergent coronary angiogram revealed occlusion of the distal right coronary artery. Primary percutaneous coronary intervention was performed, preceded by lesion assessment using intravascular ultrasound (IVUS).

Angiographic and Clinical Impact of Novel Revascularization for Occluded Femoropopliteal Prosthetic Bypass Graft: A Combination of Surgical Thrombectomy and Drug-Coated Balloon Angioplasty.

Background: Previous reports have revealed various endovascular intervention techniques for prosthetic femoropopliteal bypass occlusion (PFPBO); however, treatment for PFPBO remains challenging for most interventionalists and vascular surgeons because the procedure is complicated. Most of the reported techniques involve device implantation. In the present study, we performed a combination of surgical graft thrombectomy and drug-coated balloon angioplasty for PFPBO without implanting any additional devices. Furthermore, we determined the favorable long-term results of this treatment using follow-up angiography. Case Presentation. A 77-year-old man with a history of chronic kidney disease and coronary artery disease presented to our clinic with rest pain on his left leg. Seven years prior to the current consult, he underwent femoropopliteal bypass (FPB) surgery using a prosthetic graft due to in-stent occlusion of the left superficial femoral artery (SFA). Four years after surgery, a duplex ultrasound scan revealed stenosis of the proximal anastomosis site; hence, medical therapy was continued. On the current consult, diagnostic angiography revealed occlusion of the FPB and infrapopliteal vessels. In the first attempt at recanalization, the guidewire was unable to pass through the occluded SFA. Therefore, another technique was performed to revascularize the FPBO and infrapopliteal vessels. We obtained an angiography of the left leg after inserting the guiding sheath via the right common femoral artery (CFA). First, surgical thrombectomy using a Fogarty catheter via the exposed left CFA was performed. Following endovascular therapy via the right CFA, we performed drug-coated balloon angioplasty for anastomotic stenosis and recanalized occlusive infrapopliteal vessels. Restenosis was not observed on follow-up angiograms. On further follow-up angiography, there was notable regression of the residual stenosis at the proximal anastomosis of the prosthetic graft. Conclusion: This novel revascularization strategy may be a viable treatment option for PFPBO.

Association of infective endocarditis caused by Abiotrophia defectiva with mycotic aneurysm formation: A case report and the review of the literature.

A 74-year-old woman with a history of mitral valve prolapse with mitral regurgitation was transferred to our hospital due to infective endocarditis. Blood culture revealed Abiotrophia defectiva which is known as a nutritional variant streptococcus. Transesophageal echocardiography revealed posterior leaflet (P2) prolapse due to rupture of tendon chordae with severe mitral regurgitation and vegetation on posterior leaflet. Magnetic resonance imaging (MRI) revealed multiple infarction lesions in left temporal lobe and parietal lobe and mycotic aneurysm formation of right middle cerebral artery. Because A. defectiva cannot be cultured on non-supplemented media, their prevalence may be underreported. Learning objective: A number of causative microorganisms of infective endocarditis have been identified. Streptococci and staphylococci account for 80 % of cases of infective endocarditis. Abiotrophia defectiva does not grow in ordinary growth media and its prevalence may be underreported. It is important to know A. defectiva causes infective endocarditis with mycotic aneurysm formation.

Novel RT-PCR Using Sugar Chain-Immobilized Gold-Nanoparticles Correlates Patients' Symptoms: The Follow-Up Study of COVID-19 Hospitalized Patients.

Background: The transmissible capacity and toxicity of SARS-CoV-2 variants are continually changing. We report here the follow-up study of hospitalized COVID-19 patients from 2020 to 2022. It is known that the PCR diagnosis for hospitalized patients sometimes causes confusion because of the incompatibility between their diagnosis and symptoms. We applied our sugar chain-immobilized gold-nanoparticles for the extraction and partial purification of RNA from specimens for quantitative RT-PCR assay and evaluated whether the results correlate with patients' symptoms. Methods and Results: Saliva specimens were taken from hospitalized patients with mild or moderate symptoms every early morning. At the time of RT-PCR diagnosis, two methods for the extraction and partial purification of RNA from the specimen were performed: a commonly used Boom (Qiagen) method and our original sugar chain-immobilized gold nanoparticle (SGNP) method. For symptoms, body temperature and oxygen saturation (SpO2) of patients were monitored every 4 h. Conclusions: It was clear that patients infected with the Delta variant needed more time to recover than those with the Omicron variant, and that the SGNP method showed more realistic correlation with the symptoms of patients compared with the common Qiagen method.

Differential Diagnosis of Coronary Angiographic Filling Defect.

In this case, an air bubble was trapped in the mid right coronary artery and it was difficult to differentiate with calcification or thrombus. A correct diagnosis of "filling defect" is necessary because device selection is different for each case. Intravascular ultrasound is useful for differential diagnosis of calcification, thrombus, or air bubble.

Characteristics of recurrent in-stent restenosis after second- and third-generation drug-eluting stent implantation.

BACKGROUND: In second- and third-generation drug-eluting stent (DES) era, in-stent restenosis (ISR) is not commonly seen. However, a few patients still need repeat revascularizations for recurrent ISR even after second- and third-generation DES implantation. METHODS: From January 2012 to March 2017, 2339 lesions underwent second- and third-generation DES (Nobori, Promus Element, Resolute Integrity, Xience, Ultimaster and Synergy) implantation, of which 95 lesions (4.1%) underwent revascularization for first ISR. All lesions were divided into two groups of recurrent ISR group and non-recurrent ISR group. After successful optical coherence tomography (OCT) guided revascularization for all lesions, we investigated characteristics of recurrent ISR, and 2 years follow-up were completed. RESULTS: The mean age was 70.8 ± 11.7 years, and 73.2% were males. Among 56 DES-ISR lesions which were assessed by OCT, recurrent ISR was seen in 33.9% (N = 19) at 2 years follow-up after revascularization for first ISR. Serum low-density lipoprotein-cholesterol (LDL-C) level was higher in recurrent ISR group compared with non-recurrent ISR group (114.1 ± 53.9 mg/dl vs. 90.9 ± 27.8 mg/dl, P = 0.04) and heterogeneous tissue pattern was more frequently found in recurrent ISR group compared with non-recurrent ISR group (63.2% vs. 27.0%, P = 0.03). Multivariate analysis identified a heterogeneous tissue pattern (odds ratio 3.71; 95% confidence interval 1.09-12.59; P = 0.03) as an independent predictor of recurrent restenosis. CONCLUSION: Recurrent ISR of second- and third-generation DES was associated with heterogeneous tissue pattern of first ISR, and high LDL-C level was associated with recurrence.

Characteristic Analysis of Trigonelline Contained in Raphanus sativus Cv. Sakurajima Daikon and Results from the First Trial Examining Its Vasodilator Properties in Humans.

Vascular disease poses a major public health problem worldwide. Trigonelline isolated from Raphanus sativus cv. Sakurajima Daikon (Sakurajima radish) induces nitric oxide production from vascular endothelial cells and enhances vascular function. Here, we investigated the characteristics of trigonelline and its effects on endothelial function after consumption of Sakurajima radish by humans. Our results show that Sakurajima radish contains approximately 60 times more trigonelline than other radishes and squashes. Additionally, no significant differences were observed between varieties of Sakurajima radish, suggesting that any type of Sakurajima radish can be ingested for trigonelline supplementation. The effects of cooking and processing Sakurajima radish were also evaluated, as were the effects of freezing, and changes in osmotic pressure and pH. A first-in-human trial using Sakurajima radish showed that ingestion of 170 g/day of Sakurajima radish for ten days increased blood trigonelline concentrations and significantly improved flow-mediated dilation, which is a measure of vascular endothelial function. Overall, our findings suggest that the trigonelline contained in Sakurajima radish may contribute to improved human vascular endothelial function. Hence, Sakurajima radish may enhance vascular endothelial function as a functional food.

Obstructive shock with mediastinal hematoma caused by chest compressions after successful primary percutaneous coronary intervention.

A 75-year-old man with a history of hypertension was transferred to our hospital due to pulseless ventricular tachycardia. When return of spontaneous circulation was achieved, an electrocardiogram showed ST elevation in V1-4 leads. Successuful primary percutaneous coronary intervention was performed. However, on the next day, the patient's systolic blood pressure dropped to 60 mmHg despite using high-dose inotropic agents. Echocardiography and chest computed tomography revealed large mediastinal hematoma. A diagnosis of obstructive shock caused by massive mediastinal hematoma was made. Emergency surgical evacuation of hematoma and hemostasis was successfully performed. .

Left Ventricular Pseudo-aneurysm with Ventricular Septal Rupture Due to Anterior ST-segment Elevation Myocardial Infarction.

We report a case with the simultaneous occurrence of pseudo-aneurysm of the left ventricle and ventricular septal rupture, which was successfully surgically repaired. A 77-year-old woman with a history of aortic valve replacement and coronary bypass graft presented to our clinic due to chest pain. She was diagnosed with anterior ST-segment elevation myocardial infarction (STEMI) based on an electrocardiogram. Echocardiography revealed pseudo-aneurysm of the left ventricle and ventricular septal rupture. Coronary angiography revealed 99% stenosis with delayed contrast filling in the mid left anterior descending artery. Surgical repair with a bovine pericardium patch was performed, and the postoperative course was uneventful.

In-stent restenosis assessed with frequency domain optical coherence tomography shows smooth coronary arterial healing process in second-generation drug-eluting stents.

INTRODUCTION: The pathophysiology and mechanism of in-stent restenosis (ISR) after implantation of second-generation drug-eluting stents (DESs) are not fully clear. We compared the morphological characteristics of ISR between first- and second-generation DESs using frequency domain optical coherence tomography (OCT). METHODS: Patients who underwent follow-up coronary angiography (CAG) after first-generation (CYPHER™ and TAXUS™) and second-generation (Nobori®, PROMUS Element™, Resolute Integrity and XIENCE) DES implantations were examined. ISR was defined as lesions of over 50% diameter stenosis at follow-up CAG. Frequency domain OCT was performed at the time of revascularisation of ISR. Tissue morphology was assessed at minimum lumen area. OCT images of DESs at both early (≤ 1 year) and late (> 1 year) phase follow-up were compared. RESULTS: On qualitative OCT assessment, the ratios of homogeneous, layered, heterogeneous without-attenuation and heterogeneous with-attenuation morphologies were 57.1%, 17.1%, 20.0% and 5.7%, respectively, for second-generation DES ISR (n = 35), and 16.7%, 25.0%, 25.0% and 33.3%, respectively, for first-generation DES ISR (n = 36). At late phase follow-up, homogeneous morphology was significantly more common for second-generation DES ISR compared to first-generation DES ISR (first-generation: 8.0% vs. second-generation: 50.0%; p < 0.01) while heterogeneous with-attenuation morphology was significantly more common for first-generation DES ISR (first-generation: 44.0% vs. second-generation: 5.6%; p < 0.01). CONCLUSION: Homogeneous tissue morphology was more frequently found for second-generation than first-generation DES ISR, especially in the late phase. This suggested that neointimal hyperplasia was the main mechanism in second-generation DES ISR, and that the neointima was stabilised, much like in bare metal stent implantation.

Association of morphologic characteristics on optical coherence tomography and angiographic progression patterns of late restenosis after drug-eluting stent implantation.

OBJECTIVES: To gain insight into the pathophysiology of late drug-eluting stent (DES) restenosis. BACKGROUND: Restenosis of DES has a different time course from that of bare metal stents. METHODS: Patients who underwent follow-up coronary angiography (CAG) twice (six to nine months and 18 to 24 months) after DES implantation were examined using optical coherence tomography (OCT). All lesions with target lesion revascularization at first follow-up were excluded. Late catch-up was defined as lesions that progressed from less than 50% diameter stenosis (DS) at the first CAG to more than 50% DS at the second CAG. Lesions with the late catch-up were further divided into two groups; lesions with jump-up (less than 25% DS at the first CAG) and lesions with gradual progression (25-50% DS at the first CAG). RESULTS: Of the 25 patients who had late ISR, 23 patients (10 jump-up/13 gradual progression) were examined with OCT at late follow-up and enrolled in this study. In the qualitative OCT assessment, each ratio of homogeneous, layered, heterogeneous with or without attenuation tissue morphologies were in jump-up group, and gradual progression group were 0% and 15%, 0% and 23%, and 60% and 8%, and 40% and 54%, respectively. All of jump-up group showed heterogeneous restenotic tissue, while 62% of gradual progression group showed heterogeneous restenotic tissue (P = .04). CONCLUSIONS: These findings suggest different pathophysiology of the late catch-up after DES implantation between the jump-up and gradual progression groups.

Simple balloon dilation for drug-eluting in-stent restenosis: an optical coherent tomography analysis.

BACKGROUND: Although drug-eluting stent (DES) has significantly reduced restenosis, the treatment of DES-in-stent restenosis (ISR) remains a challenge with high restenosis rate. METHODS: We examined whether morphologic appearance of restenosis tissue by optical coherent tomography (OCT) had an impact on outcomes after balloon angioplasty for DES-ISR. The morphologic appearance of restenosis tissue was qualitatively assessed for tissue structures such as homogeneous, layered, and heterogeneous patterns. RESULTS: Using OCT, 50 patients with DES-ISR were divided into 2 groups: 25 lesions with homogeneous or layered patterns (homo/layered group) and 25 lesions with heterogeneous patterns (hetero group). Acute gain was larger in the hetero group (1.33 ± 0.41 mm vs. 1.06 ± 0.32 mm in the homo/layered group, P = 0.03). On intravascular ultrasound analysis, post-procedural percent neointimal area was smaller in the hetero group (27.4 ± 9.2% vs. 34.0 ± 11.2% in the homo/layered group, P = 0.05). Angiographic follow-up was performed in 37 lesions (74%). Follow-up minimal lumen diameter was larger in the hetero group (1.75 ± 0.89 mm vs. 1.01 ± 0.81 mm in the homo/layered group, P = 0.04). Target lesion revascularization rates tended to be lower in the hetero group (20% vs. 43% in the homo/layered group, P = 0.12). CONCLUSIONS: Balloon angioplasty was more effective for DES-ISR with heterogeneous tissue appearance than DES-ISR with homogeneous/layered tissue appearance. OCT assessment of DES-ISR morphology may be a useful adjunct in determining clinical strategies. Simple balloon dilatation is a possible treatment strategy for DES-ISR lesions with a heterogeneous appearance on OCT images.

Late regression of Cypher in-stent restenosis.

We encountered a case of late regression after sirolimus-eluting stent restenosis. We report this case with intravascular ultrasound imaging demonstrating an intraluminal echolucent tissue, which looks like a black hole.

Enjoying hobbies is related to desirable cardiovascular effects.

An unhealthy lifestyle can increase the risk of cardiovascular disease. However, the mechanism by which lifestyle influences the development of cardiovascular disease remains unclear. Since coronary endothelial function is a predictor of cardiovascular prognosis, the goal of this study was to characterize the effect of enjoying hobbies on coronary endothelial function and cardiovascular outcomes. A total of 121 consecutive patients (76 men, 45 women) with almost normal coronary arteries underwent Doppler flow study of the left anterior descending coronary artery following sequential administration of papaverine, acetylcholine, and nitroglycerin. On the basis of responses to questionnaires, patients were divided into two groups; the Hobby group (n = 71) who enjoyed hobbies, and the Non-hobby group (n = 50) who had no hobbies. Cardiovascular outcomes were assessed at long-term follow-up using medical records or questionnaire surveys for major adverse cardiovascular events (MACE).The average follow-up period was 916 +/- 515 days. There were no significant differences in demographics when comparing the two groups. The percent change in coronary blood flow and coronary artery diameter induced by acetylcholine was significantly greater in the Hobby group than in the Non-hobby group (49% +/- 77% vs 25% +/- 37%, P < 0.05, 4% +/- 13% vs -3% +/- 20%, P < 0.05, respectively). The MACE rate was significantly lower in the Hobby group than in the Non-hobby group (P < 0.01). Enjoyment of hobbies was the only independent predictor of MACE (odds ratio 8.1 [95% confidence interval 1.60, 41.90], P = 0.01) among the variables tested. In the early stages of arteriosclerosis, enjoying hobbies may improve cardiovascular outcomes via its favorable effects on coronary endothelial function.