Long-term survival of a patient with amyotrophic lateral sclerosis (ALS) who received autologous adipose-derived mesenchymal stem cells.

OBJECTIVE: Amyotrophic lateral sclerosis (ALS) is a progressive debilitating neurodegenerative disease with a life expectancy of 3-5 years from initial symptoms. We report a case of ALS who received autologous adipose-derived mesenchymal stem cells (ADSC) and was followed up for 7 years. CASE REPORT: A 46-year-old man noticed weakness of his legs, difficulties on going down the stairs and coughing during eating in 2009. After complete workout, a diagnosis of ALS was confirmed. His ALS Functional Rating Scale-R (ALSFS-R) was 43. Symptoms rapidly progressed and he coughed and choked during eating. Starting in 2013, the patient received a total of six intravenous infusions of autologous ADSC. Changes in electromyogram, nerve conduction, and ALSFS-R were assessed. RESULTS: Soon after the administration, he noticed that he did not cough during conversation or eating food. Although he had difficulty in walking down the stairs, he remained well without coughing, dysarthria, or dysphagia. His ALSFS-R increased up to 45. Fascicular potentials were not detected in any muscles examined including trapezius muscle and rectus femoris muscles. The patient was well for 7 years after ADSC therapy by the time of this report and more than 10 years from the time of onset. CONCLUSIONS: The present case suggests that autologous ADSC can be administered safely and may be potentially useful in patients with ALS. Further investigations are warranted in order for the results to be generalized to other ALS patients.

Efficacy of programmed intermittent bolus epidural analgesia in thoracic surgery: a randomized controlled trial.

BACKGROUND: Continuous epidural infusion (CEI) has some disadvantages, such as increased local anesthetic consumption and limited area of anesthetic distribution. Programmed intermittent bolus (PIB) is a technique of epidural anesthesia in which boluses of local anesthetic are automatically injected into the epidural space. The usefulness of PIB in thoracic surgery remains unclear. In this study, we aimed to compare the efficacies of PIB epidural analgesia and CEI in patients undergoing thoracic surgery. METHODS: This randomized prospective study was approved by the Institutional Review Board. The study included 42 patients, who were divided into CEI (n = 21) and PIB groups (n = 21). In the CEI group, patients received continuous infusion of the local anesthetic at a rate of 5.1 mL/90 min. In the PIB group, a pump delivered the local anesthetic at a dose of 5.1 mL every 90 min. The primary endpoints were the frequency of patient-controlled analgesia (PCA) and the total dose of local anesthetic until 36 h following surgery. Student's t-test, the chi-square test, and the Mann-Whitney U test were used for statistical analyses. RESULTS: The mean number of PCA administrations and total amount of local anesthetic were not significantly different between the two groups up to 24 h following surgery. However, the mean number of PCA administrations and total amount of local anesthetic at 24-36 h after surgery were significantly lower in the PIB group than in the CEI group (median [lower-upper quartiles]: 0 [0-2.5] vs. 2 [0.5-5], P = 0.018 and 41 [41-48.5] vs. 47 [43-56], P = 0.035, respectively). Hypotension was significantly more frequent in the PIB group than in the CEI group at 0-12 h and 12-24 h (3.3% vs. 0.5%, P = 0.018 and 7.9% vs. 0%, P = 0.017, respectively). CONCLUSION: PIB can reduce local anesthetic consumption in thoracic surgery. However, it might result in adverse events, such as hypotension. TRIAL REGISTRATION: This randomized prospective study was approved by the Institutional Review Board (IRB No. 15-9-06) of the Fukuoka University Hospital, Fukuoka, Japan, and was registered in the clinical trials database UMIN ( ID 000019904 ) on 24 November 2015. Written informed consent was obtained from all patients.

Higher ratio of ischemic stroke to hemorrhagic stroke in summer.

BACKGROUND: The aim of this study was to investigate the seasonal variation of the ratio of hemorrhagic stroke to ischemic stroke. The working hypothesis is that the ratio may vary among seasons. METHODS: A total of 13,788 patients registered in the Kyoto Stroke Registry from 1999 to 2009 were divided into 4 groups based on the season in which stroke developed. We calculated odds ratio (OR) for the incidence of stroke as a whole, cerebral infarction (CeI), cerebral hemorrhage (CH), and subarachnoid hemorrhage (SAH) in spring, autumn, and winter setting summer as a reference. Using a logistic regression, we evaluated the seasonal variation of ORs for CH/CeI and for SAH/CeI with adjustment for age, gender, and risk factors. RESULTS: Incidence of CeI in autumn was lower than in summer (OR: 0.93; 0.87-0.98, P = 0.013). Incidence of CH was higher in spring (OR: 1.36; 1.23-1.49, P < 0.001), in autumn (OR: 1.16; 1.05-1.28, P = 0.004), and in winter (OR: 1.37; 1.25-1.51, P < 0.001) than in summer. Incidence of SAH was higher in spring (OR: 1.51; 1.28-1.79, P < 0.001) and in winter (OR: 1.44; 1.22-1.70, P < 0.001) than in summer. OR for CH/CeI in spring, autumn, and winter were 1.28 (1.13-1.45, P < 0.001), 1.26 (1.11-1.43, P < 0.001), and 1.35 (1.19-1.53, P < 0.001), respectively. ORs for SAH/CeI were 1.46 (1.19-1.79, P < 0.001), 1.34 (1.09-1.66, P = 0.007), and 1.50 (1.22-1.84, P < 0.001), respectively. CONCLUSIONS: Seasonal variations differed among stroke subtypes. The OR for CH/CeI and for SAH/CeI was lower in summer and higher in the rest of seasons independent of age, gender, and risk factors.

Lower hazard ratio for death in women with cerebral hemorrhage.

OBJECTIVES: The aim of the study was to clarify the hazard ratio for death within 30 days after stroke comparing women to men. MATERIAL AND METHODS: We reviewed all stroke patients registered in the Kyoto Stroke Registry (from January 1999 to December 2009) in Japan. Hazard ratio (HR) for death and 95% confidence interval were calculated by the Cox regression in stroke and in each stroke subtype: cerebral infarction (CI), cerebral hemorrhage, (CH) and subarachnoid hemorrhage (SAH). We also evaluated HR for death in women in each consciousness level at the onset of stroke: the Japan Coma Scale (JCS) 0 (alert), JCS 1-digit code (disoriented but awake), JCS 2-digit code (arousable with stimulation), and JCS 3-digit code (unarousable). RESULTS: A total of 13,788 patients were analyzed. HR for death comparing women to men were 1.04 (0.88-1.23, P = 0.66 in stroke as a whole), 0.91 (0.69-1.21, P = 0.51 in CI), 0.53 (0.41-0.71, P < 0.01 in CH), and 0.89 (0.60-1.30, P = 0.535 in SAH) after adjustment for age and histories of hypertension, arrhythmia, diabetes mellitus and hyperlipemia and uses of tobacco and alcohol. Stratified by JCS, HR for death in women with CH were 0.32 (0.11-0.94 in JCS0), 0.48 (0.28-0.82 in JCS1), 0.49 (0.28-0.83 in JCS2), and 0.79 (0.65-0.97 in JCS3), respectively. HR for death in women with CI in JCS3 was significantly lower than in men (0.71; 0.52-0.98). CONCLUSION: We evaluated HR for death comparing men to women in stroke and in each stroke subtype. Women with CH had lower HR for death within 30 days after stroke than men.

Prognosis of arterial aneurysm after surgery in patients with Behçet's disease.

AIM: Despite improvements in therapeutic modalities, the treatment of arterial aneurysms complicating Behçet's disease (BD) is still challenging. This study examined the long-term prognosis after surgery for arterial aneurysms in BD. METHODS: This study included 9 patients with BD (8 men and 1 woman) who underwent surgery for arterial aneurysms between 1989 and 2008. The outcomes after the surgical intervention were assessed, including procedure-related complications and survival. RESULTS: The initial surgical procedures were performed for aortic or iliac aneurysms in 5 patients and for lower-extremity aneurysms in 4 patients. There was no operative mortality. The mean follow-up period was 135±69 months, ranging from 53 to 259 months. Patients with aortic or iliac aneurysms underwent graft interposition with Dacron prostheses. Their postoperative courses were uneventful, and all patients were alive during the follow-up with no procedure-related complications. Those treated for lower-extremity aneurysms tended to show perioperative and postoperative complications, including aneurysmal degeneration of the autogenous vein graft in 2 patients. One patient who initially underwent surgery for a popliteal artery aneurysm died due to the rupture of a dissecting aortic aneurysm after serial surgical interventions for multiple aneurysms. Concomitant aortic or iliac aneurysms in 2 patients were followed up without any change in size under medical treatment using colchicine and corticosteroids. CONCLUSION: Although we cannot draw a firm conclusion because of the small number of cases in the present series, graft interposition can lead to a favorable prognosis in BD patients with aortic or iliac aneurysms, whereas surgical treatment of BD-related lower-extremity aneurysms is frequently associated with short- and long-term postoperative complications. Immunosuppressive therapy might possibly improve treatment outcomes.

Usefulness of the Bollinger scoring method in evaluating peripheral artery angiography with 64-low computed tomography in patients with peripheral arterial disease.

AIM: There are various angiographic and runoff scoring systems for evaluating stenosis and arterial occlusion in patients with peripheral artery disease (PAD). The report from the BASIL trial revealed that the Bollinger scoring system, originally designed to classify intra-arterial digital subtraction angiography (IADSA), was sensitive to differences in PAD. The purpose of the present study was to evaluate the application of the Bollinger scoring system to a 64-low multidetector computed tomography (MDCT) in PAD patients. METHODS: Patients with PAD who underwent both a 64-MDCT and DSA within a 4-year period were enrolled in the study. Two observers analyzed the MDCT and DSA images for each patient. We divided the arterial tree from the common iliac artery to the plantar arch into 16 segments and scored 0-15 points for each segment as reported by Bollinger, according to the severity and extent of disease. We analyzed the reliability of differences in scores between the DSA and MDCT by the intraclass correlation coefficients (ICCs). RESULTS: We reviewed 100 consecutive patients (127 limbs) and assessed a total of 1929 segments. The Bollinger score of the 2 tests were same in 39.6% of all segments. The difference between the 2 tests were within 2 points in 77.3% of the above-knee segments (70.1-91.6% in each segments), 58.8% of the below-knee segments with the exception of plantar arch (42-74%). The ICC values showed relatively good reliability, but in the CFA the ICC values showed poor reliability. CONCLUSION: The Bollinger scoring method is a useful tool to evaluate peripheral artery angiography with 64-low CT in patients with PAD.

Efficacy of revascularization for critical limb ischemia in patients with end-stage renal disease.

OBJECTIVE: To evaluate the outcomes of surgical revascularization for critical limb ischemia in patients with end-stage renal disease (ESRD). PATIENTS AND METHODS: From 2004 to 2010, 184 patients with 213 critically ischaemic limbs caused by arteriosclerosis were admitted to The University of Tokyo Hospital. The outcomes of primarily surgical revascularization-based treatments were retrospectively compared in patients with ESRD (ESRD group: 79 patients, 101 limbs) and without ESRD (non-ESRD group: 105 patients, 112 limbs) during the same period. RESULTS: Arterial reconstruction was performed on 56 limbs in 46 patients in the ESRD group and 78 limbs in 73 patients in the non-ESRD group (55% vs. 70%; p = .03). Major amputation was performed in 6 of 48 limbs with patent grafts in the ESRD group because of uncontrolled infection or progression of necrosis. The limb salvage rate after arterial reconstruction was significantly lower in the ESRD group than in the non-ESRD group (p = .0019). The postoperative survival rate was lower in the ESRD group than in the non-ESRD group, although this difference was not significant (p = .052). Associated cardiovascular disease and systemic infection were the most frequent causes of death in the ESRD group. There was no significant difference in graft patency between the two groups after distal bypass surgery; however, the limb salvage rate was significantly lower in the ESRD group than in the non-ESRD group (p = .03). CONCLUSIONS: Critical limb ischemia associated with ESRD has a poor prognosis. Infection control is particularly important for achievement of good treatment outcomes.

Fate of the asymptomatic contralateral limb after initial intervention for ipsilateral critical limb ischemia.

AIM: In Trans-Atlantic Inter-Society Concensus (TASC) II, patients at risk for critical limb ischemia (CLI) without symptoms are termed "chronic subclinical ische mia," but research are still lacking. The objective was to find out whether clinically asymptomatic contralateral limbs at the time of treatment for ipsilateral CLI could be regarded as "chronic subclinical ischemia". METHODS: Ninety-six patients with CLI who had no symptoms in the contralateral limb were retrospectively reviewed. The symptoms of the contralateral limb after initial intervention for the ipsilateral limb were surveyed. Risk factors for developing CLI and tissue loss were then analyzed. RESULTS: Five patients (5.2%) became claudicants, 37 patients (38.5%) had symptoms of CLI, and 14 (14.6%) experienced tissue loss during the follow-up period. The overall CLI-free rates at 12, 36, and 60 months were 79.2%, 55.2%, and 45.8%, respectively, while the tissue loss-free rates at 12, 36, and 60 months were 91.3%, 78.8%, and 78.8%, respectively. Risk factor for developing CLI on the contralateral limb was having skin perfusion pressure (SPP) <40 mmHg at the surgery for ipsilateral limb. The presence of SPP <40 mmHg and end stage renal failure with hemodialysis resulted in a significantly high probability of tissue loss. CONCLUSION: Patients with CLI with an asymptomatic contralateral limb with an SPP value <40 mmHg are at a high risk of developing CLI and tissue loss during the follow-up period. Information on the contralateral limb at initial surgery may help to speculate the fate of the asymptomatic contralateral limb.

Effect of bolus injection of 20 ml saline with arm elevation on the onset time of vecuronium administered via a peripheral vein: a randomised controlled trial.

We investigated whether a bolus injection of 20 ml saline with arm elevation might shorten the onset time of vecuronium administered via a dorsal hand vein. Thirty patients were randomly allocated to the bolus saline group or control group. General anaesthesia was induced and maintained with remifentanil and propofol. Vecuronium 0.1 mg.kg(-1) was administered to all patients, followed in the treatment group by bolus injection of 20 ml saline and arm elevation. Response to train-of-four stimulation was measured by acceleromyography at the adductor pollicis muscle. The mean (SD) lag time was 47.2 (14.5) s in the bolus saline group and 67.9 (12.2) s in the control group (p = 0.0002). The time to 95% block of T1 was 104.6 (29.9) s in the bolus saline group and 128.3 (15.8) s in the control group (p = 0.011). Bolus saline injection results in shortened lag time and onset time of neuromuscular block with vecuronium.

Spontaneous T/NK-cell lymphoma associated with simian lymphocryptovirus in a Japanese macaque (Macaca fuscata).

A 5-year-old female Japanese macaque (Macaca fuscata) was humanely destroyed because of severe anaemia with poor response to treatment. At necropsy examination, marked splenomegaly and systemic enlargement of lymph nodes were observed. Microscopical examination revealed diffuse proliferation of neoplastic lymphoid cells in the spleen and lymph nodes with infiltration of the liver, lung, gastrointestinal tract, kidney and bone marrow. Immunohistochemically, the neoplastic cells expressed CD3 and CD4, but not CD20, CD79α or CD8, consistent with a T helper phenotype. A portion of neoplastic cells expressed the natural killer (NK) cell marker CD56. In-situ hybridization detected Epstein-Barr virus (EBV)-encoded small RNAs in the neoplastic cells, indicating the involvement of simian lymphocryptovirus (LCV). This is the first report of simian LCV-associated T/NK-cell lymphoma with the predominant expression of T-cell antigens in non-human primates.

Outcomes after open surgery and endovascular aneurysm repair for abdominal aortic aneurysm in patients with massive neck atheroma.

OBJECTIVE: We retrospectively analysed surgically treated abdominal aortic aneurysm (AAA) in patients with massive atheroma in the aneurysmal neck and compared the outcomes of endovascular aneurysm repair (EVAR) and open surgery (OS) to determine an appropriate strategy for massive neck atheroma cases. METHODS: A retrospective study was performed in 326 consecutive patients who underwent EVAR and in 247 patients who underwent OS. We defined massive neck atheromas if the following characteristics were observed: (1) thickness ≥ 5 mm; (2) the circumference of the infrarenal aorta ≥ 75%; and (3) length ≥ 5 mm. Twenty-eight patients (8.5%) in the EVAR group and 22 (8.9%) in the OS group met these criteria. We modified the previously published reporting standards on the basis of the selection of systemic and embolisation-related complications. RESULTS: Patients in the EVAR group had less intra-operative blood loss, shorter operation time, and shorter hospital stays after the operation (P < 0.01). No perioperative deaths were observed in either group. Major complications were categorised as early (in-hospital) or late (outpatient, within 6 months). Five and three patients in the OS and EVAR groups had early complications, but the difference was not statistically significant. In contrast, 7 patients in the EVAR group had late complications, compared to no patients in the OS group (P = 0.01). Kaplan-Meier analysis revealed a significantly higher survival rate in the OS group (P = 0.011). Two of the 4 patients with suprarenal clamping developed major complications. Mild eosinophilia was observed in 10 patients in the EVAR group. Proteinuria occurred or worsened in 5 EVAR patients and 1 OS patient. CONCLUSION: Compared to OS patients, EVAR patients with massive neck atheroma tend to develop late-phase complications possibly related to cholesterol crystal embolisation. The clinical features of massive neck atheroma patients receiving EVAR should be carefully monitored even after hospital discharge.

Long-term results of endovascular treatment for splenic artery aneurysms.

AIM: The aim of this paper was to evaluate our single-center experience of the management of splenic artery aneurysm (SAA), with particular attention to the long-term results of endovascular treatment. METHODS: Thirty-eight patients with the diagnosis of SAA at the Tokyo University Hospital during the past 23 years were retrospectively reviewed. Interventions were considered for patients with SAA>2 cm in diameter. Nine patients were treated by transcatheter embolization (TE), and 8 by open surgical repair (SR). Twenty-one patients were observed (OB). TE was performed with microcoils placed distal and proximal to the aneurysm in the afferent artery to isolate the aneurysm. RESULTS: In the TE group, the primary technical success rate was 100%. No 30-day mortality or any catheter-related complication was observed. The median length of hospital stay after TE, excluding one patient who required further surgery, was shorter than that after SR (8 versus 16 days, P=0.001). During follow-up (median =45 months), no patient died and no recurrence of SAA was observed. In the SR group, all aneurysms were repaired successfully without any severe complication, and no aneurysm-related death occurred during follow-up (median =57 months). In the OB group, no aneurysm rupture or increase in aneurysm size was observed during follow-up (median =35 months). CONCLUSION: TE provided good early and long-term results, comparable to those obtained with conventional SR. In addition, TE had several advantages associated with its minimal invasiveness. TE by the isolation technique could be the first-line strategy for all SAA requiring treatment.

Surgical treatment of patients with congenital vascular malformation-associated aneurysms.

OBJECTIVES: Aneurysms associated with congenital vascular malformation (CVM) comprise critical complication. We review our experience with extracranial CVM-associated aneurysms and attempt to clarify their clinical features. PATIENTS AND METHODS: The prevalence, site, size and morphology of the accompanying aneurysms of 48 consecutive CVM patients, who were managed at our hospital from 1999 to 2008, were evaluated. After diagnosis or treatment, the patients were followed up, and the recurrence of aneurysms and patient survival were assessed. RESULTS: CVM-associated aneurysms were found in 14 patients (29%). CVMs were classified according to the Hamburg classification. The patients were classified into groups as follows: four (31%), in the 'predominantly arteriovenous (AV) shunting defect type'; eight (47%), 'combined vascular defects + predominantly AV shunting defects type'; and two (11%), 'combined vascular defects type'. All aneurysms except one situated at the CVM were saccular, whereas nine were fusiform aneurysms; all the ruptured aneurysms and seven out of the nine enlarging aneurysms were saccular. Surgical treatment was performed 8 times in six patients. During the postoperative follow-up period, recurrence and an aneurysm rupture were encountered in one patient each. CONCLUSION: Aneurysm is not a rare complication of CVM. It is important to treat CVM before the emergency presents. In addition to the treatment for malformation, regular screening for and proper management of the aneurysms in CVM patients are indispensable.

[Solitary capillary hemangioma in the lung: report of a case].

We report a case of pulmonary solitary capillary hemangioma of 59-year-old woman who visited our hospital for an abnormal chest shadow. She had no symptoms, but a computed tomography (CT) revealed a small irregular nodule at the periphery of right S9. Early lung cancer was suspected. Video-assisted thoracic surgery (VATS) was performed for the difinitive diagnosis and treatment in January, 2008. Macroscopically, the nodule showed ill defined margin and irregular in shape. Partial resection of the lung was performed and the histopathological diagnosis was solitary capillary hemangioma. Postoperative course was uneventful and there is no signs of recurrence.

Current status of the medical expenses for the treatment of arteriosclerosis obliterans in Japan.

AIM: We aimed to determine the current status of the medical expenses for the treatment of arteriosclerosis obliterans (ASO) and evaluate the cost effectiveness of the medical practices employed in ASO treatment in Japan. METHODS: We performed a prospective observational study using 140 ASO patients. The cost of the medical practices comprised the costs of outpatient treatment, pharmacological agents, and hospitalization. To compare the average monthly costs, the patients were divided into preintervention, postintervention, or conservative-therapy groups. To compare the total costs and effectiveness of each treatment, the patients who had first visited our division during the study period were classified into surgery, endovascular-revascularization (EVR), or conservative-therapy groups. The adverse reactions of the 4 most popular agents for ASO were investigated, and bleeding events were assessed specifically. RESULTS: The average monthly costs for outpatient treatment and pharmacological agents were yen 168,002 in conservative cases, yen 149,871 in preoperation cases, and yen 128,527 in postoperation cases. The mean total costs were yen 5,407,950 in conservative cases, yen 7,375,290 in surgical cases, and yen 2,631,650 in EVR cases. The average change of the gauge in clinical status was 0.57 in conservative cases, 2.13 in surgical cases, and 2.25 in EVR cases. Warfarin induced more bleeding complications than the other agents. CONCLUSION: The costs of pharmacological agents represented much of the medical costs in any treatment groups.

A case of unilateral adrenal hyperplasia being difficult to distinguish from aldosterone-producing adenoma.

Unilateral adrenal hyperplasia (UAH) is very rare, and shows similar endocrine features to aldosterone-producing adenoma (APA). We report a case of UAH diagnosed preoperatively as APA. Pathological analysis showed that the adrenal mass did not contradict a diagnosis of APA. However, in situ hybridization and real-time PCR indicated that the hyperplastic zona glomerulosa cells rather than the adenoma cells demonstrated intense mRNA expression of steroidogenic enzymes necessary for production of aldosterone. UAH is believed to account for less than 1% of primary aldosteronism, but it is possible that some cases of UAH may be mistakenly considered to be APA, and that the actual frequency of UAH may thus be higher than presumed. Recently, partial adrenalectomy has been attempted. It should be borne in mind that cases exist in which it is difficult to differentiate between APA and UAH only by preoperative hormonal and radiologic investigations.

Objective assessment of nerve injury after greater saphenous vein stripping.

AIM: The complication of nerve injury after greater saphenous vein stripping for varicosity is subjective, and a method for objective evaluation has never been established. The aim of this study was to evaluate postoperative sensory changes by quantitative assessment of current perception threshold (CPT), and to clarify the relation between CPT and symptoms. PATIENTS AND METHODS: Between January 2003 and August 2005, 27 limbs in 18 patients were enrolled. Quantitative sensory function was determined through CPT using a Neurometer (Neurotron, Inc., USA), with which saphenous nerve neural fiber selective minimum sensing values against three electrical stimuli (2000, 250, 5 Hz) were measured. CPT measurements were scheduled on the day before the operation, and 2-7 days, 1, 3, and 6 months after the operation. RESULTS: An increase in CPT value of more than 20% or decrease to below 50% compared to the preoperative value with at least two stimuli was defined as CPT abnormality. Subjective symptoms were observed in 13 limbs in the early postoperative period, and 10 limbs showed CPT abnormality. In 6 limbs with a CPT increase over 20% with all three stimuli, neurological symptoms continued for 6 months. CONCLUSIONS: CPT evaluation provides an objective indication of neurological symptoms in the lower limb following varicose vein surgery.

Reduced vascular reserve measured by stressed single photon emission computed tomography carries a high risk for stroke in patients with carotid stenosis.

AIM: A few studies have observed reduced vascular reserve measured by single photon emission computed tomography (SPECT) to be a risk factor for stroke in patients with carotid artery occlusion, but stenosis has been excluded from these former studies. This study has evaluated the prognosis of reduced vascular reserve in patients with stenosis, and the effect of carotid endarterectomy (CEA) on these patients. METHODS: Forty patients diagnosed as having >70% stenosis of the carotid artery at the University of Tokyo Hospital, between 2001 and 2004, underwent acetazolamide-stress SPECT test first. A resting SPECT study was performed on a different day from the stressed SPECT study. The patients were grouped as having reduced vascular reserve or normal vascular reserve from the SPECT results. Analysis of risk factors and the stroke-free curve analysis for reduced vascular reserve was performed. RESULTS: Of the 40 patients, 24 (60%) had reduced vascular reserve and 18 underwent CEA. The mean follow-up period was 21.5+/-15.5 months (mean+/-SD). Four strokes occurred during follow-up: in 1 patient with CEA and 3 without CEA. All stroke patients had reduced vascular reserve. The patients with reduced vascular reserve without any surgery had a significantly lower stroke-free rate compared with those with normal vascular reserve or reduced vascular reserve, but also receiving CEA. CONCLUSIONS: We propose performing SPECT tests in patients with severe carotid stenosis regardless of symptoms, and performing CEA on those with a reduction in vascular reserve.

Carotid endarterectomy may reduce the high stroke rate for patients with the disease of abdominal aorta and peripheral arteries.

AIM: The prevalence of carotid stenosis is reported to be high among patients with arteriosclerosis, but the hazards of carotid stenosis and the benefits of carotid endarterectomy (CEA) on long-term event-free survival are still unknown. The aim of this prospective study was to screen preoperative patients with arterial disease for carotid stenosis, and to determine whether CEA had any effect on stroke during the postoperative follow-up period. METHODS: From 1999 to 2003, 406 consecutive preoperative patients with arterial disease underwent routine carotid duplex scan. Patients with known carotid stenosis and those due to undergo operation in emergency were excluded from the study. CEA was performed before or simultaneously with vascular surgery if necessary. The prevalence and risk factors for carotid stenosis were studied, and the patients were followed up for stroke or death. RESULTS: Among the 406 patients examined, 19.4% had greater than 50% stenosis and 11.3% had greater than 70% stenosis. The risk factors for carotid stenosis were having occlusive arterial disease (P=0.0001), and history of stroke (P=0.0038). Long-term follow-up study revealed that patients with greater than 70% carotid stenosis without CEA had a higher tendency for stroke or death, but the stroke rate in patients with severe stenosis who underwent CEA remained low, as in patients with less than 70% stenosis. CONCLUSIONS: Patients with greater than 70% carotid stenosis, diagnosed before arterial operation who did not undergo CEA, had a higher risk for stroke during the postoperative follow-up period. However, their risk could be reduced by performing CEA before or simultaneously with scheduled vascular surgery.

Long-term results of combined iliac endovascular intervention and infrainguinal surgical revascularization for treatment of multilevel arterial occlusive disease.

AIM: The purpose of this study was to investigate the long-term results of combined iliac endovascular intervention and infrainguinal surgical revascularization. METHODS: A retrospective review of 39 infrainguinal bypasses combined with iliac endovascular intervention in 35 patients over a 16-year period was performed (Combined group). These results were compared to those of 43 infrainguinal bypasses performed with suprainguinal bypass operation in 39 patients (Surgical group), who had iliac lesions not amenable to angioplasty/stenting. There was no significant difference in the preoperative limb ischemic symptoms between them. RESULTS: Although the proportion of patients with coronary artery disease in the Combined group was significantly higher than that in the Surgical group, there was a trend toward lower morbidity/mortality in the Combined group compared with the Surgical group (8.6% vs 15.4%; P=0.3706). No significant differences in the rates of clinical and hemodynamic improvement and limb salvage rate were observed between the two groups. The primary patency rate of infrainguinal bypass at 1, 3, and 5 years was 83.2%, 80%, and 71.2% in the Combined group, and 97.1%, 89.9%, and 80.5% in the Surgical group, respectively. The secondary patency rate at 1, 3, and 5 years was 91.9%, 91.9%, and 76.3% in the Combined group, and 97.1%, 89.9%, and 84.6% in the Surgical group, respectively. Importantly, there was no significant difference in the primary/secondary patency rates between the two groups (Kaplan-Meier, log-rank test, primary patency, P=0.116; secondary patency, P=0.4407). CONCLUSIONS: Infrainguinal surgical reconstruction combined with iliac endovascular procedure may reduce operative risk, and further, long-term patency is comparable to that in the Surgical group.