The prognosis of patients on hemodialysis with foot lesions.

OBJECTIVE: Many studies have shown the high prevalence and incidence of peripheral arterial disease and the marked morbidity and mortality associated with peripheral arterial disease in hemodialysis patients. The purpose of this retrospective study was to clarify the probability of survival and limb salvage in patients with foot lesions and how to manage these patients. METHODS: Data were collected in a retrospectively maintained database for 319 lower limbs with foot lesions in 234 hemodialysis patients treated in a university hospital between 1980 and 2011. Variances influencing survival and limb salvage were compared using log-rank tests and Cox regression analysis. These variables were examined using Kaplan-Meier analysis. Significant factors in bivariate analysis were included in a logistic regression model to determine independent predictors and the probability of failure. RESULTS: The 234 patients (72% men) were a mean age of 65.4 years on admission, and 84% had diabetes. The mean duration of hemodialysis was 6.8 years. During the follow-up period, 171 patients (73%) died. The 1-, 3-, 5-, and 7-year survival rates were 65.2%, 35.5%, 23.4%, and 12.8%, respectively. According to Cox multivariate models, age at admission and ischemic changes on an electrocardiogram independently increased the risk of death (hazard ratios, 1.02 and 1.48, respectively). Conversely, hyperlipidemia independently decreased the risk of death (hazard ratio, 0.56). Critical limb ischemia was present in 247 limbs (77%). Arterial reconstruction was done in 88 limbs (28%), and 119 limbs (37%) required major amputation. The overall 1-, 3-, 5- and 7-year limb salvage rates were 68.9%, 57.2%, 53.8%, and 51.7 %, respectively. According to Cox multivariate models, patent arterial reconstruction and albumin independently decreased the risk of major amputation (hazard ratios, 0.265 and 0.392, respectively). CONCLUSIONS: Hemodialysis patients with foot lesions have a poor prognosis, with high rates of mortality and amputation. Prompt assessments of the severity of systemic conditions, such as cardiac ischemia, and focal wound conditions, such as ischemia and infection, are necessary to treat hemodialysis patients with foot lesions.

Stent strut penetration during thoracic endovascular aortic repair: report of a case.

We experienced a serious complication of proximal stent strut penetration (PSSP) during thoracic endovascular aortic repair in a 74-year-old man who underwent two-stage hybrid treatment for a distal arch thoracic aortic aneurysm. First, a debranching right common carotid-left common carotid-left subclavian artery bypass was performed. Second, a TALENT Thoracic Stent Graft (Medtronic, Tokyo, Japan) was inserted at Zone 1 (Ishimaru). At deployment, a proximal bare strut accidentally everted and penetrated the aortic wall vertically. Postoperative computed tomography revealed that one crown of the proximal strut had penetrated the aortic wall vertically and had produced an intramural hematoma around the strut. The patient was observed carefully and discharged from the hospital without any sequelae. Seven months after the procedure, there was no remarkable change and his aneurysm was well excluded. PSSP can cause retrograde type-A aortic dissections. A bare strut tends to cause proximal strut penetration more frequently than a covered strut. More caution should be taken in the deployment of a stent graft with a bare strut.

Partial debranching hybrid stent graft for distal aortic arch aneurysms.

PURPOSE: To evaluate the early outcomes of treating distal aortic arch aneurysms (DAAAs) with a partial debranching hybrid stent graft, and to analyze the morphology of distances among the supra-aortic branches. METHODS: We used this stent graft to treat DAAA in 12 patients, by debranching the left common carotid artery (LCCA) and the left subclavian artery (LSA). With computed tomography (CT) data on the collective total 28 thoracic aortic aneurysms, the distances from the LSA to the LCCA and those from the LSA to the brachiocephalic artery (BA) were measured using multiplanar reconstruction (MPR) and centerline of flow (CLF) methods. RESULTS: All procedures were done in two stages and all stent grafts were deployed in zone-1. The devices used were the TALENT in seven patients and the TAG in five patients. There were no operative deaths, paraplegia, or type-1 or -3 endoleaks. One patient suffered minor cerebral infarction. The distance from the LSA to the BA was longer than that from the LSA to the LCCA by 10 mm in the CLF method and by 13 mm in the MPR method. CONCLUSIONS: It was possible to achieve a longer proximal landing zone by debranching two supra-aortic branches, the LCCA and the LSA. The partial debranching hybrid stent graft was less invasive and more effective for DAAAs.

Mid-term results of endovascular abdominal aortic aneurysm repair: is it possible to predict sac shrinkage?

PURPOSE: To evaluate the mid-term results of endovascular repair of abdominal aortic aneurysms and to predict subsequent sac shrinkage. METHODS: From December 2006 to April 2010, 114 abdominal aortic aneurysms were treated with stent grafts. The intraoperative sac pressure was measured by a microcatheter. Correlations between the diameter change and relevant factors were determined by a logistic regression analysis. RESULTS: Stent grafts were deployed successfully in all patients. Type-2 endoleaks were noted in 25 patients (22%); there were no type-1 or type-3 endoleaks at discharge. The clinical success rate was 99%. The diameter was reduced in 40 patients (56%) but remained unchanged in 32 (44%). There were no aneurysms that increased in diameter. At 2 years after the repair the rate of cumulative survival was 87% and freedom from secondary intervention was 95%. The sac pressure index after stent grafting with a reduced diameter was 0.56 ± 0.11 and that of patients with an unchanged diameter was 0.52 ± 0.14. There were no significant differences between the two groups. Persistent type-2 endoleaks had a slightly negative effect on sac shrinkage (P = 0.052). CONCLUSIONS: The mid-term results of endovascular aneurysm repair were satisfactory. Although it was difficult to predict the fate of a sac after stent grafting, persistent type-2 endoleaks were observed to have a slightly negative impact on sac shrinkage.

Treatment of Primary Varicose Veins in Japan: Japanese Vein Study XVII.

Purpose: This study aimed at clarifying the changes in treatments for primary varicose veins in Japan. Methods: A questionnaire was mailed to the members of the Japanese Society of Phlebology. The contents of the survey covered the treatment and treatment strategy of varicose vein cases in 2013. The results were examined and compared with the results of previous surveys conducted by the aforesaid society in 1998, 2004 and 2009. Results: Of 36078 patients, 43958 limbs were reported from 201 institutions. Saphenous type was the most common type of varicose veins that developed in patients aged 70-79 years. The C4-6 cases according to the Clinical-Etiology-Anatomy-Pathophysiology (CEAP) classification occurred significantly more in males than in females (p <0.01). For the treatments of saphenous type and of segment type (dilatation of peripheral branch), endovenous laser ablation (EVLA) was performed most frequently (51%), while the frequency of stripping and of high ligation decreased. EVLA was performed with tumescent local anesthesia, which required one day of hospitalization. Conclusion: In our study, the number of patients with varicose veins increased especially in the elderly. Surgical treatments were selected for a number of patients, and EVLA was the most commonly adopted method of treatment in Japan. (This article is a translation of Jpn J Phlebol 2016: 27; 249-57.).

Ultrasonographic findings and the clinical results of treatment for lymphedema.

We undertook this study using ultrasonography to examine structural changes occurring in the subcutaneous tissue with lymphedema. Ultrasonographic images were taken in 178 outpatients and 29 inpatients, with the images of the subcutis fluid accumulation, which was categorized into three types ( grade 0: absent, grade 1: a minimal amount of water, grade 2: stone-paved image due to excess water). Initial percentage of excess volume was correlated with the tissue fluid (grade 0: 7.5%, grade 1: 17.1%, grade 2: 30.5%, p <0.01). The higher the grade of fluid accumulation, the more important was the absolute reduction of lymphedema volume (grade 0: 2.5%, grade 1: 14.8%, grade 2: 33.2%, p <0.01). The percentage of severe lymphedema (stage2b + 3) was higher in inpatients than outpatients(89.3% vs. 45.8%), however, a significant decrease in the percentage of volume reduction was found for inpatients (29.4 ± 15.1% vs. 15.4 ± 14.2%, p <0.01). Echographic images can help to determine whether compression therapy will reduce lymphedema and to evaluate the treatment results by measuring tissue fluid. For severe lymphedema, a compression bandage was more effective than an elastic stocking. (English translation of Jpn J Phlebol 2013; 24: 287-294).

Huge hemangioma in the chest mimicking a breast tumor: report of a case.

A 35 year-old man first noticed an elastic mass like breast tumor in his left chest 17 years ago. It enlarged to the size of a child's head. Computed tomography showed a well-circumscribed mass in the left chest. Lumpectomy was performed. The mass was located under the thin major pectoralis muscle, covered with a white fibrous capsule. The specimen weighed 1360 g and measured 18 × 14 × 8 cm. Histological examination revealed a cavernous hemangioma. To the best of our knowledge, this is the first reported case of a chest hemangioma arising from connective tissue and located under the major pectoralis muscle.

Intraoperative sac pressure measurement during endovascular abdominal aortic aneurysm repair.

PURPOSE: Intraoperative sac pressure was measured during endovascular abdominal aortic aneurysm repair (EVAR) to evaluate the clinical significance of sac pressure measurement. METHODS: A microcatheter was placed in an aneurysm sac from the contralateral femoral artery, and sac pressure was measured during EVAR procedures in 47 patients. Aortic blood pressure was measured as a control by a catheter from the left brachial artery. RESULTS: The systolic sac pressure index (SPI) was 0.87 +/- 0.10 after main-body deployment, 0.63 +/- 0.12 after leg deployment (P < 0.01), and 0.56 +/- 0.12 after completion of the procedure (P < 0.01). Pulse pressure was 55 +/- 21 mmHg, 23 +/- 15 mmHg (P < 0.01), and 16 +/- 12 mmHg (P < 0.01), respectively. SPI showed no significant differences between the Zenith and Excluder stent grafts (0.56 +/- 0.13 vs. 0.54 +/- 0.10, NS). Type I endoleak was found in seven patients (15%), and the SPI decreased from 0.62 +/- 0.10 to 0.55 +/- 0.10 (P = 0.10) after fixing procedures. Type II endoleak was found in 12 patients (26%) by completion angiography. The SPI showed no difference between type II endoleak positive and negative (0.58 +/- 0.12 vs. 0.55 +/- 0.12, NS). There were no significant differences between the final SPI of abdominal aortic aneurysms in which the diameter decreased in the follow-up and that of abdominal aortic aneurysms in which the diameter did not change (0.53 +/- 0.12 vs. 0.57 +/- 0.12, NS). CONCLUSIONS: Sac pressure measurement was useful for instant hemodynamic evaluation of the EVAR procedure, especially in type I endoleaks. However, on the basis of this small study, the SPI cannot be used to reliably predict sac growth or regression.

A case of persistent sciatic artery aneurysm accompanied by a persistent sciatic vein.

A persistent sciatic artery is a rare anomaly. On the other hand, a persistent sciatic vein is frequently associated with Klippel-Trenaunay syndrome. In a 71-year-old female with a complete-type persistent sciatic artery aneurysm, we performed aneurysmectomy and right femoropopliteal bypass surgery. The right popliteal vein drained into the femoral vein via a lower-type persistent sciatic vein and the deep femoral vein. The superficial femoral artery and vein were hypoplastic. Since only 4 cases of a coexisting persistent sciatic artery and vein have been reported, we report this extremely rare case.

Quantitative assessment of therapeutic effects in the critically ischemic limb using (99m)Tc-diethylene-triamine-pentaacetic acid human serum albumin.

PURPOSE: To investigate the reliability and limitations of a new radioisotope method using (99m)Tc-diethylenetriamine-pentaacetic acid human serum albumin (Tc-99m-DTPA-HSA) and to evaluate the diagnostic ability of isotope infusion for assessing hemodynamic changes in the foot before and after treatment. METHODS: Hemodynamic changes before and after treatment were assessed in 21 limbs with ulcer or gangrene, by analyzing changes in the time-activity curve, the uptake ratio, and the values obtained with noninvasive techniques. RESULTS: There were significant differences between each pair of the three types of time-activity curve and their uptake counts. The uptake ratio was correlated with ankle blood pressure (ABP) and toe blood pressure (TBP), but not with transcutaneous oxygen pressure (tcPO(2)) or skin perfusion pressure (SPP). The hemodynamic change induced by pharmacotherapy was subtle, but that induced by arterial reconstruction was remarkable. Although there was not always a good correlation between the degree of hemodynamic change and the clinical outcome in limbs treated with pharmacotherapy, the hemodynamic change was quantitatively assessed. CONCLUSION: Our study suggests that this isotope technique is a useful quantitative method to evaluate hemodynamic change from a different perspective to conventional noninvasive methods.

Transcutaneous carbon dioxide tension for the evaluation of limb ischemia.

PURPOSE: Understanding the hemodynamics of critical limb ischemia caused by chronic peripheral arterial occlusive disease is important to evaluate its severity and the efficacy of treatment. We investigated the usefulness of transcutaneous carbon dioxide tension (tcPCO(2)) measurement for evaluating ischemic limbs, in conjunction with the measurement of ankle pressure (AP), toe pressure (TP), skin perfusion pressure (SPP), and transcutaneous oxygen tension (tcPO(2)). METHODS: We measured tcPCO(2) in the dorsum of the foot in 158 patients (304 limbs) with arteriosclerosis obliterans. RESULTS: The tcPCO(2) in normal limbs without any clinical sign or abnormal noninvasive measurement was 43.7 +/- 3.7 mmHg; that in noncritical ischemic limbs was 45.5 +/- 9.0 mmHg, which was not significantly different from that in the normal limbs; and that in critically ischemic limbs was 87.6 +/- 35.5 mmHg, which was significantly different from that in the normal limbs. All limbs with a tcPCO(2) of 100 mmHg or higher, indicative of critical ischemia, had a tcPCO(2) of less than 100 mmHg after revascularization. CONCLUSION: We found tcPCO(2) to be a useful measurement for diagnosing the severity of limb ischemia, and for evaluating the effect of treatment, especially in patients with critically ischemic limbs.

Interface pressure and stiffness of various elastic stockings during posture changes and exercise.

The importance of measuring interface pressure and stiffness to characterize the elastic properties of materials has been stressed with regard to elastic stockings and elastic bandages. The objective of this study was to compare the pressure profiles of nine different elastic stockings and to quantify the effects of posture changes and exercise on compression. Using a pressure transducer (Air Pack Type Analyzer), the interface pressure associated with nine different elastic stockings was measured at level B1 during supine resting, standing, and exercise. The elastic stockings examined could be divided into two categories according to extensibility: short stretch (< 105% extensibility) and long stretch (> 105% extensibility). Short-stretch stockings include thick round-knitted stockings, firm round-knitted stockings, and flat-knitted stockings. Short-stretch stockings showed a higher peak working pressure and a larger pressure amplitude during exercise than long-stretch stockings. Short-stretch stockings can be expected to have more pronounced benefits for augmenting muscle pumping in the same way as short-stretch bandages. In selecting suitable elastic stockings for patients, the stiffness should be taken into account in addition to interface pressure.

Clinical reliability and utility of skin perfusion pressure measurement in ischemic limbs--comparison with other noninvasive diagnostic methods.

PURPOSE: We studied whether the measurement of skin perfusion pressure (SPP) is useful for evaluating ischemic limbs and predicting wound healing. METHODS: Two hundred eleven patients (age range, 45 to 90 years; mean age, 69.6 +/- 9.2 years; 170 men and 41 women), 403 limbs with arteriosclerosis obliterans, were included in this study. Half of the patients had diabetes or were receiving dialysis or both. RESULTS: Significant correlations were found between SPP and ankle blood pressure (ABP), SPP and toe blood pressure (TBP), and SPP and the transcutaneous oxygen pressure (tcPO2) (P < .0001, r = 0.75; P < .0001, r = 0.85; P < .0001, r = 0.62; respectively). In 94 limbs with ulcer or gangrene, wound healing was predicted by the SPP. The mean SPP (mean +/- SD) in the healed-wound group (25 limbs, 48 +/- 20 mm Hg) was greater than that in the unhealed-wound group (69 limbs, 23 +/- 11 mm Hg) (P <.001). According to the receiver operating characteristic (ROC) curve, the cut-off value of SPP was 40 mm Hg (sensitivity, 72%; specificity, 88%). Furthermore, we studied whether the combination of SPP and another measurement could predict wound healing more accurately than could any single variable. There was a strong correlation between SPP, TBP, and the healing rate (P < .001, r = 0.69) and healing could be accurately predicted if the SPP was greater than 40 mm Hg and if the TBP was greater than 30 mm Hg. CONCLUSIONS: Our results suggest that measurement of SPP is an objective method for assessing the severity of peripheral arterial disease or for predicting wound healing.

The Clinical Course of Buerger's Disease.

The clinical and social characteristics of 118 patients with Buerger's disease (thromboangiitis obliterans: TAO) were surveyed. The prognosis for many patients is relatively favorable. Arterial reconstruction plays a role in shortening the healing times of ischemic ulcers despite its poor long-term results. Of 118 patients, 13 underwent major lower limb amputation (11%), 33 underwent foot or toe amputation (28%), one underwent hand amputation (1%), and 12 underwent finger amputations (10%) after the onset of the disease. The progression of symptoms was surely influenced by smoking, but this was not the only deleterious factor as there were patients with stable TAO which was unaffected by their continued smoking. In 66 patients, the new occurrence of ulceration and gangrene was not observed over the age of 60. Ten of 13 patients (77%) who underwent major lower limb amputation lost their jobs, but only 7 of 105 patients without major amputation lost their jobs (7%). In all patients, the progression of symptoms was self-limited and recurrent ulcers occurred less frequently with ageing. To avoid factors that markedly influence the quality of life, early treatment and strict instructions prohibiting smoking should be conducted.

Abdominal aortic aneurysm surgery for octogenarians.

PURPOSE: To define the indications for abdominal aortic aneurysm (AAA) surgery in octogenarians. METHODS: We reviewed septuagenarians and octogenarians with a nonspecific AAA diagnosed at our hospital between January, 1990 and June, 2006. RESULTS: Among a total 628 patients seen, 306 were in their 70s (group A) and 108 were in their 80s or older (group B). The mortality rate associated with elective surgery was 1.9% in group A and 7.0% in group B. Of the survivors, 12 (5.7%) of 210 in group A and 8 (15.1%) of 53 in group B died within 2 years. Of the patients who did not undergo surgery, 8 of 53 in group A and 8 of 31 in group B had AAAs greater than 6 cm in diameter. The rupture-free rates of AAAs greater than 6 cm in diameter were 64% at 1 year and 0% at 4 years in group A, and 88% at 1 year and 26% at 3 years in group B. The rupture-free rates of AAAs smaller than 6 cm in diameter were 95% at 3 years and 85% at 5 years in group A, and 100% at 5 years in group B. CONCLUSIONS: We concluded that AAAs over 6 cm in diameter were an appropriate indication for surgery in octogenarians.