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.

Pirogoff amputation is a viable option to maintain ambulation in chronic limb-threatening ischemia with extensive midfoot tissue loss: a report of two cases.

Eliminating necrotic and infected tissues is crucial for limb salvage in patients with chronic limb-threatening ischemia (CLTI). However, extensive lesions that involve the midfoot frequently result in transtibial amputation, restricting ambulation and independent life. The Modified Pirogoff amputation, which includes a 90° rotation of the calcaneus and fixation with the tibia, has good functional outcomes in trauma cases. Here, we report two patients with CLTI successfully managed by a combination of revascularization and modified Pirogoff amputation, resulting in preserved ambulation without a prosthesis. Modified Pirogoff amputation may be a good alternative in revascularized CLTI with extensive tissue loss of the midfoot.

Successful treatment of a patient with a 'flow-through' type II endoleak associated with an aberrant renal artery after endovascular aneurysm repair.

Identification and control of responsible feeding arteries are crucial in treating type II endoleaks after endovascular aortic repair (EVAR). A 78-year-old female patient required management of a type II endoleak 8 years after EVAR. A persistent endoleak from the inferior mesenteric artery (IMA) enlarged the size of an aneurysm sac. Sac angiography from the IMA revealed a flow-through endoleak from the IMA to an aberrant renal artery (ARA). After coil embolization of the ARA through the sac together with the IMA, the sac shrank. Control of flow-through vessels may be essential for managing post-EVAR enlargement due to type II endoleaks.

Long-Term Outcomes following Common Femoral Endarterectomy.

Thromboendarterectomy of the common femoral artery (CFA) for occlusive disease is a crucial procedure in vascular surgery. As an outcome reference for emerging endovascular procedures and new devices, we need more robust evidence of the outcome of this gold standard technique. The purpose of this study was to report 10-year results after femoral endarterectomy (FEA). A retrospective review of medical records at our institution identified eighty consecutive patients (91 limbs) who underwent FEA for CFA lesions. Indications for FEA included 50 limbs (55%) for intermittent claudication (IC) and 39 limbs (43%) with chronic limb-threatening ischemia (CLTI). Two limbs (2%) underwent FEA to prevent hemodynamic steal during extra-anatomical bypass. Adjunctive procedures included endovascular therapy in 32%. CFAs were closed with patch angioplasty in 44%. With a mean follow-up period of 39 months, the survival rates at 3 and 8 years were 85% and 77%, respectively. Limb salvage rates were 92% and 87%. Primary patencies were 98% and 84%. Freedom from target lesion revascularization was 95% at 3 years and 91% at 8 years. Our findings support the durability of FEA, with comparable long-term procedural results in CLTI patients as well as IC patients. Since the FEA is a gate maneuver for hybrid revascularization in CLTI patients, our findings support a strategy combining open and endovascular approaches. Femoral endarterectomy remains a durable solution for common femoral occlusive disease in IC and CLTI in the era of endovascular therapy.

Tailor-Made Tapering Grafts for Large-Neck Aorta.

Patients having a large aortic neck poses a challenge in abdominal aortic aneurysm surgery both in endovascular and open aneurysm repair, sometimes necessitating paravisceral or thoracoabdominal aneurysm repair which carries considerable perioperative risk. Here, we describe techniques of using a tailor-made tapering graft in open surgery that can be adjusted for large neck morphology. This technique helps avoid discrepancies between the proximal aorta and graft, and postoperative acute kidney injury by clamping at lower levels. The conscientious use of this technique in selected patients realizes satisfactory outcomes both in the short term and midterm in the demanding anatomy of large aortic necks.

Egg-shell like Calcification as a Protective Factor for Splenic Artery Aneurysm Dilatation.

BACKGROUND: The purpose of this study was to evaluate the factors associated with asymptomatic splenic artery aneurysm (SAA) dilatation. METHODS: Among patients with SAA admitted to our department from 2001 to 2018, 70 lesions in 59 patients were selected and analyzed retrospectively. There were no cases of rupture or pregnancy in the follow-up period. We defined egg-shell appearance as SAA with >75% calcification of the outer shell. We measured the dilatation rate (mm/year) and evaluated the comorbidity and anatomical factors using univariate and multiple linear regression models. Post-hoc multiple linear regression models were fitted to evaluate the possible interactions. RESULTS: The mean age was 61.4 years (range 35-85 years), and the initial aneurysm diameter was 15.1 mm (range 3-47 mm). The mean dilatation rate was 0.26 mm/year (range 0-3.2 mm/year) during the follow-up period (average 4.6 years). Univariate analysis revealed that, portal hypertension (PHT) (P = 0.0003), egg-shell appearance (P = 0.007), and aneurysm diameter > 20 mm (P = 0.05) were significantly associated with the dilatation rate. Multivariate analysis revealed that egg-shell appearance was found to be an independent inverse risk factor of dilatation rate (P = 0.006). The multivariate analysis, including interaction terms, revealed a stronger effect of PHT and diameter >20 mm in cases with no egg-shell appearance (P = 0.08 and P = 0.05 for interactions, respectively). CONCLUSIONS: The egg-shell appearance of SAA was an independent inverse risk factor affecting the SAA dilatation rate. The dilatation rates in the case of PHT and diameter >20 mm were restricted in the presence of the egg-shell appearance.

Hemodynamic Simulation of Pancreaticoduodenal Artery Aneurysm Formation Using an Electronic Circuit Model and a Case Series Analysis.

Objective: To assess mechanisms underlying aneurysm formation using a simple electronic circuit model. Materials and Methods: We created a simple circuit model connecting the celiac artery (CA) to the superior mesenteric artery via the pancreaticoduodenal arcade. We retrospectively reviewed 12 patients with true pancreaticoduodenal artery aneurysms (PDAAs) who received open or endovascular treatment between 2004 and 2017. We set the resistance of each artery and organ voltage and calculated flow volume and rate in response to degrees of simulated CA stenosis from 0% to 99.9%. Results: Flow volume rates of the anterior pancreaticoduodenal artery and posterior pancreaticoduodenal artery decreased to zero when CA stenosis increased from 0% to 50% and then increased drastically, at which point flow direction reverted and the flow was up to three times the initial rate. The gastroduodenal artery (GDA) also showed reversed flow with severe CA stenosis. In 12 patients with PDAA, eight presented with a CA lesion, and the other patients presented with comorbidities causing the arteries to be pathologically fragile, such as Marfan syndrome, Behçet's disease, and segmental arterial mediolysis. All four GDA aneurysms were not accompanied by CA lesions. Conclusion: The mechanism underlying CA-lesion-associated PDAA formation may be partially explained using our model.

Geometric analysis of ruptured and nonruptured abdominal aortic aneurysms.

OBJECTIVE: The objective of this study was to use parameters to determine the geometric differences between ruptured abdominal aortic aneurysms (AAAs) and nonruptured AAAs. METHODS: Computed tomography data of 38 ruptured AAAs and 215 electively repaired (nonruptured) AAAs were collected from multiple institutes. We compared the ruptured AAA group and nonruptured AAA group with 1:1 matching by using the Mahalanobis distance, which was calculated using the patient's age, sex, and AAA diameter. We selected the longitudinal AAA image in multiplanar reconstruction view, placed a hypothetical ellipse on the aneurysm's protruded curve, and placed a circle on the portion connecting the aneurysm and the aorta. We then measured the aspect ratio (the vertical diameter divided by the horizontal diameter) and fillet radius (the radius of arc). RESULTS: The aspect ratio was significantly lower in the ruptured group than in the nonruptured group (2.02 ± 0.53 vs 2.60 ± 1.02; P = .002), as was the fillet radius (0.28 ± 0.18 vs 0.81 ± 0.44; P < .001). Receiver operating characteristic analysis revealed that the area under the curve of the aspect ratio was 0.688, and the optimal cutoff point was 2.23, with sensitivity and specificity of 0.55 and 0.76, respectively. The area under the curve of the fillet radius was 0.933, and the optimal cutoff was 0.347, with sensitivity and specificity of 0.97 and 0.87, respectively. CONCLUSIONS: The geometric analysis performed in this study revealed that ruptured AAAs had a smaller fillet radius and smaller aspect ratio than nonruptured AAAs did.

Proresolving Lipid Mediators Resolvin D1 and Protectin D1 Isomer Attenuate Neointimal Hyperplasia in the Rat Carotid Artery Balloon Injury Model.

BACKGROUND: Specialized proresolving mediators from ω-3 polyunsaturated fatty acid may control resolution of inflammation. We evaluated the influence of two specialized proresolving mediators, resolvin D1 (RvD1) and protectin D1 isomer (PD1 iso) on neointimal hyperplasia after balloon injury. MATERIALS AND METHODS: Sprague Dawley male rats at 12-14 wk of age were injured as a model of balloon angioplasty. Then, 1 µg/rat of RvD1 or PD1 iso was administered intravenously via the tail vein immediately and 2 d after angioplasty. The proliferation of injured artery and the infiltration of leukocytes, monocytes, and macrophages at 3 d after injury were evaluated by immunostaining. The activity of the inflammatory transcription factor nuclear factor kappa-light-chain-enhancer of activated B cells (NFκB) in the injured artery at 3 d after injury was evaluated using an enzyme-linked immuno sorbent assay kit. The proliferation of the neointima was evaluated by calculating the ratio of the neointimal and medial areas using specimens at 14 d after injury. RESULTS: RvD1 and PD1 iso attenuated proliferation of medial cells (P < 0.05) and infiltration of leukocytes (P < 0.05) and monocytes/macrophages (P < 0.01). Although both RvD1 and PD1 iso mitigated NFκB activity (P < 0.01), RvD1 attenuated this activity more strongly (P < 0.01). RvD1 decreased neointimal hyperplasia by 37.3% (P < 0.01), whereas PD1 iso decreased neointimal hyperplasia by 31.8% (P < 0.05) (RvD1 versus PD1 iso: P = 0.51). CONCLUSIONS: RvD1 and PD1 iso reduced the activity of inflammatory transcription factor NFκB within the injured artery and attenuated inflammatory cell infiltration, leading to a reduction in early inflammation and subsequent neointimal hyperplasia.

Morphological analysis using geometric parameters for splenic aneurysms.

Background Considering the unique characteristics of splenic artery aneurysms, we hypothesized that hemodynamic forces could play an important role in splenic artery aneurysm formation and that splenic artery geometry should be correlated with aneurysm development. Methods Tortuosity of the splenic artery was evaluated three-dimensionally by calculating the curvature using software and the original modeling system. We selected 54 splenic artery aneurysm patients who had undergone thin-slice computed tomography imaging with contrast. We compared the splenic artery aneurysm group to non-vascular patients via propensity-score matching (35 patients in each group). The splenic artery length index, average curvature, and maximum curvature were analyzed. Results Splenic artery aneurysm patients tended to have a longer splenic artery and the curvature was more severe compared to the non-vascular control patients. The average curvature of splenic artery aneurysm patients was associated with the dilatation rate in female patients. Conclusion Females with a tortuous splenic artery may have an increased risk of aneurysm formation.

Morphological Changes and Device Migration After Stent Graft Insertion　- Clinical Application of an Image-Based Modeling System and Analysis With Geometric Parameters.

BACKGROUND: Previously, we developed an image-based modeling system (V-Modeler) to investigate geometric changes in stent grafts (SGs) following their implantation for abdominal aortic aneurysms (AAAs). The aims of the present study were to improve this system for clinical use, to chronologically analyze postoperative morphological changes in SGs, and to demonstrate scenarios of SG migration.Methods and Results:Contrast-enhanced computed tomography data from 36 patients who underwent endovascular aneurysm repair (EVAR) for AAAs were used, with 72 centerline paths, in total, analyzed for bilateral SG legs. The existing V-modeler system was modified by introducing a penalty term, optimizing the number of control points using Akaike's information criterion, and changing the degree of the function from 3 to 5. Geometric parameters were then analyzed immediately, as well as >1 year after EVAR. Eight migrations were found and although overall SG curvature and curvature at the distal (leg) site did not change, curvature at the proximal (trunk) site of SGs decreased over time. Subanalysis revealed that SGs with severe curvature showed the same trend, whereas distal curvature increased in the non-severe curvature group. In addition, proximal curvature decreased more in Excluder than Zenith devices. CONCLUSIONS: The present study demonstrates SG behavior after implantation with numerical values for SG length and curvature.

A classification of NOergic neurons in the inferior colliculus of rat according to co-existence with classical amino acid transmitters.

Since the localization of nitric oxide synthase (NOS) can be identified by enzyme histochemistry for NADPH-diaphorse (NADPH-d), this method has been used widely for mapping NOS-containing (presumably NOergic) neurons in the central nervous system. So far several studies suggest that NADPH-d is present in distinct neuronal populations in the inferior colliculus (IC), a major processing center for both the ascending and descending auditory pathway, and NO may play an important role in audition. On one hand, there is evidence from several lines of research that the IC makes extensive use of the neuroactive amino acids, in particular the inhibitory transmitter g-aminobutyric acid (GABA) and the excitatory amino acid glutamate (GLU). However, lacking is a description of the distribution of NOergic neurons to which traditional neurotransmitters may be linked. The present research utilized NADPH-d enzyme histochemistry in combination with immunocytochemistry to determine if NO may colocalize with either or both GABA and glutamate in distinct subpopulations of IC neurons. The NADPH-d positive neurons were predominantly found in two main subdivisions of the IC: the external cortex (ECIC) and the dorsal cortex (DCIC). The large numbers of these NADPH-d positive neurons appeared immunostained for GLU while only a small number, seemed to belong to the small cells (somatic area < 100 microm2) similarity to stellate cells group was positive for GABA throughout the cortex of the IC. Owing to no coexistence between GABA and GLU in the same NADPH-d positive neuron in the pairs of adjacent sections of the IC by the mirror-image technique, the present results consequently support that NOergic neurons could be subdivided into at least three distinct populations with a large proportion of about 77% being GLUergic, much lower frequency of about 11% being GABAergic and the remaining 12% expressing non-GABA and non-GLU. In summary, the existence of two functionally distinct populations of NO/GABAergic and NO/GLUergic neurons in the NOergic neurons of IC suggest that at least two differential pattern of GLU-mediated excitatory NO transmission and GABA-mediated inhibitory NO transmission are involved in the networking of auditory communication in the cortex of IC.

Stimulatory Effects of CO(2) Laser, Er:YAG Laser and Ga-Al-As Laser on Exposed Dentinal Tubule Orifices.

We investigated the effects of lasers irradiation on the exposed dentinal tubule. Human tooth specimens with exposed dentinal tubule orifices were used. Three types of lasers (CO(2) laser, Er:YAG laser and Ga-Al-As laser) were employed. The parameters were 1.0 W in continuous-wave mode with an irradiation time of 30 s for the CO(2) laser, 30 mJ in continuous-wave mode with an irradiation time of 60 s for the Er:YAG laser, and 1.0 W in continuous-wave mode with an irradiation time of 60 s for the Ga-Al-As laser. A non-irradiated group was used as a control. After laser irradiation, the dentinal surface of each sample was observed using SEM. Afterwards, all samples were immersed in methylene blue dye solution in order to evaluate the penetration of the dye solution and observe the change in dentinal permeability after laser irradiation. SEM observation showed that the control group had numerous exposed dentinal tubule orifices, whereas these orifices were closed in the laser-irradiated groups. There was consistent dye penetration into the pulp chamber in the control group, whereas no dye penetration was evident in the laser-irradiated groups. Therefore, laser appears to be a promising treatment for reducing permeation through exposed dentinal tubules.

Development of functional imidazole derivatives: the influence of alkaline metal cations on the rates of CL reactions of 2-(phenyl and 4-dimethylaminophenyl)-4-hydroperoxy-4-3',4'-(15-crown-5)phenyl-5-3''-4''-(15-crown-5)phenyl-4H-isoimidazoles.

Although several investigations have focused on luminescence modulation by chelation with metal cations using bidentate ligands or crown ether systems, a bis(crown ether) system has not yet been used for modulation of chemiluminescence (CL) reactions. In the CL reaction of 2-(phenyl and 4-dimethylaminophenyl)-4-hydroperoxy-4-3',4'-(15-crown-5)phenyl-5-3'',4''(15-crown-5)phenyl-4H-isoimidazoles 2a and b possessing a bis(15-crown-5 ether) moiety, the rate acceleration was observed in the presence of K(+), Rb(+) and Cs(+) due to the holding effect of the bis-crown moiety, but no rate acceleration was observed by Li(+) and Na(+) due to the template effect of the crown moiety. The acceleration of the CL reaction rates is ascribable to the conformational change induced by the scissor-like motion of the bis-crown moiety assisted by the holding effect.

Generation of a new red fluorescent condensed hetero-aromatic compound: 7,20-dimethyl-7,20-dihydro-7,20-diaza-naphto[a]dibenzo[j,q]perylene.

A coupling reaction of 5-methylbenz[b]acridin-12(5H)-one (MBA) with Zn and TiCl(4) provided a red fluorescent (FL) compound, as opposed to 5,5'-dimethyl-12,12'-bibenzo[b]acridylidene (DMBBA), probably through photochemical cyclization and aromatization by dehydrogenation of the overcrowded intermediate DMBBA. The structure of the red FL compound was assigned to 7,20-dimethyl-7,20-dihydro-7,20-diaza-naphto[a]dibenzo[j,q]perylene (DANDBP) and the fluorescence efficiency for DANDBP was determined to be 0.23 +/- 0.01.

Photoreaction of a 2,11-diaza[3.3]paracyclophane derivative: formation of octahedrane by photochemical dimerization of benzene.

Upon photoirradiation at 300 nm, the title diazaparacyclophane (R = COCF3) provided an octahedrane by the photodimerization of its benzene chromophores. This is the first photochemical formation of octahedrane, namely, via the dimerization of benzene. No octahedrane formation was observed for the photolysis of corresponding carbon-bridged paracyclophane. Thus the nitrogen bridges play an important role in the excited state to afford the octahedrane.

Novel parallel reaction between a [1,5] sigmatropic alkylthio shift and a [1,5] sigmatropic hydrogen shift observed in a 2H-azepine ring.

Although heating 2-methoxy-2H-azepine results in a [1,5] sigmatropic hydrogen shift, heating 2-propylthio-2H-azepine results in not only a [1,5] sigmatropic hydrogen shift but also a [1,5] sigmatropic propylthio shift. Kinetic measurements reveal that migratory aptitudes increase in the order of MeO < H, PrS. These [1,5] sigmatropic shifts are discussed on the basis of ab initio DFT calculations. [reaction: see text].

Electrophilic behavior of the pi delocalized azepinium ion: Friedel-Crafts reactions with benzenes and five-membered aromatic heterocycles.

[reaction: see text] Although the reactivity of tropylium ion with aromatic substrates is low, the reaction of azepinium ion with aromatic substrates such as benzene, phenol, furan, and thiophene resulted in the formation of 2-aryl-2H-azepine as a major product. An exceptional result in the formation of ring-contracted product was observed in the reaction with pyrrole.

Reaction of 2-methoxy-3H-azepine with NBS: efficient synthesis of 2-substituted 2H-azepines.

[reaction: see text] The reaction of 2-methoxy-3H-azepines, in the presence or absence of a nucleophile, with N-bromosuccinimide (NBS) gave a regioselective 1,4-adduct from which the corresponding 2H-azepine derivatives were formed via base-promoted hydrogen bromide elimination, generally in moderate to quantitative yield. Competitive formation of 4-bromo-2-methoxy-3H-azepine by electrophilic substitutuion or 3H-azepin-2-yl 2H-azepin-2-yl ether by transetherification was minimized at lower reaction temperatures. Quantitative substitution of 2-(2',4',6'-trichlorophenoxy)-2H-azepine derivatives, formed in moderate yield from the respective 3H-azepine and NBS in the presence of 2,4,6-trichlorophenol (TCP), by various nucleophiles gave the corresponding 2-substituted 2H-azepine. Among these nucleophiles were alkanethiol and alkylamine that are not tolerated in the reaction of 3H-azepine and NBS.

["Restricted ablation" of elongated uvula mucosa by the injection of the ethanol/steroid mixture: a new treatment for snoring and OSAS].

We developed a "Submucosal Ethanol/Steroid (E/S) Injection Method (SEIM)" using an injection prepared by dissolving steroid with powerful antiinflammatory effect, which has the excellent effect of contractile reduction in oral tissues. In this clinical trial, the ablation effect of SEIM on the abnormally elongated uvula and the soft palate was examined in each one clinical case of obstructive sleep apnea syndrome (OSAS) and simple snoring. In the OSAS, we found that the uvula was reduced from 15 to 10mm, the visual analog scale (VAS) of snoring was reduced from 10 to 4 points, and the respiration disturbance index of the apnea-hypopnea index (AHI) improved from 35.3 to 26.1 after treatment. In simple snoring, the uvula was reduced from 11 to 8.5mm and VAS was relieved from 7 to 2 points after treatment. Our approach will produce a great clinical significance for not only OSAS or simple snoring but also treatment of the allergic rhinitis, etc, because the contractile tissue reduction can be attained safely in these diseases without open surgical wounds and unnecessary deformation or destruction of the mucosal structure.