Morphologic Features of Carotid Plaque Rupture Assessed by Optical Coherence Tomography.

BACKGROUND AND PURPOSE: Rupture of the plaque fibrous cap and subsequent thrombosis are the major causes of stroke. This study evaluated morphologic features of plaque rupture in the carotid artery by using optical coherence tomography in vivo. MATERIALS AND METHODS: Thirty-six carotid plaques with high-grade stenosis were prospectively imaged by optical coherence tomography. "Plaque rupture" was defined as a plaque containing a cavity that had overlying residual fibrous caps. The fibrous cap thickness was measured at its thinnest part for both ruptured and nonruptured plaques. The distance between the minimum fibrous cap thickness site and the bifurcation point was also measured. Optical coherence tomography identified 24 ruptured and 12 nonruptured plaques. RESULTS: Multiple ruptures were observed in 9 (38%) patients: Six patients had 2 ruptures in the same plaque, 2 patients had 3 ruptures in the same plaque, and 1 patient had 5 ruptures in the same plaque. Most (84%) of the fibrous cap disruptions were identified at the plaque shoulder and near the bifurcation point (within a 4.2-mm distance). The median thinnest cap thickness was 80 µm (interquartile range, 70-100 µm), and 95% of ruptured plaques had fibrous caps of <130 µm. Receiver operating characteristic analysis revealed that a fibrous cap thickness of <130 µm was the critical threshold value for plaque rupture in the carotid artery. CONCLUSIONS: Plaque rupture was common in high-grade stenosis and was located at the shoulder of the carotid plaque close to the bifurcation. A cap thickness of <130 µm was the threshold for plaque rupture in the carotid artery.

Effects of valsartan and amlodipine on home blood pressure and cardiovascular events in Japanese hypertensive patients: a subanalysis of the VART.

The Valsartan Amlodipine Randomized Trial (VART) was performed to compare the beneficial effects of valsartan and amlodipine on cardiovascular events in Japanese hypertensive patients. In this subanalysis of the VART, we assessed the relationship between home blood pressure (HBP) levels and cardiovascular events in the enrolled patients. We enrolled 1021 patients with mild-to-moderate hypertension in the VART. The participants were allocated randomly to either the valsartan group or the amlodipine group. The primary end point was a composite of all-cause death, sudden death, cerebrovascular events, cardiac events, vascular events and renal events. A total of 621 patients (valsartan group: 305 and amlodipine group: 316) completed the measurements of HBP (morning and evening) throughout the trial. Both the agents evenly and significantly lowered morning HBP and evening HBP throughout the trial. There was no significant difference in the primary end point between the two groups. However, we observed significant decreases in the left ventricular mass index and urinary albumin to creatinine ratio in the valsartan group but not in the amlodipine group. There were no significant differences in HBP levels and the main outcome of the cardiovascular events between the valsartan and amlodipine groups. However, in the valsartan group, significant improvements in left ventricular hypertrophy and microalbuminuria were observed.

Three-year cardiovascular events and disease progress in patients with peripheral arterial disease: results from the Japan Medication Therapy for Peripheral Arterial Disease (J-METHOD).

AIM: To investigate the current status of peripheral arterial disease (PAD) drug treatment in Japan, and the effects of drug treatment, risk factors, and complications on disease progress and onset of cardiovascular events in PAD patients. METHODS: In this prospective observational cohort study, 557 PAD patients were followed up for 3 years, and the current status of PAD treatment, risk factors, and cardiovascular events were monitored. RESULTS: Three drugs, i.e., beraprost sodium, cilostazol, and aspirin, were most frequently used. The patients who had undergone vascular reconstruction of the lower limbs before enrollment showed significant improvement in ABI. Among the patients who had not undergone vascular reconstruction before enrollment, there was a significant improvement in ABI after treatment with beraprost. During the observation period, cardiovascular deaths occurred in 35 patients (6.3%), heart diseases in 63 (11.3%), brain diseases in 39 (7.0%), and events in the lower limbs in 94 (16.9%). The factors affecting the increase of the cardiovascular events were explored by multivariate analysis (Cox regression analysis). As a result, age (75 years or older), ischemic heart disease and increase in severity on the Fontaine classification were identified as significant factors for cardiovascular deaths, whereas kidney disorders and increase in severity on the Fontaine classification were identified for heart diseases, the number of oral drugs for treating PAD was identified for brain diseases, and age (younger than 75 years), dialysis, ABI (less than 0.7) and aspirin were identified for the events in the lower limbs. CONCLUSION: As a result of the three-year follow-up on the Japanese PAD cohort, the current status of PAD treatment, risk factors, and cardiovascular events could be identified.

[Aortic valve replacement and hemiarch replacement in a patient with a porcelain aorta].

We report a case of aortic valve replacement and hemiarch replacement with reconstruction of the brachiocephalic artery in a patient with a porcelain aorta. A 65-year-old man was admitted to the hospital for aortic stenosis. Computed tomography demonstrated severe aortic calcification and extensive calcification covering a wide area of the aorta. The echocardiography showed a highly calcified aortic valve and a pressure gradient of 109 mmHg across the aortic valve. At surgery, calcification of the ascending aorta was severe and involved its entire circumference. Therefore, 2 cannulae were inserted to the right axillary and right femoral arteries for extracorporeal circulation. We performed replacement of the ascending aorta and hemiarch with reconstruction of the brachiocephalic artery under circulatory arrest and antegrade cerebral perfusion, as well as aortic valve replacement with a 21 mm St. Jude Medical mechanical valve. He had no major cardiac complications during the postoperative course, and was discharged on postoperative day 33.

[Aortic valve replacement and repeat coronary artery bypass grafting in a patient with a patent internal thoracic artery bypass graft; report of a case].

We report a case of aortic valve replacement and repeat coronary artery bypass grafting in a patient with a patent internal thoracic artery bypass graft. A 77-year-old man, who underwent coronary artery bypass grafting (CABG) 10 years ago, was admitted to the hospital for aortic stenosis and angina pectoris. Transthoracic echocardiography demonstrated severe aortic calcification with an 86 mmHg gradient across the aortic valve. Coronary angiography demonstrated the patency of all grafts and 90% stenosis of the left circumflex coronary artery. At surgery, a full median sternotomy was performed. The adhesions around the heart and great vessels were severe and the left internal thoracic artery (LITA) was found adherent to the heart and sternum. The LITA and saphenous vein graft (SVG) graft were dissected carefully. Retrograde coronary sinus (CS) perfusion was performed with antegrade myocardial protection for cardiac arrest. We performed aortic valve replacement (AVR) with a 17 mm St. Jude Medical Regent Valve and CABG to the circumflex artery with the saphenous vein under cardiopulmonary bypass. His postoperative course was uneventful. He was discharged from our hospital without major complications.

[Recurrent cardiac myxoma that developed rapidly in a short period].

A 55-year-old woman, who had undergone extirpation of left atrial myxoma 3-years before, was admitted to our hospital with dyspnea. Chest computed tomography revealed a low density mass in the left atrium (LA) with a diameter of 54 mm. Transthoracic echocardiography showed that the mass was attached to the left atrial septal wall and had a pendulum-like movement. We urgently performed an operation for recurrent left atrial myxoma. Through atrial transseptal approach, a huge myxomatus tumor was observed in the LA. The stalk was on the endocardium at the cranial side of the previous autologous pericardial patch. The tumor was completely excised along with the patch. We repaired the disrupted endocardium and performed Dacron patch repair of the atrial septal defect. The patient recovered uneventfully and was discharged 14 days after surgery. The excised tumor was found to be myxoma on pathological examination similar to the previous tumor. We report a case of recurrent left atrial myxoma with rapid growth in a short time period.

Petrous apex cholesterol granuloma treated via the endoscopic transsphenoidal approach.

Numerous surgical approaches have been used to treat petrous apex cholesterol granulomas. They are usually treated via the transtemporal- or middle fossa approach; some are managed endoscopically. We present a patient treated by the endoscopic transsphenoidal approach and review the literature.

[Embolism of the lower limb caused by native aortic valve thrombosis].

Native aortic valve thrombosis is an uncommon event with heart valve disease, during cardiac catheterization, bacterial endocarditis, or a hypercoagulative state as in antiphospholipid antibody syndrome. We report a case of thrombus formation on a native aortic valve, which was found by the transesophageal echocardiography during thrombectomy of the lower limb. We supposed that the atheromatous plaque of aortic valve was related to thrombus formation.

A comparison of the inflammatory response and the recovery of bowel function between trans- and extraperitoneal approaches of abdominal aortic aneurysmectomy.

AIM: To determine whether surgical stress is less with transperitoneal or extraperitoneal abdominal aortic aneurysmectomy, blood concentrations of inflammatory cytokines and other inflammatory markers with recovery of bowel function were examined. METHODS: Patients who underwent abdominal aortic aneurysmectomy electively via the transperitoneal (T-group; n=15) or the extraperitoneal approach (E-group; n=17) were evaluated. Inflammatory cytokines (interleukin[IL]) IL-6, IL-8, C-reactive protein concentrations, and systemic inflammatory response syndrome score were determined before operation and after operation on days (POD) 1, 3, 7, and 14. Recovery of bowel function was estimated by the time taken for resumption of bowel movement and oral intake, and by the volume of fluid collection from the nasogastric tube. RESULTS: Cytokine (IL-8) concentrations were higher in the T-group than the E-group with significant difference on POD 7 (4.8+/-0.5 versus 3.4+/-0.2 pg/mL, respectively; P=0.02). Recovery of bowel function and oral intake were earlier, and the volume of fluid collection from the nasogastric tube was smaller in the E-group than the T-group significantly. CONCLUSIONS: Early recovery of bowel function and low concentration of inflammatory cytokines suggest that the extraperitoneal approach to the abdominal aorta is less stressful to the transperitoneal approach. Postoperative inflammatory response may mainly depend on damage of the bowel in the operation of the abdominal aortic aneurysm.

[Chondrosarcoma of the chest wall].

We report 2 patients with chondrosarcoma of the chest wall. They were a 67-year-old woman (case 1) with an anterior chest wall tumor and a 68-year-old woman (case 2) with a painful rib tumor. Their computed tomography (CT) both revealed calcified tumors. Case 1 underwent a wide resection by partial sternectomy, with free surgical margins. Case 2 underwent tumor resection with the posterior part of the 3rd rib, with positive surgical margin in the vertebral site, and received adjuvant radiotherapy. Both patients were pathologically diagnosed as having grade II chondrosarcoma. In their postoperative courses, they are free from recurrence. Wide resection is likely to be the key to successful management of chest wall chondrosarcoma.

[Prognosis of resected stage I bronchioloalveolar carcinoma of the lung].

In this retrospective study, we investigated the prognosis of 25 patients with resected bronchioloalveolar carcinoma (BAC) of 3.0 cm or less in diameter. We assigned a diagnosis of BAC for non-invasive tumors as defined by the World Health Organization (WHO) classification. The patients ranged in age from 47 to 78 years with an average of 64.0 years. Eighteen patients (72%) were male and 7 patients (28%) were female. All the patients underwent complete resection. As the mode of surgical resection, at least lobectomy was performed in 84%. Sections of the resected tumor were stained by HE and Elastica, and then examined by light microscopy. The tumors ranged in size from 0.5 to 3.0 cm with an average of 1.9 cm. Neither pleural involvement nor vascular permeation was seen in BACs. There was also no lymph node involvement for BACs. The 5-year disease-free survival rate of all 25 patients with BAC was 100%. The unequivocally recognizing invasive features by morphology is important for a prospect of the prognosis of resected BACs.

Off-pump reconstruction of pseudoaneurysm of the descending thoracic aorta.

We report 2 cases of postoperative pseudoaneurysm of the descending thoracic aorta, repaired successfully by temporary bypass graft without extracorporeal bypass. One patient presented with a large recurrent pseudoaneurysm that developed 30 years after ligation of a patent ductus arteriosus. The other patient presented with a pseudoaneurysm 18 years after thoracic aortic reconstruction for a traumatic aneurysm. In both cases, a temporary bypass graft was created from a major branch of the aortic arch to the femoral artery prior to definitive reconstruction. The postoperative course was uncomplicated by organ dysfunction or neurologic deficit. Creation of a temporary bypass graft can avoid the need for cardiopulmonary bypass in selected patients. By avoiding heparin use, blood loss is decreased, especially when dense pulmonary adhesions from previous surgery are present.

[A new formula to calculate perfusion rate in advanced hemodilution and tepid cardiopulmonary bypass].

BACKGROUND: During cardiopulmonary bypass, perfusion flow rate is generally calculated only with the patient body surface. Recently, far advanced hemodilution during cardiopulmonary bypass and tepid bypass circulation are common. PURPOSE: We have arrived at an appropriate flow rate formula, in which factors like temperature, hemoglobin concentration, the target mixed venous oxygen saturation (SvO2), and the amount of oxygen consumption are included. Our formula was compared with the conventional one. MATERIAL AND METHOD: Seventy-four points of cardiopulmonary bypass data under total cardiopulmonary bypass in 33 patients were studied. Our formula's validity was re-evaluated. Then, the SvO2 values were predicted by applying the flow rate value as per conventional calculation in to our formula. RESULTS: The flow rate of our formula and the actual flow rate are well correlated (r = 0.9212). In the prediction of the SvO2 by the conventional method, 36.5% were calculated to have a SvO2 of less than 60%. Furthermore, with a hemoglobin concentration of 7 g/dl, 73.3% were calculated to have a SvO2 of less than 60%. With a body temperature of 34 degrees centigrade, 53.8% were calculated to have a SvO2 of less than 60%. On the other hand, to maintain SvO2 level at 70% by the conventional method, if the patient hemoglobin concentration was 10 g/dl, temperature should be maintained at 36 degrees centigrade, and when hemoglobin concentration is 7 g/dl, the temperature should be maintained at 33 degrees centigrade. CONCLUSION: In advanced hemodilution or tepid cardiopulmonary bypass, use of appropriate flow rate formula is recommended, which takes into account the indispensable factors such as hemoglobin levels, temperature, and the target SvO2.

Arterial reconstruction in Buerger's disease: by-pass to disease-free collaterals.

BACKGROUND: Arterial reconstructions for ischemia in patients with Buerger's disease are technically challenging. This retrospective review was conducted to identify the critical factor for a successful outcome in bypass surgery for Buerger's disease. DESIGN OF STUDY: retrospective review. SETTING: University hospital, hospitalized patients. PATIENTS: since 1993, we performed 10 arterial reconstructions in 8 patients with Buerger's disease. There were 8 tibial artery bypasses and 2 collateral artery bypasses. One bypass was performed in the upper extremity. INTERVENTIONS: bypass surgery with autogenous vein graft. MAIN OUTCOMES MEASUREMENTS: graft patency. RESULTS: Over a mean follow-up period of 41.8 months, there were 3 graft occlusions. Of these, 2 were of bypasses to a patent but diseased tibial artery. One graft was occluded due to a toe stenosis which had been previously detected. The 2 collateral artery bypasses were patent at the last follow-up. CONCLUSIONS: In Buerger's disease, distal arterial reconstruction is frequently necessary to prevent ischemic limb loss. Collateral artery bypass is an option when the main arteries are affected by the disease. A patent but diseased artery should be avoided as a target for reconstruction.

Inflammatory solitary iliac artery aneurysms: a report of two cases.

Inflammatory abdominal aortic aneurysms are associated with atherosclerosis, which are characterized by specific clinical manifestation. We treated two patients with unilateral solitary iliac artery aneurysms with perianeurysmal fibrosis which compressed the ureter resulting in ipsilateral hydronephrosis. After the iliac artery aneurysm was repaired with a prosthetic graft, the hydronephrosis resolved. Microscopically, there was clear evidence of atherosclerosis in one case. There was a characteristic inflammatory reaction around the adventitia in both aneurysms. Localized iliac perianeurysmal fibrosis has not been particularly described. The clinicopathologic similarities between these cases and inflammatory abdominal aortic aneurysms suggest the same pathogenesis.

Staged vascular reconstruction along with repeatedly performed angiography to prevent ischemic limb loss with Buerger's disease: report of a case.

An aggressive approach to vascular reconstruction should be adopted in patients with Buerger's disease and peripheral ischemia who are often young and otherwise active. A patient with severe Buerger's disease is reported who was treated successfully by complete vascular reconstruction with staged bypass surgery while also performing repeated angiography to preserve the foot function. A 48-year-old man with Buerger's disease presented with necrosis of the foot. Angiography showed occlusion of the right distal external iliac artery and no runoff below the knee. Repeated angiography after performing a lumbar sympathectomy demonstrated patency of the distal portion of the deep femoral artery. Angiography was again performed after a reconstruction of the deep femoral artery and patency of the anterior tibial artery was observed. A staged bypass operation on the tibial artery was therefore able to achieve a prompt healing of both the toe ulcers and plantar wound.

Identification of the critical spinal arteries with F wave-polysynaptic response complex monitoring: an experimental study.

PURPOSE: The main cause of paraplegia after surgery for descending thoracic aortic aneurysms and thoracoabdominal aortic aneurysms is spinal cord ischemia caused by ligation of the critical spinal arteries that are associated with the great radicular artery (GRA). In this experimental study, we attempted to identify the critical spinal arteries with F wave-polysynaptic response complex (FPC) monitoring. The FPC, which we are using as a monitor of spinal cord ischemia, is myogenic potentials evoked by the tibial nerve stimulation through the anterior horn cells. METHOD: In 18 rabbits, infrarenal lumbar arteries were clamped until there was an FPC amplitude reduction (FPCAR) of at least 60%. The rabbits were classified according to the number of arteries clamped to produce the FPCAR (group A, 1 artery; group B, 2 arteries; group C, 3 arteries). Selective angiography of each lumbar artery was performed in all rabbits. RESULTS: An FPCAR was observed in all 18 rabbits. In all nine rabbits in group A, the FPCAR was caused by the clamping of one particular lumbar artery. The GRA was shown by means of selective angiography to originate directly from this lumbar artery. In the nine rabbits in groups B and C, 11 FPCARs were observed. Of these, nine FPCARs in nine rabbits were caused by the clamping of lumbar arteries that included the vessel from which the GRA originated. CONCLUSION: Temporary clamping of lumbar arteries with FPC monitoring can be used as a means of detecting the critical spinal arteries from which the GRA originates.