Thick endothelialization of the self-expandable valve causes delayed coronary obstruction.

Delayed coronary obstruction is a rare complication occurring after transcatheter aortic valve replacement (TAVR). Although TAVR has become popular, in some cases, the therapeutic strategy should be carefully selected depending on the patient's anatomical and/or functional restrictions. We report a rare case of delayed coronary obstruction in which coronary obstruction was caused by thick endothelialization of the nitinol frame of the prosthetic valve. A 79-year-old female who had undergone TAVR 4 months before presented with mild chest pain and was admitted to our institution. Computed tomography and coronary angiography revealed that the space from the sinus of Valsalva to the nitinol frame was narrow and separated from the inside of the nitinol frame because of critical endothelialization. Therefore, an emergency surgical aortic valve replacement was performed. The patient had an uneventful postoperative course and was discharged 20 days postoperatively without any complications.

[Thoracic Endovascular Aortic Repair and Abdominal Aorta Replacement to Treat Stanford Type B Acute Aortic Dissection Extending through an Abdominal Aortic Aneurysm;Report of a Case].

A 69-year-old man developed sudden-onset chest and back pain and was brought to our hospital. Enhanced computed tomography (CT) revealed acute Stanford type B aortic dissection extending from the distal aortic arch to a 72 mm abdominal aortic aneurysm( AAA). The acute phase was managed by antihypertensive therapy, and the patient was followed up. Twenty days after the onset of aortic dissection, entry closure of aortic dissection by thoracic endovascular aortic repair and abdominal aorta replacement were performed simultaneously. Aorta remodeling was confirmed by postoperative CT, and the patient's postoperative course was uneventful. In the treatment of patients with acute aortic dissection and AAA, surgical intervention timing and strategy must be considered carefully.

Appropriate Surgical Treatment of Symptomatic Primary Varicose Veins Decreases Systemic Inflammatory Biomarkers.

Objective: To evaluate the relationship between systemic inflammatory biomarkers and efficacy of surgical treatment of primary varicose veins of the lower extremities. Methods: Total 12 patients who underwent endovenous laser ablation or stripping of varicose veins and six healthy subjects were enrolled. Structural and molecular changes of varices were assessed by immunohistochemical staining with anti-monocyte chemotactic protein-1 (MCP-1). MCP-1 and interleukin-6 (IL-6) levels in systemic antecubital blood were measured before and at 12 weeks after treatment. Results: Immunohistochemical staining revealed prominent manifestation of MCP-1-positive endothelial cells in the walls of varices. Preoperative serum MCP-1 and IL-6 levels in the patients were significantly higher than those in the control (166±12 pg/mL vs 99±10 pg/mL, p=0.003; 5.1±0.95 pg/mL vs 0.0±0.0 pg/mL, p=0.001, respectively). The values were significantly correlated with the severity of chronic venous insufficiency (CVI). Postoperative serum MCP-1 level significantly decreased compared with the preoperative level (152±10 pg/mL vs 166±12 pg/mL, p=0.048). The values after endovenous laser ablation did not significantly decrease compared with those after stripping. Conclusion: Varicose veins with CVI increase inflammatory biomarker levels in the local tissue and systemic blood. Appropriate treatment of symptomatic varicose veins decreases inflammatory biomarker levels.

Recurrent venous thrombosis during direct oral anticoagulant therapy in a patient with protein S deficiency.

Protein S (PS) deficiency is an inherited thrombophilia associated with an increased risk of venous thromboembolism (VTE). In Japan, unfractionated heparin followed by warfarin has been historically applied for the treatment of VTE. Recent evidence showed that direct oral anticoagulants (DOACs) were non-inferior to standard therapy with warfarin, with significantly less bleeding in patients with VTE. However, it is unknown whether DOACs are effective for the treatment of VTE in patients with thrombophilia, including protein S deficiency, due to lack of evidence. Here, we report a case of recurrent venous thrombosis during edoxaban therapy in a patient with protein S deficiency, which was successfully treated using high-dose apixaban therapy. J.Med. Invest. 66 : 182-184, February, 2019.

Pseudoaneurysm of the Perforating Peroneal Artery following Ankle Arthroscopy.

The use of standard anterolateral and anteromedial portals in ankle arthroscopy results in reduced risk of vascular complications. Anatomical variations of the arterial network of the foot and ankle might render the vessels more susceptible to injury during procedures involving the anterior ankle joint. The literature, to our knowledge, reports only one case of a pseudoaneurysm involving the peroneal artery after ankle arthroscopy. Here, we report the unusual case of a 48-year-old man in general good health with the absence of the anterior tibial artery and posterior tibial artery. The patient presented with a pseudoaneurysm of the perforating peroneal artery following ankle arthroscopy for traumatic osteoarthritis associated with nonunion of the medial malleolus. The perforating peroneal artery injury was repaired by performing end-to-end anastomosis. The perforating peroneal artery is at higher risk for iatrogenic injury during ankle arthroscopy in the presence of abnormal arterial variations of the foot and ankle, particularly the absence of the anterior tibial artery and posterior tibial artery. Before ankle arthroscopy, surgeons should therefore carefully observe the course of the perforating peroneal artery on enhanced 3-dimensional computed tomography, especially in patients with a history of trauma to the ankle joint.

Pseudoaneurysm of the Anterior Tibial Artery following Ankle Arthroscopy in a Soccer Player.

Ankle arthroscopy carries a lower risk of vascular complications when standard anterolateral and anteromedial portals are used. However, the thickness of the fat pad at the anterior ankle affords little protection for the thin-walled anterior tibial artery, rendering it susceptible to indirect damage during procedures performed on the anterior ankle joint. To our knowledge, only 11 cases of pseudoaneurysm involving the anterior tibial artery after ankle arthroscopy have been described in the literature. Here we reported a rare case of a 19-year-old soccer player who presented with pseudoaneurysm of the anterior tibial artery following ankle arthroscopy using an ankle distraction method and underwent anastomosis for the anterior tibial artery injury. Excessive distraction of the ankle puts the neurovascular structures at greater risk for iatrogenic injury of the anterior tibial artery during ankle arthroscopy. Surgeons should look carefully for postoperative ankle swelling and pain after ankle arthroscopy.

Long-term Results After Open Mitral Commissurotomy for a One-Month-Old Infant With Mitral Stenosis.

The strategy for an infant with congenital mitral stenosis should be determined by three important factors: left ventricular volume, the degree of the systemic outflow tract obstruction, and the type of mitral valve dysfunction. A successful staged biventricular repair in early infancy for a patient who had congenital mitral stenosis with short chordae, hypoplastic left ventricle and coarctation of the aorta, and the long-term results are described. There were the following important hemodynamic factors that led to the successful biventricular repair in the patient. Total systemic output was barely supplied through the hypoplastic left ventricle after closure of the ductus arteriosus on admission. The neonate underwent repair of coarctation of the aorta alone as the initial stage at 9 days after birth. Also, spontaneous closure of the foramen ovale following repair of coarctation of the aorta accelerated the progressive left ventricular growth. Open mitral commissurotomy with an interatrial fenestration using the modified Brawley's approach was performed for a 40-day-old infant. Good left ventricular growth and good mitral valve function have been observed for 18 years after open mitral commissurotomy. Appropriate early augmentation of left ventricular inflow through the mitral valve might be effective for growth of a hypoplastic left ventricle. J. Med. Invest. 64: 187-191, February, 2017.

[Complications of graft infection after endovascular aortic aneurysm repair].

OBJECTIVE: The endovascular approach to aortic aneurysm repair is widely spreading as an alternative to open repair. However infectious complications may be devastating. We described the experiences with infected aortic endografts and reviewed treatment and outcomes. METHODS: Eight patients were treated due to infected aortic endografts between June 2008 and March 2014. Seven males and 1 female with median age of 66 years( range, 38-84years) had 5 infected thoracic endovascular aortic repairs (EVARs) [5/142:3.5%] and 3 endovascular aortic repairs (EVARs)[3/387:0.8%]. Median time from repair to presentation was 12 months (range, 2-27 months). As the factors associated with infection, hemodialysis due to chronic kidney disease in 1, surgical treatment for the huge atheroma in 1, dental treatment in 2, treatment for infected aneurysm in 1, urinary tract infection after surgery for prostate in 1, aortoenteric fistula after TEVAR in 2 were considered. RESULTS: Five patients were treated with endograft explantation. The surgical mortality was 40% (2/5), during a follow-up, one more patient died with intracranial hemorrhage. The remaining 3 patients who were considered too high risk to remove the infectious endografts were treated conservatively with antibiotics. In 2 of them 1 died of respiratory failure, and multiple organ failure in 1. CONCLUSIONS: Infection of the endograft is a rare but devastating complication after endovascular repair of aortic aneurysms. Surgical removal of the infected prosthesis is accompanied with higher mortality, but antibiotics therapy cannot eradicate or cure the infection. In all cases, the factors associated with infection were calculated, and degenerative or infectious thrombi around the endovascular stent grafts were noted. Therefore, we consider that prophylactic antibiotic treatment may be necessary to prevent the bacteremia in the case of other surgical therapy or dental treatment.

Efficacy and Optimal Timing of Endovascular Treatment for Type B Aortic Dissection.

OBJECTIVES: To determine the efficacy and the optimal timing of thoracic endovascular aortic repair (TEVAR) for closing the primary entry in uncomplicated patients with chronic type B aortic dissection and a patent false lumen (FL). METHODS: Thirteen patients underwent TEVAR for aortic dissection between 2008 and 2012. These patients had chronic dissection with a patent FL and expansion of the aorta. Early TEVAR was performed for five patients within 1-7 months from the index dissection (TEVAR-EC group) and delayed TEVAR was performed for eight patients within 1-16 years (TEVAR-DC group). Changes in the diameters and volumes of the true lumen (TL) and FL and the aortic remodeling were assessed by multidetector computed tomography for 3 years after TEVAR. RESULTS: The reduction rate of FL in the thoracic aorta was notably higher in the TEVAR-EC group than in the TEVAR-DC group regardless of the presence or absence of distal retrograde flow. There was a significant TL expansion despite different timings of TEVAR. CONCLUSIONS: Early TEVAR resulted in good prognosis and preferable aortic remodeling in uncomplicated patients with chronic type B aortic dissection and a patent FL, and we recommend early TEVAR within seven months after the index dissection.

[Reconstruction of pulmonary blood flow in the Norwood procedure; Blalock-Taussig shunt; from bench to surgery].

Although the right-ventricle to pulmonary artery( RV-PA) shunt as a source of pulmonary blood supply of Norwood procedure has improved early outcomes, disadvantages including right ventricular dysfunction or arrhythmias have been reported. So it has been still remained controversial whether BT shunt or RV-PA conduit should be selected. We examined the influence of Blalock-Taussig( BT) shunt size on regulation of the pulmonary blood flow in experimental model of a univentricular heart to determine the specific guidelines regarding suitable shunt size in the Norwood procedure. The canine univentricular heart model with the ratio of shunt size to body weight (SS/BW) of 0.8 to 1.1 showed significant negative correlation between the pulmonary/systemic blood flow ratio( Qp/Qs)and arterial PCo2, but those with SS/BW of 1.1 to 1.4 did not. Similar phenomena were shown with the grouped data on relationship between the Qp/Qs and inspired oxygen fraction. These findings imply that when SS/BW is 0.8 to 1.1, the Qp/Qs is controllable by physiologic respiratory manipulations. In the context of our clinical experiences, SS/BW of 0.9 to 1.0 is considered a useful index for suitable BT shunt in the Norwood procedure.

Iliac access conduit facilitates endovascular aortic aneurysm repair and ipsilateral iliofemoral bypass.

It may be difficult to access a route to deliver a stent-graft for abdominal aortic aneurysm in high-risk patients with bilateral iliofemoral occlusive disease. These two patients underwent both endovascular aortic aneurysm repair by a modified iliac access conduit technique and sequential ipsilateral iliofemoral artery bypass using the conduit, which provided excellent results. The iliac access conduit facilitates endovascular aortic aneurysm repair and ipsilateral iliofemoral bypass of high-risk patients with abdominal aortic aneurysm and bilateral iliofemoral occlusive disease.

Delayed-onset severe heparin-induced thrombocytopenia after total arch replacement under cardiopulmonary bypass.

An extremely rare case with delayed-onset heparin-induced thrombocytopenia (HIT) is described. A 46-year-old man underwent arch replacement for aortic dissection under cardiopulmonary bypass and initial exposure of unfractionated heparin. In post operative 7 days, persistent atrial fibrillation was occurred, so a continuous infusion of heparin (10000 IU/day) and Vitamine K antagonist (Warfarin) taking was started for preventing thrombosis. By 32 days after the operation, his platelet count had fallen (3×10(3)/µL) and oral hematoma and ecchymoma of bilateral lower legs were occurred. The value of HIT antibodies and the IgG antibody was 2.485 and 1.586 on 32-postoperative day, respectively. Heparin was immediately discontinued, and argatroban administrated. Platelet exceeded above 100×10(3)/µL on 12 days of the therapy. To our knowledge, few cases of delayed-onset severe HIT associated with CPB surgery have been reported in Japan.

Ezetimibe monotherapy ameliorates vascular function in patients with hypercholesterolemia through decreasing oxidative stress.

AIM: Ezetimibe, an inhibitor of cholesterol intestinal absorption, is a lipid lowering agent. However, anti-atherogenic effects of ezetimibe have not been fully elucidated. Therefore, the objective in this study was to clarify the vascular protective effects of ezetimibe in patients with hypercholesterolemia. METHODS: Ezetimibe was administered to 20 patients with hypercholesterolemia (group E), and 20 age- and sex-matched patients with hypercholesterolemia were followed as controls (group C). Difference in metabolic profiles and cardiovascular surrogate markers before ezetimibe treatment and after 12 weeks of ezetimibe treatment were statistically evaluated. RESULTS: Ezetimibe treatment significantly reduced serum levels of low-density lipoprotein cholesterol (LDL-C) and malondialdehyde-modified low-density lipoprotein (MDA-LDL). In addition, the values of body mass index, body weight, waist circumference, plasma HbA1c and urinary albumin were significantly decreased in group E compared to those in group C. On the other hand, high-density lipoprotein cholesterol (HDL-C) and adiponectin levels were significantly increased in group E compared to those in group C. The values of brachial-ankle pulse wave velocity (ba-PWV), mean arterial blood pressure (m-ABP), and % of flow-mediated dilation (FMD) were significantly improved in group E. Furthermore, ultrasonic studies demonstrated amelioration of the vascular stiffness of common carotid arteries in group E but not in group C. These vascular protective effects of ezetimibe were statistically correlated with the decreased values of MDA-LDL and MDA-LDL-to-LDL-C ratio but not with those of LDL-C. CONCLUSION: Ezetimibe has a lipid lowering-independent vascular protective effect in patients with hypercholesterolemia through decreasing oxidative stress.

Functional restoration of endothelial cells of the cryopreserved heart valve.

PURPOSE: Although several approaches have been tried to improve the durability of cryopreserved valves, cellular restoration after thawing remains to be investigated. The aim of our study was to assess the functional restoration of endothelial cells of cryopreserved heart valves by in vitro culture for an alternative step to improving longevity. METHODS: Cryopreserved human umbilical vein endothelial cells (HUVECs) and porcine aortic cusps were cultivated for 14 days after thawing. Then the cellular activity of the enzymes cytosolic esterase and mitochondrial dehydrogenase was measured. The cellular viability of cryopreserved cusps was also assessed using confocal laser scanning microscopy. RESULTS: The number of viable HUVECs decreased markedly after cryopreservation and thawing but recovered to pre-cryopreservation level after 14 days of culture. In contrast, the enzyme activity of the cryopreserved porcine aortic cusps showed recovery at 7 days of in vitro tissue culture after thawing. Confocal laser scanning microscopy findings showed that the cellular cytosolic esterase activity of cryopreserved cusps deteriorated after thawing but displayed considerable recovery by day 14 of culture. CONCLUSION: The functional recovery of endothelial cells in cryopreserved heart valves seems to require tissue culture of at least 14 days. Ex vivo endothelial restoration of cryopreserved heart valves may add to heart valve durability.