Expression and localization of vascular endothelial growth factor in normal abdominal aorta and abdominal aortic aneurysm.

AIM: The genesis of abdominal aortic aneurysms is associated with remodeling of the vascular wall by angiogenesis as well as proteolysis. Vascular endothelial growth factor (VEGF) is known to be a regulator of angiogenesis and to simultaneously stimulate elastolytic proteinases. We analyzed the expression and localization of VEGF in human abdominal aortic aneurysms compared to normal human aorta METHODS: Eighteen infrarenal aortic aneurysm samples were collected at the time of abdominal aortic aneurysm surgery, while nine normal aortic samples were obtained from autopsy specimens. Immunohistochemical staining was performed to detect VEGF. Immunoenzyme or immunofluorescent double staining was also used to identify those cells presenting VEGF. RESULTS: VEGF was expressed in 18 (100%) of the 18 abdominal aortic aneurysm samples, while 0 (0%) in the 9 normal abdominal aorta samples. Of the 18 samples of aneurysms, all 18 displayed positive VEGF immunostaining in macrophages, 12 in smooth muscle cells (SMCs), and 9 in endothelial cells (ECs). CONCLUSION: Our study clearly demonstrated the expression of VEGF in ECs, and SMCs, and macrophages of abdominal aortic aneurysms as well as its absence in those cells of normal abdominal aorta, suggesting that VEGF may play an important role in aneurysm formation via its direct and/or indirect actions.

Relationship between parameters of air plethysmography and types of superficial venous reflux in patients with primary varicose veins.

AIM: We investigated whether parameters of air plethysmography (APG) were correlated with types of superficial venous reflux as categorized by ascending venography in patients with primary varicose veins. METHODS: Two hundred and eight limbs with primary varicose veins in 135 patients were evaluated by both APG and ascending venography. Venous hemodynamics was assessed with APG. The location of incompetent vein segments was determined based on the results of ascending venography. RESULTS: Seventy-seven limbs had incompetence of the greater saphenous vein (GSV, G group), 36 had incompetence of the lesser saphenous vein (LSV, L group), and 77 had incompetence of the GSV and LSV (GL group). Twenty-five limbs did not have incompetence of the GSV or LSV (N group). The venous filling index (VFI) differed significantly between the N and the G and GL groups, the L group and the G and GL groups, and the G and GL groups. No significant difference was found between the N and L groups. The venous volume, ejection fraction, and residual volume fraction did not differ significantly among all four groups. CONCLUSION: The VFI as measured by APG discriminates well between limbs with incompetence of the GSV and those without incompetence of the GSV or LSV, and between limbs with incompetence of the GSV and those with the LSV in patients with primary varicose veins, suggesting that the hemodynamic severity of superficial venous reflux progresses with involvement from the LSV to the GSV to both saphenous veins.

Intermediate-term results of angioscopy-assisted anterior valve sinus plication for primary deep venous insufficiency.

AIM: The intermediate-term efficacy of angioscopy-assisted anterior valve sinus plication for primary deep venous insufficiency was evaluated. METHODS: Twelve limbs in 11 patients had class 4 or higher disease on the SVS/ISCVS classification. Descending venography revealed grade-3 or 4-reflux in all limbs. The limbs were treated with angioscopy-assisted anterior valve sinus plication of the highest valve of the superficial femoral vein. Clinical evaluation and air plethysmography were performed at the final follow-up. RESULTS: The mean follow-up was 38.4 months with a range of 24 to 48 months. Postoperative descending venography revealed significant improvement of the reflux of the superficial femoral vein. At the final follow-up, all patients reported relief of subjective symptoms. The ulcers healed and did not recur in the single limb with class-6 disease, the ulcers did not recur in four class-5 limbs, and there was a distinct clinical improvement with resolution of skin changes in the seven class-4 limbs. The venous filling index measured by air plethysmography was in a normal range in 8 of the 12 limbs. CONCLUSIONS: Angioscopy-assisted anterior valve sinus plication may be a surgical technique that results in intermediate-term clinical and hemodynamic improvement in patients with primary deep venous insufficiency.

Relationship between air-plethysmographic venous function and clinical severity in primary varicose veins.

AIM: The role of air plethysmography (APG) in the diagnosis of chronic venous insufficiency has not been well established. The purpose of this study was to elucidate the relationship between APG parameters and clinical severity in patients with chronic venous insufficiency. METHODS: Two hundred and ninety-four limbs in 154 patients with primary varicose veins were evaluated by APG. Limbs were categorized according to the clinical classification of chronic venous disease suggested by the Ad Hoc Committee on Reporting Standards in Venous Disease of the North American Chapter of the Society for Vascular Surgery and International Society for Cardiovascular Surgery (SVS/ ISCVS). RESULTS: The venous filling index (VFI) was significantly higher in classes 2, 3, 4, and 5+6 than in class 0 or 1, and did not differ among classes 2, 3, 4, 5+6. The ejection fraction did not differ significantly among the 6 classes, and the residual volume fraction was significantly higher in classes 2, 3, 5+6 than in class 0. CONCLUSIONS: APG is a reasonable method for distinguishing the presence or absence of chronic venous insufficiency, but it cannot discriminate the clinical severity. Among APG parameters, the VFI is the most useful diagnostic parameter in the evaluation of chronic venous insufficiency.

Presence of prostacyclin receptor in arteriosclerotic human femoral artery.

AIM: Prostacyclin, which is mainly synthesized by vascular endothelial cells, exerts antiplatelet and smooth-muscle-relaxant effects, thereby maintaining cardiovascular homeostasis. Prostacyclin analogues have been clinically proven to improve ischemic symptoms and prevent the occurrence of vascular events in the lower extremities of patients with arteriosclerosis obliterans. We examined the presence of prostacyclin receptor (IP receptor) in an arteriosclerotic human femoral artery. METHODS: Specimens of the femoral artery were obtained at the time of limb amputation from an 83-year-old woman. Atherosclerotic lesions and associated changes such as calcification were evident. The specimens were stained with hematoxylin and eosin, and processed for immunohistochemistry. RESULTS: A monolayer of cells was observed on the luminal side of the femoral artery. Single immunohistochemistry showed the presence of the IP receptors on cells of the luminal side of the femoral artery. Triple-immunofluorescence staining revealed colocalization of IP-receptor-positive cells and cells positive for von Willebrand factor, a marker of vascular endothelial cells. CONCLUSIONS: We investigated the presence of the IP receptor in the human femoral artery immunohistochemically, and demonstrated their strong expression in endothelial cells. This finding suggests that prostacyclin or prostacyclin analogues may act on their receptors on endothelial cells in patients with arteriosclerosis obliterans.

Long-term results of treatments for varicose veins due to greater saphenous vein insufficiency.

AIM: The purpose of this study was to determine the long-term recurrence rates of greater saphenous vein (GSV) insufficiency after treatments for primary varicose veins, and to elucidate risk factors for recurrence. METHODS: This was a multicenter retrospective analysis of 376 limbs of 296 patients treated for primary varicose veins due to GSV insufficiency from January 1996 to December 1997. The recurrence-free rates after stripping surgery, saphenofemoral ligation, and sclerotherapy were estimated. The risk factors for the recurrence of primary varicose veins were estimated by multiple regression analysis. RESULTS: The follow-up period was 3.1+/-1.3 (mean+/-SD) years. The recurrence-free rates at 4 years after stripping, saphenofemoral ligation and sclerotherapy were 80.7%, 64.5%, and 51.3%, respectively. The saphenofemoral ligation group and sclerotherapy group had significantly higher recurrence rates than the stripping group (P=0.002, P<0.001, respectively). There was no difference in recurrence rates between the saphenofemoral ligation group and sclerotherapy group (P=0.074). Logistic regression analysis revealed that being female (P<0.029) and treatment without stripping (P<0.001) increased the recurrence rate. CONCLUSIONS: Stripping surgery may be the treatment of first choice for patients with varicose veins due to GSV insufficiency. Patients who have not received stripping surgery and female patients require closer follow-up.

The less incisional retroperitoneal approach for abdominal aortic aneurysm repair to prevent postoperative flank bulge.

One of the postoperative complications of retroperitoneal incision is a flank bulge that is suggested to be caused by 11th intercostal nerve injury leading to denervation of the ipsilateral muscles. To avoid this complication, we have tried to minimize retroperitoneal incision for abdominal aortic aneurysm (AAA) repair. The feasibility of the less incisional retroperitoneal approach for the repair of AAA to prevent postoperative flank bulge was investigated. Twenty-seven patients undergoing elective repair for infrarenal AAA through the left retroperitoneal approach were divided into group-L (less incision: 11.9+/-1.8 cm, n = 7) and group-C (conventional incision: 17.8+/-1.9 cm, n = 20). All operations were performed by a traditional hand-sewn anastomosis without laparoscopic support. Five bifurcated grafts were used in group-L and 15 in group-C. The postoperative course of all patients was uneventful except that one patient in group-C required reoperation for bleeding. Intraoperative parameters of both groups were almost comparable. All patients in group-L were extubated in the operating theater, whereas it was possible only for 11 patients in group-C. Resumption of alimentation was significantly earlier in group-L (P = 0.0117). There was no significant difference in postoperative hospital stay between groups. No late flank bulge was experienced. Significant late atrophy of the left rectus muscle (left/right thickness-ratio = 0.59+/-0.24) was seen in group-C (P = 0.0042 vs preoperative value), which was not observed in group-L (P = 0.0008 between groups). The less incisional retroperitoneal AAA repair seems feasible and safety technique that might prevent postoperative flank bulge and reduce surgical stress.

Autologous transplantation of peripheral blood endothelial progenitor cells (CD34+) for therapeutic angiogenesis in patients with critical limb ischemia.

AIM: Intramuscular injection of endothelial progenitor cells (EPCs) may constitute an alternative treatment strategy for patients with critical limb ischemia (CLI). We performed transplantations of EPCs (CD34(+)) extracted from peripheral blood in patients with CLI. The objective of this report is to present the method and early results of intramuscular autologous peripheral blood CD34(+) cell transplantation in the ischemic limb. METHODS: CD34(+) cell transplantation was performed in 2 limbs of 2 patients with CLI, in cases in which it was not possible to perform surgical or percutaneous revascularization. The patients received a granulocyte colony-stimulating factor (G-CSF) prior to the treatment. CD34(+) cells were retrieved from peripheral blood and injected directly into the muscle of the ischemic limb. RESULTS: CD34(+) cells retrieved in patient 1 were 1 x 10(5)/ml and in patient 2 were 1.6 x 10(5)/ml. Transcutaneous oxygen pressure in the foot increased and clinical symptoms improved. Newly visible collateral blood vessels were directly documented by angiography. CONCLUSION: Satisfactory clinical improvement was achieved by using peripheral blood EPCs (CD34(+)) in the patients with CLI. No complications arose following the intramuscular administration of peripheral blood CD34(+) cells.

Albumin-coated knitted Dacron aortic prosthses. Study of postoperative inflammatory reactions.

BACKGROUND: The purpose of this study was to investigate the postoperative inflammatory reactions to albumin-coated Dacron grafts (ACGs), which are used in the repair of abdominal aortic aneurysm (AAA). EXPERIMENTAL DESIGN: a retrospective study with a follow-up period of 14 days. SETTING: University hospital. PATIENTS: 50 patients admitted for elective AAA repair from January 1997 to January 2000. INTERVENTIONS: each patient underwent AAA repair with an ACG (Bard, albumin-coated Dacron graft). MEASURES: the white blood cell (WBC) count, plasma C-reactive protein (CRP) concentration, and body temperature (BT) were determined. The preoperative data, the highest values of the postoperative data, and the values 2 weeks postsurgery were analyzed. RESULTS: The BT, CRP, and WBC increased and peaked at the 1st week postsurgery and then decreased gradually. The BT and WBC levels returned to normal within 2 weeks. The CRP level continued to show slightly elevated values in the 2nd week, but it was not significantly different compared to the preoperative data. CONCLUSIONS: The use of an albumin-impregnated prosthesis for the reconstruction of AAA is biocompatible, since no significant increases in inflammatory reactions are observed in the 2nd week postsurgery.

Combined spinal and epidural anesthesia for abdominal aortic aneurysm surgery in patients with severe chronic pulmonary obstructive disease.

BACKGROUND: The presence of chronic obstructive pulmonary disease (COPD) should not be considered a contraindication to operation but should rather identify those patients that require special preoperative and postoperative pulmonary care. The purpose of this paper is to report our experience in the use of combined spinal and epidural anesthesia (CSEA) for open AAA repair in such patients. METHODS: From April 1997 to November 1998, three patients with severe COPD underwent elective open infrarenal AAA repair under CSEA. All the patients satisfied one or more of the following criteria: a room air PaO2 =or<60 mmHg, PaCO2 =or>45 mmHg, FEV1 =or<50% of predicted, and/or FVC =or<75% of predicted, and one of them was on home oxygen preoperatively. Preoperative preparation of the patients consisted of breathing exercises with incentive espirometry, elimination of underlaying pulmonary infections and usage of bronchodilator therapy. RESULTS: All the patients tolerated surgery safely. None of them developed postoperative complications, including pneumonia and other respiratory conditions. No significant changes in room air arterial blood gas or pulmonary function was recognized before and after surgery. CONCLUSIONS: CSE anesthesia is a viable anesthetic option for conventional AAA surgery in patients with severe COPD since it can preserve spontaneous breathing and provide additional respiratory benefits over general anesthesia.

Induction of angiotensin converting enzyme in neointima after intravascular stent placement.

BACKGROUND: To investigate the morphological changes of the arterial wall and the expression of angiotensin converting enzyme (ACE) in the arterial wall after stent placement in a canine model. METHODS: Seventeen mongrel dogs underwent stent placement (Gianturco's Z stent) in the aorta. Six animals were sacrificed at 4 weeks after stent implantation, and the other 5 animals at 12 weeks. The normal aorta was harvested from 6 dogs. The specimens were stained with hematoxylin-eosin (H&E) as well as by immunohistochemistry (smooth muscle specific a-actin, and ACE). Histomorphometric analysis was performed using the sections stained with H&E and smooth muscle specific a-actin. RESULTS: The total intimal area was significantly increased at all time points as compared with the control aorta. The a-actin positive intimal area was also significantly increased at all time points as compared with the control aorta. In the control aorta, luminal endothelial cells as well as a-actin positive medial cells occasionally exhibited faint cytoplasmic staining for ACE. In the 4- and 12-week stented aorta, a-actin positive cells in the neointima and media as well as macrophages in the adventitia stained strongly positive for ACE. CONCLUSIONS: ACE was induced in the neointima after stent placement of the canine aorta. Considering its multiple biological actions, ACE may be associated with the pathogenesis of neointimal hyperplasia after stent placement.

A rare case of atherosclerotic popliteal artery aneurysm in a young adult.

Popliteal artery aneurysms are not so clinically frequent but are the most common peripheral aneurysms. They usually affect older men aged over 60 and are caused by atherosclerosis. Whenever they occur in younger men, other more unusual etiologies such as trauma, infection, inflammatory arteritis or popliteal entrapment are responsible. In this paper we present the case of a young male with an atherosclerotic popliteal artery aneurysm without a history of penetrating trauma or other possible etiologies.

Prosthetic grafts for above-knee femoropopliteal bypass. A multicenter retrospective study of 564 grafts.

BACKGROUND: Many prosthetic grafts including expanded polytetrafluoroethylene (ePTFE) and polyethylene terephthalate (Dacron) have recently been used for above-knee femoropopliteal bypass. The purpose of this study was to identify the factors affecting patency performance and patient survival. METHODS: A multicenter retrospective analysis of 496 patients who received 564 grafts between 1990 and 1999 (325 ePTFE and 239 Dacron). Follow-up extended to 114.5 months, with a mean of 30.8 months (+/-25.9 months). RESULTS: The overall primary patency rate for all grafts was 71.4% at 5 years, 73.7% for ePTFE, and 68.9% for Dacron grafts. The secondary patency rates at 5 years were 84.1% for ePTFE, and 83.8% for Dacron. No significant differences were found. The logistic regression analysis revealed that younger age at operation and smoking history were correlated with decreased primary patency rate. The patency rates were unaffected by postoperative administration of oral anticoagulants or antiplatelet agents, although pharmacotherapy contributed to the improvement of survival rates. Renal failure, cerebral infarction and Dacron decreased survival rate. CONCLUSIONS: We conclude that the patency performances of prosthetic grafts are satisfying. However, the choice of prosthetic grafts for younger patients or patients with a smoking history need to be carefully considered. Cerebral infarction, chronic renal failure and Dacron grafts may decrease the survival rate. The operative indications should be determined carefully in these cases. The administration of beraprost sodium is recommended for postoperative pharmacotherapy.

Popliteal venous aneurysms: involvement of tibial nerve in aneurysmal wall.

Primary popliteal venous aneurysms are very rare vascular abnormalities, with 50 cases reported in the English literature. Thromboembolic complications are common in popliteal venous aneurysms. Since medical treatment has been proved inadequate, surgical repair is recommended with a minimum time delay. However, it involves some risk because of the complex anatomy of the popliteal space. We report on a case of popliteal venous aneurysm, in which the tibial nerve was involved in the aneurysmal wall and was injured by surgical repair.

Successful endovascular stent-grafting for thoracic aortic aneurysms in systemic lupus erithematosus. Report of 2 cases and review of the literature.

Systemic lupus erythematosus (SLE) is frequently associated with cardiovascular manifestations but rarely complicated with aortic disease, and surgical treatment is often complicated with later anastomotic dehiscence. We report successful endovascular stent-graft placement (EVSGP) as an alternative to conventional treatment of the aortic aneurysm in patients with SLE and review of the literature. Clinical cases included a 58-year-old woman with a saccular aneurysm of the distal aortic arch and a 52-year-old woman who had the aortic dissection in the whole descending thoracic aorta. Both patients underwent placement of the stent-graft in the diseased aorta through the iliac artery and received steroid perioperatively. Mortality was compared between surgical and medical treatment in the reported 39 cases of SLE associated with aortic aneurysm. Both patients were successfully treated by EVSGP and no inflammatory signs were seen after the procedure. There were no recurrence in the short follow-up period (up to 23 and 15 months after the procedure). In review of the literature, operative mortality (13.6%) was superior to that in patients receiving medical treatment only (53.3%), but two of 19 operative survivors died of rupture afterward. EVSGP can be a useful alternative to conventional treatment of the aortic aneurysm in patients with SLE, although it lacks the support of long-term follow-up data currently.

Popliteal artery entrapment syndrome. Reconstruction of the transected medial head of the gastrocnemius muscle.

Popliteal artery entrapment syndrome (PAES) is an uncommon cause of arterial insufficiency, especially in younger, athletic patients. Surgical treatment should be performed in all cases of PAES whether the artery is occluded or not. Although transection of the compressing muscle or fascial band is required to obtain good results, controversy exists about reconstruction of the transected muscle or fascial band. We present a case of a young athlete with PAES for whom rapid recovery of the athletic activity was provided by reconstruction of the divided medial head of the gastrocnemius muscle.

Congenital pelvic arteriovenous malformation: uncommon symptoms of lower limb venous hypertension.

Congenital pelvic arteriovenous malformations (AVMs) are rare and their clinical behavior is quite variable. A case of congenital pelvic AVM manifesting with unusual extrapelvic symptoms of ipsilateral leg pain is described. The causes of symptoms associated with congenital pelvic AVMs are discussed.

Effects of fibronectin bonding on healing of high porosity expanded polytetrafluoroethylene grafts in pigs.

BACKGROUND: We developed a new fibronectin bonding to expanded polytetrafluoroethylene (ePTFE) and previously reported that, in a dog carotid implant model, fibronectin bonding improves graft healing in high porosity ePTFE grafts. The purpose of this study was to further investigate the effect of the fibronectin bonding on graft healing in a pig carotid implant model. METHODS: Fifteen pigs received a high porosity ePTFE graft treated with the fibronectin bonding (fibronectin-bonded graft) on one side and an untreated graft (non-bonded graft) on the contralateral side. The grafts were explanted at intervals of 3 and 6 weeks and subjected to histological studies. RESULTS: At 3 weeks, the neointima of fibronectin-bonded grafts was better organized than that of non-bonded grafts. At 6 weeks, the morphologic features of the neointima were the same in fibronectin-bonded and non-bonded grafts. The neointima was completely organized. CONCLUSIONS: Together with the previous results with the dog model, fibronectin bonding could be expected to improve healing of the high porosity ePTFE grafts in humans.