Prosthesis use and the change in activities of daily living following below-knee amputation in patients undergoing hemodialysis.

INTRODUCTION: Patients undergoing hemodialysis are at an increased risk of peripheral arterial disease, amputation of lower extremities, and decline of activities of daily living. Although a prosthesis is used to support activities of daily living, no previous study reported the association of prosthesis use with the change in activities of daily living following leg amputation in hemodialysis patients. The purpose of this study was to compare the changes in activities of daily living following amputation between those who created a prosthesis and those who did not. METHODS: This study was a single-center, retrospective observational study. We screened medical records for hemodialysis patients who underwent below-knee amputation (BKA) and activities of daily living were examined two times with the functional independence measure (FIM) before BKA and at discharge. They were divided into two groups according to the creation of a prosthesis. FINDINGS: We identified 28 eligible patients, among whom 12 patients used a prosthesis (prosthesis group), whereas 16 patients did not (non-prosthesis group). The FIM score was significantly decreased following BKA in the non-prosthesis group, whereas it was not significantly changed in the prosthesis group. The change in FIM score was significantly different between the two groups, and the difference remained significant after considering potential confounders. DISCUSSION: The results of this study showed that use versus nonuse of a prosthesis was an independent factor associated with changes in activities of daily living in hemodialysis patients following BKA, supporting the important role of a prosthesis in maintaining activities of daily living in hemodialysis patients who need BKA.

The real-world data of lipid-lowering treatment in patients with peripheral artery disease and its association with severity of disease.

BACKGROUND: The risk of coronary artery disease in peripheral arterial disease (PAD) is high, life prognosis is poor, and lipid-lowering treatment with statins has been reported to improve prognosis. In clinical practice, however, hypolipidemia is more common in patients with severe PAD and statin prescription rates appear to be low, but specific data are scarce in Japan. Therefore, we conducted this cross-sectional study in collaboration with other centers of vascular surgery to determine the rate of statin prescriptions for PAD patients in real-world practice, the rate of achievement of low-density lipoprotein (LDL) cholesterol control targets, and whether statin non-use is a determinant factor of critical limb ischemia (CLI). METHODS: A total of 246 PAD patients (97 with CLI) from 5 sites were included in this study. Medical history and blood test data were obtained from medical records and interviews with patients, and were compared between CLI and non-CLI patients. RESULTS: Statin prescription rate was only 34 %. The overall LDL cholesterol control target rate was 46 % of CLI cases and 51 % of non-CLI cases, according to the lipid management criteria of the Japanese Society for Atherosclerosis 2022 guidelines. Patients in the CLI group had a lower mean body mass index and lower LDL cholesterol levels than those in the non-CLI group, suggesting that these factors were responsible for the lower statin prescription rate. However, multivariate analysis revealed that statin non-use was one of the determinants of CLI. CONCLUSIONS: Statin prescription rates for PAD patients were low in real-world practice settings in the field of vascular surgery. Since statin non-use is a determinant of CLI, there is a need to educate physicians engaged in treatment regarding lipid-lowering treatment with statins.

Transmission dynamics of a linear vanA-plasmid during a nosocomial multiclonal outbreak of vancomycin-resistant enterococci in a non-endemic area, Japan.

The spread of vancomycin-resistant enterococci (VRE) is a major threat in nosocomial settings. A large-scale multiclonal VRE outbreak has rarely been reported in Japan due to low VRE prevalence. We evaluated the transmission of vancomycin resistance in a multiclonal VRE outbreak, conducted biological and genomic analyses of VRE isolates, and assessed the implemented infection control measures. In total, 149 patients harboring VanA-type VRE were identified from April 2017 to October 2019, with 153 vancomycin-resistant Enterococcus faecium isolated being grouped into 31 pulsotypes using pulsed-field gel electrophoresis, wherein six sequence types belonged to clonal complex 17. Epidemic clones varied throughout the outbreak; however, they all carried vanA-plasmids (pIHVA). pIHVA is a linear plasmid, carrying a unique structural Tn1546 containing vanA; it moves between different Enterococcus spp. by genetic rearrangements. VRE infection incidence among patients in the "hot spot" ward correlated with the local VRE colonization prevalence. Local prevalence also correlated with vancomycin usage in the ward. Transmission of a novel transferrable vanA-plasmid among Enterococcus spp. resulted in genomic diversity in VRE in a non-endemic setting. The prevalence of VRE colonization and vancomycin usage at the ward level may serve as VRE cross-transmission indicators in non-intensive care units for outbreak control.

Right heart failure caused by direct pressure of distal arch aneurysm.

We report a rare case of right heart failure caused by distal aortic aneurysm. Although aortopulmonary fistula is a common complication of giant aortic arch aneurysm, right heart failure caused by mechanical pressure by aneurysm is very rare. A 79-year-old female patient presented dyspnea. Contrast computed tomography (CT) of the thorax delineated a 78 mm aortic arch aneurysm pressing the main to left pulmonary artery and a 40 mm pericardial effusion at maximum depth at posterior side. Echocardiography showed the acceleration flow from main to left pulmonary artery and moderate pulmonary hypertension. Left ventricular function, however, was preserved. We diagnosed right heart failure caused by giant aortic arch aneurysm and performed emergency aortic arch aneurysm replacement. After the operation, pulmonary artery pressure decreased and right heart failure improved.

Long-Term Results of Crossover Bypass for Iliac Atherosclerotic Lesions in the Era of Endovascular Treatment: The Re-ACTION Study (Retrospective Assessment of Crossover Bypass as a Treatment for Iliac LesiONs).

Objective: The aim of this study was to elucidate the long-term results of crossover bypass (CB) for iliac atherosclerotic lesions in the era of endovascular treatment (EVT). Methods: A retrospective multicenter cohort study was performed. CB was performed in 242 patients between 2003 and 2014 by vascular surgeons at multiple medical centers in Japan. Results: Perioperative mortality was 1.7%. Primary patency rates were 86% at 5 years and 82% at 8 years. Univariate analysis showed that critical limb ischemia (Rutherford class 4-6), vein graft, and superficial femoral artery occlusion were significantly associated with low primary patency. In multivariate analysis, only critical limb ischemia influenced primary patency. The secondary patency rate was 87% at both 5 and 8 years. The limb salvage rate was 98% at both 5 and 8 years. The overall survival rates were 71% at 5 years and 49% at 8 years. Conclusion: The long-term results of CB were good in our study, compared with previous reports. Our results suggest that CB remains an option for the arterial reconstruction in unilateral iliac occlusive disease after EVT failed.

[Thoracic Endovascular Aortic Repair Via Internal Iliac Artery Conduit].

A 77-year-old man with a history of stent implantation in the right common iliac artery(CIA) and the left external iliac artery(EIA) was admitted to our hospital for a rapid growth of an aneurysm( max 53 mm) at Th11 level of the descending aorta. Although thoracic endovascular aortic repair (TEVAR) was required, there were many problems about access rout. The infrarenal abdominal aorta and the left EIA were severely calcified, and the lumens of the right CIA stent(5.3 mm) and the left EIA stent( 4.3 mm) were small in size. Besides, the left CIA was short(13 mm). Therefore, TEVAR was performed by retrograde approach from the left internal iliac artery( IIA) with a tube graft conduit in the hybrid operation room. IIA is a useful option for an access rout in endovascular aortic repair.

[Two-staged Hybrid Repair for Extensive Aortic Aneurysm;Report of a Case].

A 74-year-old woman progressed to extensive aortic aneurysm after 2 years and 6 months from onset of type B dissection. A computed tomography scan revealed aortic aneurysm from ascending aorta to Th12 level of descending aorta. Her appearance was very frailty. Therefore, we performed 2-staged hybrid repair for this case. First, surgical total arch replacement with elephant trunk via median sternotomy was performed. On the 47th days after the 1st operation, thoracic endovascular aortic repair was performed. The spinal drainage was done for spinal cord protection. Postoperative course was uneventful without any complications. Considering a surgical stress, 2-staged hybrid repair using a stent graft was less-invasive than 1 staged graft replacement.

[Cor Triatriatum Diagnosed in Adulthood;Report of a Case].

A 64-years-old man had cor triatriatum (Lucas-Schmidt type I A) with severe mitral regurgitation and atrial fibrillation. We perfomed resection of the anomalous septum between the accessory chamber and left atrium, and conducted mitral annuloplasty and maze procedure. Arrhythmia were not encountered after surgery. The maze procedure and resection of the anomalous septum with mitral surgery proved to be effective for atrial fibrillation with cor triatriatum.

[Extended total arch replacement with coronary artery bypass grafting( CABG) via left thoracotomy;report of a case].

The operative procedure of extensive aortic aneurysm with ischemic coronary artery disease is controversial. We report a case of arch and descending thoracic aortic aneurysm replacement with coronary artery bypass grafting(CABG)via left thoracotomy. A 70-year-old man followed up by hepatic disease was diagnosed with expanding aortic thoracic aneurysm at the other hospital. He had admission to our hospital for surgical intervention. Computed tomography(CT)revealed arch and descending thoracic aortic aneurysm, and coronary arteriography (CAG) revealed #7 90% and #13 75% stenosis. We performed arch and descending thoracic aortic aneurysm replacement with CABG via left thoracotomy. Replaced synthetic graft and bypass grafts were patent on the postoperative CT. He was discharged at 15th postoperative day with no morbidity.

[Mitral valve repair for papillary muscle rupture; report of a case].

Papillary muscle rupture associated with acute myocardial infarction (AMI) is well known, but it's incidence is rare. We report a case of mitral valve repair with artificial chordae for partial papillary muscle rupture after AMI. A 75-year-old man underwent percutaneous coronary intervention(PCI) for right coronary artery because of AMI about 2 months ago at another hospital, and suffered from dyspnea 1 week after PCI. He had emergency admission to our hospital for cardiac failure. Echo-cardiogram revealed severe mitral regurgitation due to posterior papillary muscle rupture. We performed mitral valve repair with neochorda implantation to left ventricular wall of papillary muscle rupture site and ring annuloplasty. Mitral regurgitation was well controlled on postoperative echo-cardiogram. He was discharged at 25th postoperative day with no morbidity.

Surgical experience for the pulmonary artery sarcoma.

BACKGROUND: Pulmonary sarcoma arising from the pulmonary artery is a rare disease and its prognosis is disastrous. METHODS: Five patients who underwent surgery for pulmonary artery sarcoma were reviewed. RESULTS: All patients except one were initially diagnosed with pulmonary embolism. One patient with preoperative profound shock could not wean from cardiopulmonary bypass. Two patients are still surviving for 36 and 30 months, respectively. CONCLUSIONS: Early diagnosis and complete surgical resection is perhaps the best way to improve patients with pulmonary artery sarcoma.

Right ventricular outflow tract reconstruction for primary pulmonary artery sarcoma.

Primary pulmonary artery sarcoma is extremely rare and a lethal tumor. Complete resection of the tumor and following adequate reconstruction is the only hope for cure and prolonged survival. We report a case of successful surgical excision of primary pulmonary artery sarcoma involving pulmonary trunk, pulmonary valve and right ventricular outflow tract wall, which were replaced with prosthetic valved conduit. Postoperative histopathological diagnosis was leiomyosarcoma. The patient is well without any evidence of recurrence at 10 months after surgery.