Peak Aortic Valve Jet Velocity is an Independent Predictor of Mortality of Dialysis Patients Undergoing Open Surgery for Chronic Limb Threatening Ischemia.

BACKGROUND: To investigate the impact of peak aortic jet velocity (Vmax) on the prognosis of patients undergoing open surgery for chronic limb threatening ischemia (CLTI). METHODS: Between April 2015 and March 2022, 352 patients underwent infrainguinal open surgery for CLTI. Patients who met the following exclusion criteria were excluded: subsequent infrainguinal surgeries in the registered period, no record of Vmax, history of aortic valve intervention, and Vmax ≥3.0 m/s (moderate or severe aortic valve stenosis). The remaining patients were dichotomized into 2 groups based on their Vmax values. The Youden index calculated from the receiver operating characteristic curve (ROC) was set as the cutoff value. The 2-year overall survival (OS), calculated using the Kaplan-Meier's method, was compared between the 2 groups. A Cox proportional hazards regression analysis was performed using perioperative factors including Vmax to identify independent predictors separately for dialysis and nondialysis patients and the quantitative relationship between Vmax and OS. RESULTS: One hundred and ninety-one patients, including 100 dialysis and 91 nondialysis patients, were included in the analysis. The Youden index was 1.7 m/s. The 2-year OS rates of the group with Vmax >1.7 m/s and with Vmax ≤1.7 m/s were 49% and 76% (P = 0.007), respectively, in the dialysis cohort, while they were 71% and 78% (P = 0.680) in the nondialysis cohort, respectively. Multivariate analysis identified Vmax and ejection fraction as independent predictors in the dialysis cohort and the Barthel Index at admission in the nondialysis cohort. There was a stepwise increase in the risk of death in patients with Vmax of ≥1.5 m/s and a significantly higher risk of death in dialysis patients with Vmax >2.5 m/s. CONCLUSIONS: Vmax was a significant independent predictor of all-cause death within 2 years after open surgery for CLTI in dialysis patients but not in patients managed without dialysis.

Short-Term Results of Varicose Vein Graft Used for Lower-Limb Bypass Surgery.

Objective: Due to the potential of thrombus blockage and aneurysm rupture, saphenous veins with varicose veins are not advised for use as bypass grafts. However, if no other autologous vein is accessible for use as a conduit in lower-limb bypass; varicose vein transplants may be employed. Few reports have studied the clinical results of lower-limb bypass using varicose vein grafts. We therefore investigated whether or not acceptable patency rates of varicose vein graft for lower-limb bypass could be achieved. Methods: We performed lower-limb bypass using varicose vein graft on nine limbs from June 2017 to May 2020 and conducted a retrospective analysis of prospectively collected data. Results: Early graft failure following bypass surgery using a varicose vein transplant was not detected, and major complications, such as acute graft occlusion or aneurysm dilatation, were not noted throughout the follow-up period. The primary and secondary patency of varicose vein graft was 70.0% and 100% at 3 years, respectively. Conclusion: The incidence of major problems of the varicose vein transplants does not seem to be higher than with conventional saphenous vein grafts. If there are no other appropriate autologous veins, a varicose vein graft may be useful as a conduit for bypass surgery.

YAP mediates resistance to EGF-induced apoptosis in EGFR-mutated non-small cell lung cancer cells.

Mechanisms underlying the growth and survival of non-small cell lung cancer (NSCLC) cells positive for activating mutations of the epidermal growth factor receptor gene (EGFR) have remained unclear. We here examined the functional relation between such mutant forms of EGFR and Yes-associated protein (YAP), a transcriptional coactivator of the Hippo signaling pathway that regulates cell proliferation and survival. Under the condition of serum deprivation, epidermal growth factor (EGF) induced activation of YAP in NSCLC cell lines positive for mutated EGFR but not in those wild type (WT) for EGFR. Similar EGF-induced activation of YAP was apparent in A549 lung cancer cells forcibly expressing mutant EGFR but not in those overexpressing the WT receptor. Furthermore, EGF induced apoptotic cell death in serum-deprived A549 cells overexpressing the WT form of EGFR but not in those expressing mutant EGFR, and knockdown of YAP rendered the latter cells sensitive to this effect of EGF. Our results thus suggest that activation of YAP mediates resistance of EGFR-mutated NSCLC cells to EGF-induced apoptosis and thereby contributes specifically to the survival of such cells.

Impact of cilostazol on prevention of late failure of autologous vein grafts.

OBJECTIVES: The effectiveness of postoperative medication for the prevention of late graft failure is controversial. We conducted the present study to investigate whether cilostazol improved the mid-term outcomes after infrainguinal autologous vein bypass for chronic limb-threatening ischemia (CLTI). METHODS: From April 1994 to March 2022, we performed 590 de novo infrainguinal bypass procedures using autologous vein grafts (AVGs) in three hospitals. The bypass grafts were classified according to the postoperative prescription of cilostazol. The loss of graft patency and major adverse limb events (MALEs) were set as endpoints. Patients who died within 30 days and grafts that lost primary patency within 30 days after surgery were excluded. Data up to 3 years were analyzed. The cumulative primary patency (PP), assisted primary patency (AP), secondary patency (SP), and freedom from MALE (ffMALE) rates were calculated by the Kaplan-Meier method and compared between the cilostazol group and the non-cilostazol group. After a propensity score matching, same statistical analyses were performed. In addition, a Cox proportional hazards regression analysis that included preoperative factors, intraoperative factors, and postoperative medications was performed to identify whether cilostazol is an independent predictor for the outcomes. RESULTS: A total of 523 AVGs met inclusion criteria. Kaplan-Meier curves showed that the cilostazol group was superior to the non-cilostazol group in all outcomes, while the cilostazol group was superior to the non-cilostazol group in AP and SP after a propensity score matching. A multivariable analysis showed that non-use of cilostazol was identified as an independent predictor for loss of AP, SP, and ffMALE. CONCLUSIONS: Cilostazol improved the mid-term outcomes after infrainguinal autologous vein bypass.

Regulation of PD-L1 expression in non-small cell lung cancer by interleukin-1ß.

Introduction: Programmed cell death-ligand 1 (PD-L1) is a biomarker for prediction of the clinical efficacy of immune checkpoint inhibitors in various cancer types. The role of cytokines in regulation of PD-L1 expression in tumor cells has not been fully characterized, however. Here we show that interleukin-1ß (IL-1ß) plays a key role in regulation of PD-L1 expression in non-small cell lung cancer (NSCLC). Methods: We performed comprehensive screening of cytokine gene expression in NSCLC tissue using available single-cell RNA-Sequence data. Then we examined the role of IL-1ß in vitro to elucidate its induction of PD-L1 on NSCLC cells. Results: The IL-1ß gene is highly expressed in the tumor microenvironment, particularly in macrophages. The combination of IL-1ß and interferon-γ (IFN-γ) induced a synergistic increase in PD-L1 expression in NSCLC cell lines. IL-1ß and IFN-γ also cooperatively activated mitogen-activated protein kinase (MAPK) signaling and promoted the binding of downstream transcription factors to the PD-L1 gene promoter. Furthermore, inhibitors of MAPK signaling blocked upregulation of PD-L1 by IL-1ß and IFN-γ. Discussion: Our study reports high levels of IL-1ß in the tumor microenvironment may cooperate with IFN-γ to induce maximal PD-L1 expression in tumor cells via activation of MAPK signaling, with the IL-1ß-MAPK axis being a promising therapeutic target for attenuation of PD-L1-mediated suppression of antitumor immunity.

Experience of Balloon Aortic Valvuloplasty for Severe Aortic Stenosis in Patients Scheduled for Open Surgery for Chronic Limb-Threatening Ischemia.

Objectives: To estimate the effectiveness of balloon aortic valvuloplasty (BAV) for severe aortic stenosis (SAS) in patients scheduled for open surgery for chronic limb-threatening ischemia. Materials and Methods: Clinical data of patients from 2012 to 2018 were retrieved and summarized. The early outcomes and survival after BAV and open bypass were retrospectively investigated. Results: BAV was performed on seven dialysis patients. One patient died of mesenteric infarction 3 days after BAV; however, six patients were able to undergo open bypass at an average of 10 days (7-19 days) after BAV. One patient died of hemorrhagic shock before the wound healed; five patients underwent limb salvage. Four of these five patients could not undergo surgical aortic open valve replacement owing to advanced age or poor cardiac function and died within 2 years. Only one patient who underwent radical surgery after a bypass survived more than 4 years. Conclusion: BAV enabled open surgery and limb salvage in patients with SAS. Although BAV alone cannot ensure long-term survival, the procedure will continue to be important as a bridge technique to radical surgery, such as transcatheter aortic valve implantation and aortic valve repair, which are often avoided owing to infection.

Bypass Surgery Provides Better Outcomes Compared with Endovascular Therapy in Patients with Chronic Limb-Threatening Ischemia Classified as Indeterminate Category According to the Global Vascular Guidelines.

BACKGROUND: The present study aimed to determine the preferred initial revascularization procedure between bypass surgery and endovascular therapy (EVT) in patients with chronic limb-threatening ischemia (CLTI) categorized as indeterminate according to the Global Vascular Guidelines (GVG). METHODS: We retrospectively analyzed the multicenter data of patients who underwent infrainguinal revascularization for CLTI categorized as indeterminate according to the GVG between 2015 and 2020. The end point was the composite of relief from rest pain, wound healing, major amputation, reintervention, or death. RESULTS: A total of 255 patients with CLTI and 289 limbs were analyzed. Of the 289 limbs, 110 (38.1%) and 179 (61.9%) underwent bypass surgery and EVT, respectively. The 2-year event-free survival rates with respect to the composite end point were 63.4% and 28.7% in the bypass and EVT groups, respectively (P < 0.01). Multivariate analysis revealed that increased age (P = 0.03); decreased serum albumin level (P = 0.02); decreased body mass index (P = 0.02); dialysis-dependent end-stage renal disease (P < 0.01); increased Wound, Ischemia, and foot Infection (WIfI) stage (P < 0.01); Global Limb Anatomic Staging System (GLASS) III (P = 0.04); increased inframalleolar grade (P < 0.01); and EVT (P < 0.01) were independent risk factors for the composite end point. In the WIfI-GLASS 2-III and 4-II subgroups, bypass surgery was superior to EVT with regard to 2-year event-free survival (P < 0.01). CONCLUSIONS: Bypass surgery is superior to EVT in terms of the composite end point in patients classified as indeterminate according to the GVG. Bypass surgery should be considered an initial revascularization procedure, especially in the WIfI-GLASS 2-III and 4-II subgroups.

Left Renal Vein Division during Open Surgical Repair for Abdominal Aortic Aneurysm May Cause Long-Term Kidney Remodeling.

BACKGROUND: Left renal vein division (LRVD) is a maneuver performed during open surgical repair for abdominal aortic aneurysms. Even so, the long-term effects of LRVD on renal remodeling are unknown. Therefore, we hypothesized that interrupting the venous return of the left renal vein might cause renal congestion and fibrotic remodeling of the left kidney. METHODS: We used a murine left renal vein ligation model with 8-week-old to 12-week-old wild-type male mice. Bilateral kidneys and blood samples were harvested postoperatively on days 1, 3, 7, and 14. We assessed the renal function and the pathohistological changes in the left kidneys. In addition, we retrospectively analyzed 174 patients with open surgical repairs between 2006 and 2015 to assess the influence of LRVD on clinical data. RESULTS: Temporary renal decline with left kidney swelling occurred in a murine left renal vein ligation model. In the pathohistological assessment of the left kidney, macrophage accumulation, necrotic atrophy, and renal fibrosis were observed. In addition, Myofibroblast-like macrophage, which is involved in renal fibrosis, was observed in the left kidney. We also noted that LRVD was associated with temporary renal decline and left kidney swelling. LRVD did not, however, impair renal function in long-term observation. Additionally, the relative cortical thickness of the left kidney in the LRVD group was significantly lower than that of the right kidney. These findings indicated that LRVD was associated with left kidney remodeling. CONCLUSIONS: Venous return interruption of the left renal vein is associated with left kidney remodeling. Furthermore, interruption in the venous return of the left renal vein does not correlate with chronic renal failure. Therefore, we suggest careful follow-up of renal function after LRVD.

Treatment outcomes between bypass surgery and endovascular therapy in patients with chronic limb-threatening ischemia classified as bypass-preferred category based on Global Vascular Guidelines.

OBJECTIVE: The aim of this study was to examine outcomes between bypass surgery and endovascular therapy (EVT) in patients with chronic limb-threatening ischemia (CLTI), classified as bypass-preferred according to the Global Vascular Guidelines (GVG). METHODS: We retrospectively analyzed the multi-center data of patients who underwent infrainguinal revascularization for CLTI with Wound, Ischemia, and foot Infection (WIfI) Stage 3 to 4 and Global Limb Anatomical Staging System (GLASS) Stage III, which is classified as bypass-preferred category by the GVG between 2015 and 2020. The endpoints were limb salvage and wound healing. RESULTS: We analyzed 301 patients and 339 limbs following 156 bypass surgeries and 183 EVTs. The 2-year limb salvage rates were 92.2% in the bypass surgery group and 76.3% in the EVT group, respectively (P < .01). The 1-year wound healing rates were 86.7% in the bypass surgery group and 67.8% in the EVT group (P < .01). Multivariate analysis shows decreased serum albumin level (P < .01), increased wound grade (P = .04), and EVT (P < .01) were risk factors for major amputation. Decreased serum albumin level (P < .01), increased wound grade (P < .01), GLASS infrapopliteal grade (P = .02), inframalleolar (IM) P grade (P = .01), and EVT (P < .01) were risk factors for impaired wound healing. Subgroup analysis of limb salvage in patients after EVT, decreased serum albumin level (P < .01), increased wound grade (P = .03), increased IM P grade (P = .04), and congestive heart failure (P < .01) were risk factors for major amputation. According to scoring by existence of these risk factors, 2-year limb salvage rates following EVT were 83.0% and 42.8% for the total score of 0 to 2 and of 3 to 4, respectively (P < .01). CONCLUSIONS: Bypass surgery provides better limb salvage and wound healing in patients with WIfI Stage 3 to 4 and GLASS Stage III, which is classified as bypass-preferred category by the GVG. In patients after EVT, serum albumin level, wound grade, IM P grade, and congestive heart failure were related to major amputation. Although bypass surgery may be considered as initial revascularization procedure in patients classified as bypass-preferred category, in case that EVT has to be selected, relatively acceptable outcomes can be expected in patients with less of these risk factors.

Risk Factors for Major Amputation in Chronic Limb-Threatening Ischemia Patients Classified as Wound, Ischemia, and Foot Infection Stage 4 following Infrainguinal Revascularization.

BACKGROUND: To evaluate limb salvage outcomes and risk factors for major amputation in chronic limb-threatening ischemia (CLTI) patients classified as stage 4 per the wound, ischemia, and foot infection (WIfI) classification following infrainguinal revascularization. METHODS: We retrospectively analyzed multicenter data of patients who had undergone infrainguinal revascularization for CLTI between 2015 and 2020. The endpoint was secondary major amputation defined as an above- or below-knee amputation following infrainguinal revascularization. RESULTS: We analyzed 243 patients with CLTI and 267 limbs. Bypass surgery was performed in 14 (25.5%) and 120 (56.6%) limbs from the secondary major amputation and limb salvage groups, respectively (P < 0.01). Endovascular therapy (EVT) was performed in 41 limbs (74.5%) in the secondary major amputation group and 92 limbs (43.4%) in the limb salvage group (P < 0.01). The average serum albumin levels were 3.0 ± 0.6 and 3.4 ± 0.5 g/dL in the secondary major amputation and limb salvage groups, respectively (P < 0.01). The percentage of congestive heart failure (CHF) was 36.4% and 14.2% in secondary major amputation and limb salvage groups, respectively (P < 0.01). The number of limbs with infra-malleolar (IM) P0, P1, and P2 were 4 (7.3%), 37 (67.3%), and 14 (25.5%), respectively, in the secondary major amputation group and 58 (27.4%), 140 (66.0%), and 14 (6.6%), respectively, in the limb salvage group (P < 0.01). Limb salvage rates at 1 year were 91.0% and 68.6% in the bypass and EVT groups, respectively (P < 0.01). Limb salvage rates at 1 year in patients with IM P0, P1, and P2 were 91.8%, 79.9%, and 53.1%, respectively (P < 0.01). Multivariate analysis revealed that serum albumin level [hazard ratio (HR), 0.56; 95% confidence interval (CI), 0.36-0.89; P = 0.01], hypertension (HR, 0.39; 95% CI, 0.21-0.75; P < 0.01), CHF (HR, 2.10; 95% CI, 1.09-4.05; P = 0.03), wound grade (HR, 1.72; 95% CI, 1.03-2.88; P = 0.04), IM P (HR, 2.08; 95% CI, 1.27-3.42; P < 0.01), and EVT (HR, 3.31; 95% CI, 1.77-6.18; P < 0.01) as independent risk factors for secondary major amputation being required. CONCLUSIONS: Among CLTI patients with WIfI stage 4, the limb salvage rate was poor in those with IM P1-2 following infrainguinal EVT. Low serum albumin levels, CHF, high wound grade, IM P1-2, and EVT were independent risk factors for CLTI patients requiring major amputation.

Impact of ambulatory status change on survival in patients with chronic limb-threatening ischemia undergoing infrainguinal surgical or endovascular revascularization.

OBJECTIVE: This study aimed to evaluate the influence of change in ambulatory status on the prognosis of patients with chronic limb-threatening ischemia (CLTI) undergoing infrainguinal bypass surgery or endovascular therapy (EVT). METHODS: We retrospectively analyzed data from two vascular centers for patients who underwent revascularization for CLTI between 2015 and 2020. The primary endpoint was overall survival (OS), and the secondary endpoints were changes in ambulatory status and postoperative complications. RESULTS: Throughout the study, 377 patients and 508 limbs were analyzed. In the preoperative nonambulation cohort, the average body mass index (BMI) was lower in the postoperative nonambulatory group than in the postoperative ambulatory group (P < .01). The percentage of cerebrovascular disease (CVD) was higher in the postoperative nonambulatory group than in the postoperative ambulatory group (P = .01). In the preoperative ambulation cohort, the average controlling nutritional status (CONUT) score was higher in the postoperative nonambulatory group than in the postoperative ambulatory group (P < .01). There was no difference in the bypass percentage and the EVT in the preoperative nonambulation (P = .32) and ambulation (P = .70) cohorts. According to the change in ambulatory status before and after revascularization, the 1-year OS rates were 86.8% in the ambulatory → ambulatory group, 81.1% in the nonambulatory → ambulatory group, 54.7% in the nonambulatory → nonambulatory group, and 23.9% in the ambulatory → nonambulatory group (P < .01). On multivariate analysis, increased age (P = .04), higher Wound, Ischemia, and foot Infection stage (P = .02), and increased CONUT score (P < .01) were independent risk factors for the decline in ambulatory status in patients with preoperative ambulation. In patients with preoperative nonambulation, increased BMI (P < .01) and absence of CVD (P = .04) were independent factors related to the improved ambulatory status. The percentages of postoperative complications were 31.0% and 17.0% in the preoperative nonambulation and the preoperative ambulation in the overall cohort (P < .01). Preoperative nonambulatory status (P < .01), CONUT score (P < .01), and bypass surgery (P < .01) were risk factors for postoperative complications. CONCLUSIONS: Improved ambulatory status is associated with better OS in patients with preoperative nonambulatory status after infrainguinal revascularization for CLTI. Although patients with preoperative nonambulatory status have a risk of postoperative complication, some may benefit from revascularization if they have no factors such as low BMI and CVD, improving their ambulatory status.

Respiratory Virus Infections during the COVID-19 Pandemic Revealed by Multiplex PCR Testing in Japan.

Under the strict quarantine policy imposed to combat the COVID-19 (coronavirus disease 2019) pandemic in Japan, the prevalence of respiratory infections by viruses other than SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2) has been largely unknown. However, such information on viral circulation is important in order to develop better management policies that are based on scientific data. Here, we retrospectively investigated respiratory virus infections in individuals who visited a community hospital with respiratory symptoms between June of 2020 and September of 2021 with the use of the BioFire FilmArray Respiratory Panel 2.1. Virus was detected in 65 out of a total of 328 subjects, with SARS-CoV-2 (67.7%), rhino/enterovirus (18.5%), and parainfluenza virus 3 (7.7%) accounting for most of the infections. No influenza virus or respiratory syncytial virus (RSV) infections were detected. The monthly cases of rhino/enterovirus infection were highest from winter to spring, with this temporal pattern differing from that of SARS-CoV-2. SARS-CoV-2 was detected more frequently (P < 0.001) in subjects with cough (31/104 cases, 29.8%) than in those without cough (13/224 cases, 5.8%), suggesting that cough might contribute to the prediction of COVID-19. Our findings also suggest that testing for rhino/enterovirus and parainfluenza virus 3, in addition to SARS-CoV-2, may be important for the rigorous diagnosis of respiratory virus infections. IMPORTANCE Influenza virus, RSV, adenovirus, and rhino/enterovirus were the major respiratory viruses before COVID-19 pandemic. Circulating respiratory viruses may have been affected by our strong quarantine policy during the COVID-19 pandemic. We checked the circulating respiratory viruses from our outpatients by using a multiplex PCR kit that had recently been released. SARS-CoV-2 was the most frequently detected virus, and it was followed by rhino/enterovirus and parainfluenza virus 3. No influenza virus or RSV infections were detected during our study period, suggesting that influenza virus and RSV became almost extinct. COVID-19 cases frequently experienced cough, and this frequency was statistically significantly higher than that observed in the cases without SARS-CoV-2 detection. The cough can be an indicator of COVID-19.

Importance of Flow Waveform and Flow Volume as Prognostic Indicators for the Patency of Infra-Inguinal Autologous Vein Bypass.

OBJECTIVE: To investigate the association of the intra-operative flow waveform and the flow volume with graft prognosis of the infra-inguinal vein bypass. METHODS: This was a retrospective study of intra-operative flowmetry performed for infra-inguinal autologous vein bypass between 2011 and 2020. Flow waveforms were classified as type 0 - IV according to the Kyushu University (KU) classification. The patients (n = 340) were divided into three groups based on the flow waveform predicting the graft patency: type 0/I (long patency), type II (no early occlusion but late occlusion possible), and type III/IV (early occlusion). The graft occlusion rates of popliteal artery bypass (PAB) and infrapopliteal artery bypass (IPAB) within 30 days of surgery were compared between type 0/I + II and type III/IV groups, while the midterm graft patency rates were compared between type 0/I and type II groups. Additionally, a multivariate analysis was performed to identify independent risk factors for early and late graft occlusion. RESULTS: The early graft occlusion rates of type 0/I + II and type III/IV groups were 3.9% and 0%, respectively, (p = 1.0) for PAB, and 5.3% and 46.2%, respectively, (p < .001) for IPAB. The two year primary patency rates of type 0/I and type II groups were 91% and 75%, respectively, (p = .030) for PAB, and 58% and 63%, respectively, (p = .72) for IPAB. Independent risk factors for early occlusion were none in PAB and flow waveform (type IV) in IPAB. Independent risk factors for patency loss in PAB were flow waveform (type II), end stage renal disease, and dual antiplatelet use, and those in IPAB were older age, women, lower flow volume, and iterative bypass. CONCLUSION: Intra-operative flowmetry is useful for predicting the graft prognosis in infra-inguinal vein bypass and this is dependent on the distal target artery.

Internal Iliac Artery Aneurysm Ruptures with No Visualized Endoleak 2 Years after Endovascular Repair.

We report a case of an 83-year-old man with a ruptured internal iliac artery (IIA) aneurysm after endovascular repair, which was treated via the ligation of IIA and tight suture of the aneurysm sac. Although there were no findings of obvious endoleak after endovascular treatment, the IIA aneurysm increased in size and eventually ruptured. We presumed that pressure to IIA aneurysm via the embolized IIA led to rupture. Aneurysm sac expansion may lead to a rupture despite no endoleak being detected; therefore, close follow-up or re-intervention must be considered. Tight embolization of IIA may prevent endotension in the same case.

Effects of Antithrombotic Therapy on Abdominal Aortic Aneurysm Sac Size after Endovascular Repair in Patients with Favorable Neck Anatomy.

PURPOSE: To evaluate the influence of antiplatelet or anticoagulant therapy on sac behavior after endovascular aneurysm repair (EVAR) for abdominal aortic aneurysm (AAA). MATERIALS AND METHODS: This study retrospectively analyzed data from patients with favorable neck anatomy who underwent EVAR between 2007 and 2019. Patients with ruptured AAA and ≤1 year of sac behavior evaluation were excluded. Sac shrinkage after 1 year, persistent type II endoleak, and late sac expansion were examined. RESULTS: In total, 182 patients with favorable neck anatomy were included in this study. A multivariable analysis identified an occluded inferior mesenteric artery (IMA; P = .049), the presence of a posterior thrombus (P = .009), and no antiplatelet therapy (P = .012) as factors positively associated with sac shrinkage at 1 year. Persistent type II endoleak was detected in 56 (30.8%) patients, with patent IMA (P = .006), the lack of a posterior thrombus (P = .004), the number of patent lumbar arteries (P = .004), and antiplatelet therapy (P = .039) being identified as significant risk factors. The multivariable analysis identified a larger initial AAA diameter (P < .001), the lack of a posterior thrombus (P = .038), and antiplatelet and anticoagulant therapies (P = .038 and P = .003, respectively) as risk factors for late sac expansion. CONCLUSIONS: After EVAR in patients with favorable neck anatomy, antiplatelet therapy is associated with the lack of sac regression at 1 year, whereas antiplatelet and anticoagulant therapies are risk factors for late sac expansion.

Iliac Artery Aneurysms Expand in Quadratically Proportion to the Diameter.

BACKGROUND: Iliac artery aneurysms (IAAs) are life-threatening once ruptured. Although some studies have revealed the pathology of IAAs, clinical information on IAAs is still limited. Moreover, previous studies were conducted in Western countries; thus, we aimed to identify the natural history of iliac artery aneurysms in a Japanese cohort. The purpose of this study was to investigate the IAA expansion rate in a Japanese cohort to consider the management of small IAAs and to identify indications for surgical intervention. METHODS: Patients with iliac artery aneurysms were retrospectively reviewed. The primary outcome was the expansion rate of IAAs. We also investigated the correlation between expansion rate and patients' characteristics. Natural histories, including surgical interventions and rupture, were also assessed. RESULTS: The mean expansion rate in our study was 1.59 ± 1.16 mm/year. There was a positive correlation between expansion rate and aneurysm diameter, which was estimated by y = 0.0052 × (X - 23.270)2 + 0.0632 × X - 0.0517, where y is the expansion rate, and X is aneurysm diameter. The freedom from surgical intervention rate of IAAs was 85.5% at 1 year, 54.0% at 3 years, and 41.5% at 5 years. No factors, except initial aneurysm diameter, were revealed as independent predictors of surgical intervention. We experienced one ruptured IAA, which showed unexpected rapid growth from 30.1 mm to 56.3 mm over 15 months during conservative management. This case demonstrated that IAAs ≥30 mm should be carefully followed up and considered for surgical intervention. CONCLUSIONS: We conclude that larger aneurysms have greater expansion rates. Because IAAs ≥30 mm carry a risk of rapid expansion resulting in rupture, careful follow-up, and surgical intervention should be performed if iliac artery aneurysms are ≥30 mm in diameter.

Validation of the GLASS Staging Systems in Patients With Chronic Limb-Threatening Ischemia Undergoing De Novo Infrainguinal Revascularization.

OBJECTIVES: The Global Limb Anatomic Staging System (GLASS) was proposed for evaluating the anatomic complexity of arterial disease in patients with chronic limb-threatening ischemia (CLTI). We aimed to examine the relationship between GLASS stage and treatment outcomes after infrainguinal revascularization in patients with CLTI. METHODS: We retrospectively analyzed data of patients undergoing infrainguinal revascularization for CLTI between 2010 and 2018 to examine whether GLASS stage affects the limb salvage, wound healing, and overall survival (OS). RESULTS: Throughout the study period, 153 CLTI patients and 190 limbs with Fontaine classification III and IV were analyzed for major amputation and OS, and 125 patients and 157 limbs of Fontaine classification IV were analyzed for wound healing. The number of patients with WIfI stage 1, 2, 3, and 4 was 14 (7.4%), 44 (23.2%), 65 (34.2%), and 67 (53.3%), respectively. The number of patients with GLASS stage I, II, and III was 23 (12.1%), 48 (25.3%), and 119 (62.6%), respectively. Among the 190 limbs, the number subject to bypass surgery, endovascular therapy, and hybrid therapy was 132 (69.5%), 39 (20.5%), and 19 (10.0%), respectively. A multivariate analysis showed that only WIfI stage and inframalleolar (IM) disease were risk factors for major amputation and impaired wound healing. There was no relationship between GLASS stage and limb salvage or wound healing. A multivariate analysis revealed that age, geriatric nutritional risk index and GLASS stage were risk factors for 2-year OS (P < 0.01). Patients with all risk factors had a poor prognosis (35.3% at 2 years). CONCLUSION: WIfI stage and IM disease predicted limb salvage and wound healing after infrainguinal revascularization in patients with CLTI. Although GLASS stage did not affect limb salvage or wound healing, it was a prognostic factor for poor OS. The GLASS staging could be useful for deciding between bypass surgery and endovascular therapy in prediction of prognosis.

Pulsating hemorrhagic varicose veins caused by tricuspid valve regurgitation: report of a case treated by laser ablation and foam sclerotherapy.

BACKGROUND: Varicose veins are one of the most common disease; however, secondary varicose veins caused by tricuspid valve regurgitation (TVR) are rare. CASE PRESENTATION: A patient who developed pulsating bleeding from superficial varicose veins due to TVR was successfully treated by endovenous laser ablation (EVLA) of the great saphenous vein (GSV) and repeated foam sclerotherapy of varicose veins. There were no complications, such as rebleeding or recanalization of the GSV during the 1-year follow-up period. CONCLUSIONS: We herein report a rare case of pulsatile hemorrhagic varicose veins caused by TVR that was successfully managed by combined treatment of EVLA and foam sclerotherapy. When pulsatile varicose veins are found, the presence of TVR should be suspected.

Analysis of prognostic factors for postoperative complications and reinterventions after open surgical repair and endovascular aneurysm repair in patients with abdominal aortic aneurysm.

OBJECTIVE: A definitive treatment for patients with abdominal aortic aneurysm considering age and comorbidities has not been identified. In the present study, we retrospectively validated treatment outcomes in Japanese patients and proposed the treatment strategy of open surgical repair (OSR) and endovascular aneurysm repair (EVAR). METHODS: We retrospectively analyzed data for patients undergoing EVAR or OSR between 2006 and 2017. Patients with ruptured abdominal aortic aneurysm were excluded. We examined post-operative complications, operative mortality, re-intervention and prognosis. RESULTS: Throughout the study period, 405 patients underwent EVAR and 176 patients underwent OSR. The percentage of patients with post-operative complications was 35.8% in the OSR group, compared with 13.1% in the EVAR group (P < 0.01). The operative mortality rate was 0.49% in the EVAR group and 0.57% in the OSR group (P = 1.00). With a multivariate analysis, age, hemodialysis, modified Frailty Index (mFI), and OSR were risk factors for post-operative complications. The 5-year re-intervention free survival rate was 63.0 % with hostile neck EVAR compared with 83.1 % with favorable neck EVAR and 86.1 % with OSR group (P < 0.01). With a multivariate analysis, hemodialysis, mFI, and hostile neck EVAR were risk factors for re-intervention. The 5-year overall survival rate was 51.9 % with hostile neck EVAR compared with 73.2 % with favorable neck EVAR and 79.0 % with OSR group (P < 0.01). With a multivariate analysis, age, mFI, and hostile neck EVAR were poor prognostic factors. CONCLUSION: Age, mFI, hemodialysis and hostile neck anatomy are useful predictors of post-operative complications, re-intervention and overall survival, and could be useful for informing treatment selection between OSR and EVAR.

Platelet Count Recovery after Endovascular Aneurysm Repair for Abdominal Aortic Aneurysm.

Objective: To find a new predictor of endoleak (EL) and aneurysm sac expansion after endovascular aneurysm repair (EVAR), we evaluated the platelet count recovery (PCR) process after EVAR. Materials and Methods: Two hundred five patients treated with elective EVAR from 2007 to 2015 were retrospectively analyzed. We compared the platelet count ratio until postoperative day (POD) 7 to the presurgical baseline between patients with and without persistent EL (≥ 6 months). Subsequently, we calculated the optimal platelet count ratio for distinguishing persistent EL using receiver-operating characteristics analysis. A platelet count ratio on POD7 ≥118% was defined as the PCR. We evaluated the PCR's influence on the cumulative aneurysm sac expansion rate. Results: The average platelet count ratio on POD7 rose above baseline (112%), and the ratio was attenuated by persistent EL (103%). Of 205 patients, 126 (61%) were assigned to the disturbed PCR group (PCR(-) group). Cumulative aneurysm sac expansion rate was higher in the PCR(-) group than the PCR(+) group (34.4% vs. 12.8% in 5 years, p=0.01). Conclusion: Disturbed PCR after EVAR may be associated with ELs and eventual aneurysm sac expansion.