The Impact of Repeat Endovascular Treatment on Critical Limb-Threatening Ischemia for Limb Salvage.

Chronic limb-threatening ischemia due to chronic total occlusion of below-the-knee lesions is one of the most challenging cases for endovascular treatment. Restoring perfusion is crucial, and its success depends on numerous factors. Owing to the recent development of dedicated devices and techniques, endovascular treatment is becoming an alternative to bypass surgery as a first-line treatment, even for the infra-popliteal lesion, because endovascular recanalization outcomes have considerably improved. In our present case, a self-expandable Nitinol stent was placed in the tibio-peroneal trunk to treat chronic limb-threatening ischemia. At its recurrence four years later, endovascular therapy was employed because the patient had concomitant diseases and advanced age. Finally, four times repeated revascularization prevented major amputation and preserved the functional foot. This report demonstrates that repeated endovascular therapy was practical and feasible to achieve limb salvage and preserve the functional foot.

A case of radicular cyst on deciduous tooth in a 7-year-old child.

Radicular cysts are the most common cystic lesions in the oral cavity, and have a rare occurrence in the primary dentition. We report a case of radicular cyst of mandible in child by multimodal imaging including panoramic radiography, CT, and MR imaging. A 7-year-old girl presented with swelling and without pain, and hypoesthesia on the right side of the mandible. On clinical examination, an expansive lesion with undulation was found to the buccal cortex of the right side of the mandible. Panoramic radiograph showed a unilocular radiolucency with well-defined margin, displaced tooth, and root resorption in the right mandible. Regarding CT imaging, axial soft tissue algorithm CT and bone tissue algorithm CT showed a low-attenuation internal structure and expansion of the buccal cortex of the right side of the mandible. Three-dimensional-CT showed expansion of the buccal cortex of the right side of the mandible. Multiplanar reformation imaging showed displaced tooth, root resorption, and expansion of the buccal cortex of the right side of the mandible. On T1-weighted image, the expansive lesion showed low signal intensity, and T2-weighted and STIR images revealed high signal intensity. A partial biopsy of the mandibular region was performed. Histopathological diagnosis was radicular cyst caused by apical periodontitis with abscess. This case suggests that multimodal imaging, especially CT and MR imaging, could be effective for evaluating mandibular lesions in child.

Optimal timing of echocardiography for heart failure inpatients in Japanese institutions: OPTIMAL Study.

AIMS: Guidelines for the diagnosis and treatment of acute and chronic heart failure (HF) provided by the European Society of Cardiology state that echocardiography is recommended for the assessment of the myocardial structure and function of subjects with suspected HF including HF with reduced (HFrEF), mid-range (HFmrEF), and preserved ejection fraction (HFpEF) as class I of recommendation and level C of evidence. However, the impact of timing of echocardiography on survival for hospitalized HF patients or the prevalence of echocardiography during their stay has not yet been fully investigated. Therefore, we designed and conducted a prospective multicentre study, Optimal Timing of Echocardiography for Heart Failure Inpatients in Japanese Institutions (OPTIMAL) study, to investigate and evaluate the prevalence of echocardiography during the in-hospital stay of HF patients, and the impact of timing of echocardiography on their survival. METHODS AND RESULTS: OPTIMAL was based on a nationwide, prospective, multicentre registry at 10 institutions in Japan endorsed by the Japanese Society of Echocardiography. A total of 601 patients hospitalized with HF were enrolled between August 2016 and July 2018 at the participating centres. Their mean age was 73.9 ± 13.0 years, left ventricular ejection fraction was 37.0% (26.0-50.0), and 256 patients (42.6%) were female. Admission echocardiography (admission echo) was categorized as either standard or point-of-care echocardiography performed within 3 days of admission, as was pre-discharge echocardiography (pre-discharge echo) within 3 days of discharge. The primary endpoint was defined as cardiovascular death over a median follow-up period of 18.9 months (9.3-26.5 months). Admission echo was performed for 476 patients (79.2%) and pre-discharge echo for 216 patients (35.9%). The primary endpoint of cardiovascular death occurred in 65 patients (10.8%). Kaplan-Meier curve findings indicated that survival of patients with pre-discharge echo was significantly better than that of patients without it (log-rank P < 0.001), and the same findings were obtained for patients with HFrEF, HFmrEF, and HFpEF. However, survival of patients with and without admission echo was similar (log-rank P = 0.33). CONCLUSIONS: This OPTIMAL study prospectively showed the importance of pre-discharge echo for hospitalized HF patients. Careful attention is needed regarding the haemodynamic status of HF patients by administering pre-discharge echo to avoid HF re-hospitalization after discharge, and pre-discharge echo may provide additional information for deciding the appropriate discharge time. Our findings may thus offer a new insight into the management of hospitalized HF patients.

Pseudoaneurysm and subsequent venous thromboembolism after subintimal angioplasty for chronic total occlusion in the superficial femoral artery.

Endovascular therapy (EVT) has been accepted as a minimally invasive treatment for peripheral artery disease, and its applicability has been widened with the development of techniques and devices. A long, totally occluded lesion in the superficial femoral artery (SFA) is one of the most challenging lesions for EVT due to technical difficulties in wire-crossing. Recently, intentional subintimal recanalization is often considered as an alternative option for long SFA occlusions. Previous studies have shown that subintimal approach achieved superior technical success rate and similar patency rate, compared to conventional intraluminal approach. However, there is limited information about complications of the treatment with subintimal approach. Deep vein thrombosis (DVT) due to direct compression by pseudoaneurysm in the SFA, which subsequently develops pulmonary embolism (PE), is considered as a rare complication of subintimal angioplasty for the occlusive SFA lesion. We herein present a case of a patient who developed pseudoaneurysm formation in the SFA after EVT. Although initial EVT was performed successfully with subintimal approach, DVT and PE were caused by the SFA pseudoaneurysm at sub-acute phase following the initial procedure. The pseudoaneurysm was treated with implantation of a covered stent sealing the entry point, disappearing with no endoleak. .

Impact of intravascular ultrasound-guided minimum-contrast coronary intervention on 1-year clinical outcomes in patients with stage 4 or 5 advanced chronic kidney disease.

This study aims to elucidate 1-year clinical outcomes using this technique for patients with stage 4 or 5 advanced chronic kidney disease (CKD). Research has proven that imaging-guided percutaneous coronary intervention (PCI) reduces contrast volume significantly; however, only short-term clinical benefits have been reported. Minimum-contrast (MINICON) studies are based on the registry design pattern to enroll PCI results in patients with advanced CKD stage 4 or 5 comorbid with coronary artery disease. We excluded cases of emergency PCI or maintenance dialysis from this study. In this study, we compared the intravascular ultrasound (IVUS)-guided MINICON PCI group (n = 98) with the angiography-guided standard PCI group (n = 86). Enrollment of the MINICON studies started in 2006. Before 2012, IVUS-guided MINICON PCI was performed only in 14% (stage 1), but it was 100% after 2012 (stage 2). The enrollment finished in 2016. The IVUS-guided MINICON PCI group exhibited a significantly reduced contrast volume (22 ± 20 vs. 130 ± 105 mL; P < 0.0001) and contrast-induced acute kidney injury (CI-AKI; 2% vs. 15%; P = 0.001). The PCI success rate was similarly high (100% vs. 99%; P = 0.35). At 1 year (follow-up rate, 100%), we observed less induction of renal replacement therapy (RRT; 2.7% vs. 13.6%; P = 0.01), but all-cause mortality or myocardial infarction was similar in both groups. The IVUS-guided MINICON PCI reduces CI-AKI significantly and induction of RRT at 1 year in patients with stage 4 or 5 advanced CKD.

Catheter-induced aortocoronary dissection at the ostium of anomalous left coronary artery during percutaneous coronary intervention for acute inferior myocardial infarction.

We report a case of catheter-induced aortocoronary dissection at the ostium of anomalous left coronary artery (LCA) during percutaneous coronary intervention (PCI) for acute inferior myocardial infarction (MI). Urgent coronary angiography revealed the culprit lesion of MI was the proximal segment of the right coronary artery (RCA). The anomalous LCA arose from the right sinus of Valsalva the same as the RCA. Catheter-induced aortocoronary dissection at the ostium of RCA was extended to the ostium of anomalous LCA by contrast injection. The patient fell into hemodynamic collapse due to acute occlusion of the anomalous LCA. The patient underwent successful bailout stenting at the ostium of anomalous LCA under percutaneous cardiopulmonary support (PCPS). He was weaned from PCPS system five days after PCI and was discharged. This is the first report about bailout procedure for catheter-induced aortocoronary dissection at the ostium of anomalous LCA. .

Gastrointestinal Bleeding Successfully Treated Using Interventional Radiology.

Gastrointestinal (GI) bleeding is an emergency medical condition that leads to hemorrhagic shock or circulatory instability if left untreated. A mainstay for treating GI bleeding is endoscopic therapy; more than 90% of GI bleeding can be staunched by endoscopic hemostasis. However, patients with unstable hemodynamics or GI bleeding that cannot be controlled by endoscopy require transcatheter embolization or surgical intervention. The development of several devices and embolization agents that are used in interventional radiology (IVR) leads to safe and accessible treatment via IVR. If endoscopic treatment fails, IVR is the second strategy. Herein, we report cases of GI bleeding that were successfully treated by IVR and discuss the therapeutic strategy.

Two Cases of Pneumatosis Cystoides Intestinalis With Intraperitoneal Free Air.

Intraperitoneal free air (IFA) is sometimes accompanied by pneumatosis cystoides intestinalis (PCI); therefore, proper diagnosis is essential for PCI management. We report two cases of PCI with IFA. A 70-year-old female taking anti-psychotic medication for schizophrenia presented with repeated vomiting and high-grade fever. Computed tomography revealed small, linear gaseous cysts in the intestinal wall along with IFA. Although there was no sign of peritoneal irritation, intestinal perforation was not excluded. Thus, exploratory laparotomy was performed; it revealed no ascites or perforated sites in the intestine, and revealed numerous small air bubbles in the intestinal wall and mesentery. Thus, a diagnosis of PCI was made, and ileostomy was performed to relieve intestinal pressure. The postoperative course was uneventful. A 79-year-old male with pulmonary emphysema presented with dyspnea due to abdominal distention. Cyanosis was evident, and arterial blood gas analysis revealed metabolic acidosis. CT revealed massive IFA along with multiple, small bubbly cysts under the intestinal serosa. He was intubated because of worsening respiratory conditions, and a 12-French drain was inserted to relieve the intraperitoneal pressure. There was no evidence of peritonitis, and IFA was conservatively observed.

A Prospective Multicenter Study Using a Virtual 3 Fr Percutaneous Coronary Intervention System: The V3 Registry.

OBJECTIVES: To evaluate the safety and feasibility of virtual 3 Fr (V3), sheathless 5 Fr percutaneous coronary intervention (PCI). BACKGROUND: A small-diameter guiding catheter (GC) makes less-invasive PCI possible. The V3 is an extremely slender PCI system; however, the outcome of using this system has not yet been determined. METHODS: The V3 registry is a prospective, multicenter, non-randomized study that enrolled patients who underwent elective V3-PCI. The primary endpoint was clinical success rate, and the secondary endpoints were PCI success rate in all cases, major adverse cardiac and cerebrovascular event (MACCE) at 30 days, and access-site complications. RESULTS: A total of 260 patients with 321 lesions were enrolled. Of this group, 70% were male and the mean age was 70.8 ± 10.0 years. Type B2/C lesions comprised 50.7% of the total. The clinical success rate was 95.8%, and the PCI success rate was 99.2%. PCI failure was reported in 2 chronic total occlusion cases. No MACCE was reported. Although there was no major bleeding, hematoma occurred at the puncture site in 12.7% of cases. There was a single radial artery occlusion (0.4%) without symptoms. CONCLUSIONS: PCI with the V3 was safe and feasible. Radial artery occlusion and major bleeding complications were extremely low. However, access-site hematoma frequently complicated catheter exchange.

Ruptured thoracic aortic aneurysm infected with listeria monocytogenes: a case report and a review of literature.

A 75-year-old male with a history of alcoholic liver cirrhosis, sigmoid colon cancer, and metastatic liver cancer was admitted to our institution with a complaint of a prickly feeling in his chest. On admission, a chest radiograph revealed a normal cardio-thoracic ratio of 47%. Echocardiography revealed pericardial effusion and blood chemical analyses revealed elevated C-reactive protein levels (14.7 mg/dL). On day 3, chest radiography revealed cardiomegaly with a cardio-thoracic ratio of 58% and protrusion of the left first arch. Contrast-enhanced chest computed tomography revealed a saccular aneurysm in the aortic arch with surrounding hematoma; thus, a ruptured thoracic aortic aneurysm was suspected. Emergency surgery was performed, which revealed a ruptured aortic aneurysm with extensive local inflammation. The diagnosis of an infected aortic rupture was therefore confirmed. The aneurysm and abscess were resected, followed by prosthetic graft replacement and omental packing. Histopathology of the resected aneurysm revealed gram-positive bacilli; and Listeria monocytogenes was confirmed as the causative organism by culture. Postoperative course was uneventful; on postoperative day 60, the patient was ambulatory and was discharged. Here we report the case of a male with a ruptured thoracic aortic aneurysm infected with L. monocytogenes.

Aortic valve papillary fibroelastoma associated with acute cerebral infarction: a case report.

An 80-year-old woman with a history of congestive heart failure, atrial fibrillation, and hypertension was transferred to our institution with hematemesis. Her drug regimen included 2 mg warfarin potassium/day to prevent thromboembolic events. Transthoracic echocardiography (TTE) performed at 78 years of age revealed a mass attached to the noncoronary cusp and a cardiac tumor was suspected. The patient declined surgery and was meticulously followed up with periodic TTE. Upper gastroendoscopy revealed a gastric ulcer with an exposed blood vessel; anticoagulant therapy was ceased. On day 15 of admission, acute cerebral infarction occurred. Heparin sodium and warfarin potassium were administered rapidly, and her symptoms improved. TTE revealed no alteration of the mobile, string-like mass attached to the noncoronary cusp. Cardiac tumor was considered the cause of cerebral infarction, and the patient consented to surgical therapy. Pathological examination of the resected tumor suggested papillary fibroelastoma (PFE). Although no guidelines exist for PFE management, a mobile, cardiac tumor necessitates surgical resection to prevent thromboembolic events, even when small in size.

A case report of coronary arteriovenous fistulas with an unruptured coronary artery aneurysm successfully treated by surgery.

A 58-year-old female with a history of Wolff-Parkinson-White syndrome presented at our institution with palpitations and chest pain. Electrocardiography revealed paroxysmal supraventricular tachycardia with a heart rate of 188 beats/min. Antiarrhythmic drugs were ineffective, and tachycardia was resolved by electrical cardioversion. Transthoracic echocardiography revealed abnormal vessels around the right coronary artery (RCA) and pulmonary artery (PA); in addition, we suspected coronary arteriovenous fistula (CAVF). Coronary angiography and coronary computed tomography revealed dilated fistula vessels, with a 1 cm saccular aneurysm around the RCA, originating from the proximal RCA and left anterior descending artery into the main trunk of PA. Therefore, we confirmed the diagnosis of CAVF with an unruptured aneurysm. We surgically ligated and clipped the fistula vessels and resected the aneurysm. The resected aneurysm measured 1 × 1 cm in size. Pathological examination of the resected aneurysm revealed hypertrophic walls comprising proliferating fibroblasts cells thin elastic fibers. Very few atherosclerotic changes manifested in the aneurysm walls. We report the case of a patient with CAVF and an unruptured coronary artery aneurysm who was successfully treated by surgery.

Comparison of preventive effect on cardiovascular events with different statins. -The CIRCLE study-.

BACKGROUND: Although statins vary in their effectiveness in lowering low-density lipoprotein cholesterol (LDL-C) and increasing high-density lipoprotein cholesterol (HDL-C) levels, there is little evidence that the degree of these changes can explain cardiac risk reduction in Japan. Our objective was to compare the efficacy of statins on serum lipid levels and to explore the association between those changes and cardiac events in patients after percutaneous coronary intervention (PCI). METHODS AND RESULTS: The 743 consecutive patients who underwent PCI from 2001 to 2008 were retrospectively investigated. Treatment with either atorvastatin or pitavastatin significantly reduced LDL-C compared with pravastatin or no statin. In contrast, only pitavastatin treatment significantly increased HDL-C (13.4 ± 22.9%, P=0.01 vs. no statin). Each statin significantly prevented major adverse cardiac events (MACE) compared with no statin, and pitavastatin was the most effective of all. Multivariate-adjusted analysis revealed that percent changes of both LDL-C and HDL-C independently predicted the incidence of MACE (hazard ratio [HR]: 1.015; 95% confidence interval [CI]: 1.010-1.020, HR: 0.988; 95%CI: 0.981-0.996, respectively). This relationship was preserved in patients with a baseline HDL-C level ≤ 45 mg/dl, but not HDL-C level > 45 mg/ml. CONCLUSIONS: The extent of changes in LDL-C and HDL-C with statin treatment would independently alter the risk of cardiac events in Japanese patients for secondary prevention. Statins with varying lipid-modifying ability might provide differing prognosis in patients after PCI.

Chylomicron remnants are increased in the postprandial state in CD36 deficiency.

The clustering of risk factors including dyslipidemia, hyperglycemia, and hypertension is highly atherogenic along with the excess of remnants from triglyceride (TG)-rich lipoproteins. CD36 is involved in the uptake of long-chain fatty acids (LCFAs) in muscles and small intestines. Patients with CD36 deficiency (CD36-D) have postprandial hypertriglyceridemia, insulin resistance, and hypertension. To investigate the underlying mechanism of postprandial hypertriglyceridemia in CD36-D, we analyzed lipoprotein profiles of CD36-D patients and CD36-knockout (CD36-KO) mice after oral fat loading (OFL). In CD36-D patients, plasma triglycerides, apolipoprotein B-48 (apoB-48), free fatty acids (FFAs), and free glycerol levels were much higher after OFL than those of controls, along with increases in chylomicron (CM) remnants and small dense low-density lipoprotein (sdLDL) particles. In CD36-KO mice, lipoproteins smaller than CM in size in plasma and intestinal lymph were markedly increased after OFL and mRNA levels of genes involved in FFA biosynthesis, such as fatty acid binding protein (FABP)-1 and FAS, were significantly increased. These results suggest that CD36-D might increase atherosclerotic risk by enhancing plasma level of CM remnants due to the increased synthesis of lipoproteins smaller than CM in size in the intestine.

Radiation dose reduction and coronary assessability of prospective electrocardiogram-gated computed tomography coronary angiography: comparison with retrospective electrocardiogram-gated helical scan.

OBJECTIVES: The aim of this study was to evaluate radiation dose and coronary assessability of a prospective electrocardiogram (ECG)-gated scan by 64-slice multidetector (row) computed tomography (MDCT)-coronary angiography (CA) compared with a retrospective ECG-gated helical scan. BACKGROUND: The 64-slice MDCT-CA has been widely used; however, a high radiation dose by 64-slice MDCT-CA has been reported. Prospective ECG-gated scan using "step-and-shoot" protocol can reduce radiation exposure effectively. METHODS: MDCT-CA was performed in 229 consecutive patients. Fifty-six patients were excluded because of higher heart rates of >65 beats/min; of patients with heart rates