Evolution of open aneurysmorrhaphy for management of sac expansion after endovascular repair of abdominal aortic aneurysms.

OBJECTIVE: We evaluated the perioperative and mid-term clinical outcomes of open aneurysmorrhaphy (OA) for the treatment of sac expansion after endovascular aneurysm repair (EVAR) of abdominal aortic aneurysms. METHODS: OA involves sac exposure without dissection of the proximal or distal neck, sacotomy and ligation of back-bleeding vessels, preservation of the prior stent graft, and tight closure of the sac around the stent graft. We performed a retrospective review of all patients who had undergone OA for nonruptured sac expansion after standard EVAR at our institution between January 2015 and June 2021. The primary end points were 30-day mortality and aneurysm-related death. The secondary end points were postoperative complications, overall survival, freedom from reintervention, and sac regrowth rate. RESULTS: A total of 28 patients had undergone OA. Their mean age was 76.9 ± 6.7 years. The median sac diameter at OA was 79 mm (interquartile range [IQR], 76-92 mm). The median duration from the index EVAR to OA was 82 months (IQR, 72-104 months). Preoperative computed tomography angiography confirmed a type II endoleak (EL) in 20 patients, 1 of whom had had a coexisting type Ia EL; a type IIIb EL was identified in 1 patient. Concomitant endovascular procedures had been performed in six patients to treat a type I or III EL or reinforce the proximal and distal seals. The OA technique has been modified since 2017, with the addition of more aggressive dissection of the sac and complete removal of the mural thrombus to further decrease the sac diameter. Postoperative complications occurred in two patients and included abdominal lymphorrhea and failed hemostasis of the common femoral artery requiring surgical repair in one patient each. The 30-day mortality was 0%. During the median follow-up of 36 months (IQR, 14-51 months), the overall survival was 92.7% and 86.9% at 12 and 36 months, respectively, without any aneurysm-related death. In the late (2017-2021) treatment group, the median sac diameter immediately after OA was smaller than that in the early (2015-2016) treatment group (early group: median, 50 mm; IQR, 39-57 mm; vs later group: median, 41 mm; IQR, 32-47 mm; P = .083). Furthermore, in the late group, the sac regrowth rate was lower (early group: median, 0.36 mm/mo; IQR, 0.23-0.83 mm/mo; vs late group: median, 0 mm/mo; IQR, 0-0.11 mm/mo; P = .0075) and the freedom from reintervention rate was higher (late group: 94.7% at both 12 and 36 months, respectively; early group: 71.4% and 53.6% at 12 and 36 months, respectively; log-rank P = .070). CONCLUSIONS: Our results have shown that OA for the management of post-EVAR sac expansion is feasible with acceptable mid-term outcomes. Aggressive dissection and tight plication of the sac might be imperative for better mid-term outcomes after OA.

Early clinical outcomes of retrograde in situ branched stent grafting for complex aortic arch aneurysms.

OBJECTIVE: To evaluate the early outcomes of retrograde in situ branched stent grafting (RIBS) using the gutter balloon technique for complex aortic arch aneurysms (CAAs). METHODS: The RIBS technique is an in situ needle fenestration procedure during thoracic endovascular aortic repair with the reconstruction of cervical branches. The double RIBS (D-RIBS) for the reconstruction of the left common carotid artery and the brachiocephalic artery using the gutter balloon technique was performed in 30 high-risk patients. We describe the early clinical results of the D-RIBS technique for CAAs. Primary end points were technical success and 30-day mortality. Secondary end points were postoperative complications, rates of endoleaks, overall survival, aneurysm-related death, and reinterventions. RESULTS: The mean age was 77.1 ± 6.6 years, and the mean maximum minor-axis aneurysmal diameter was 65.9 ± 8.9 mm. Twenty-six patients underwent D-RIBS for elective arch aortic aneurysm, and four patients were for reintervention after zone 2 thoracic endovascular aortic repair failure. Stent graft puncture was performed 60 times from the common carotid arteries, and technical success was achieved in all cases (100%). Postoperative complications included cerebral infarction in two patients (6.7%) and recurrent nerve palsy in one patient (3.3%). The 30-day mortality was 0%. During the median follow-up period of 14 months (6-56 months), overall survival at 12 months was 92.3% without any aneurysm-related death. Type 1 b and type 2 endoleaks were observed in one each, and no reintervention was encountered. CONCLUSIONS: Early clinical outcomes of the D-RIBS for high-risk patients with CAAs are acceptable. The gutter balloon method enables safe and reliable fenestration. Further studies and dedicated devices are warranted.

A Novel Shaggy Aorta Scoring System to Predict Embolic Complications Following Thoracic Endovascular Aneurysm Repair.

OBJECTIVE: The aim of this study was to investigate the correlation between shaggy aorta and embolic complications during thoracic endovascular aneurysm repair (TEVAR), based on a shaggy aorta scoring system. METHODS: The entire aorta was assessed based on 5 mm slice computed tomography (CT) from the sinotubular junction to the aortic bifurcation using a three dimensional workstation. One shaggy point (shaggy score) was given when the following conditions were met: 1) ulcer like thrombus, 2) maximum thrombus thickness ≥ 5 mm, and 3) mural thrombus occupies more than two thirds of the circumference of the aortic diameter on reconstructed CT of the axial statue. Subsequently, each point was added to obtain the total shaggy score. RESULTS: The outcomes of 301 patients undergoing TEVAR were evaluated. Post-operative embolic complications including stroke, acute renal failure, and distal embolisation, were identified in 21 cases (7.0%). The average shaggy score for the entire cohort was 2.4 ± 5.6 points, whereas it was 7.9 ± 7.1 in those patients with embolic complications (E group) and 2.0 ± 5.3 in those without embolic complications (N group, p = .001). There were no statistical differences in 30 day mortality (p = .70), but overall survival at two years was significantly lower in the E group (E: 58.8%, N: 93.3%, p < .001). Multivariable analysis revealed that the predictors of post-operative embolic complication were past history of cerebrovascular disease (p = .001, OR 5.90, 95% CI 2.14-16.29) and shaggy score (p < .001, OR 1.13, 95% CI 1.06-1.19). The area under the ROC curve was 0.77, and the cut off value of the shaggy score using the Youden index was 3 points (sensitivity: 71.4%, specificity: 81.4%). CONCLUSION: This shaggy score is a useful method to predict post-operative embolic complications following TEVAR. Because the risk of embolic complications was relatively high in patients with a high shaggy score, the indication for TEVAR in such patients should be considered carefully.

Discovery of attenuation effect of orexin 1 receptor to aversion of nalfurafine: Synthesis and evaluation of D-nor-nalfurafine derivatives and analyses of the three active conformations of nalfurafine.

The D-nor-nalfurafine derivatives, which were synthesized by contraction of the six-membered D-ring in nalfurafine (1), had no affinity for orexin 1 receptors (OX1Rs). The 17N-lone electron pair in 1 oriented toward the axial direction, while that of D-nor-derivatives was directed in the equatorial configuration. The axial lone electron pair can form a hydrogen bond with the 14-hydroxy group, which could push the 6-amide side chain toward the downward direction with respect to the C-ring. The resulting conformation would be an active conformation for binding with OX1R. The dual affinities of 1 for OX1R and κ opioid receptor (KOR) led us to elucidate the mechanism by which only 1 showed no aversion but U-50488H. Actually, 1 selectively induced severe aversion in OX1R knockout mice, but not in wild-type mice. These results well support that OX1R suppresses the aversion of 1. This is the elucidation of long period puzzle which 1 showed no aversion in KOR.

Li-ion transport at the interface between a graphite anode and Li2CO3 solid electrolyte interphase: ab initio molecular dynamics study.

Understanding and the control of Li-ion (Li+) transport across the interface between the anode and solid electrolyte interphase (SEI) film or electrolyte is a key issue in battery electrochemistry and interface science. In this study, we investigated the structural, electronic and free energy properties of Li+ migration between a Li-intercalated graphite anode LiCx and Li2CO3 SEI film, by using ab initio molecular dynamics and free energy calculations. We compared three types of graphite edges: H-, OH- and mixed (H, OH, COOH)-terminations, and three cases of transferred Li-ions: Li+ constructing the SEI, excess Li+ and excess Li0 (excess Li+ + e- in anode). After validation of our calculations with Li2CO3 and LiCx bulk systems, we sampled the interfacial structures under thermodynamic equilibrium and demonstrated that the OH- and mixed-terminations had larger binding energies. The calculated free energy profiles of Li+ intercalation from the Li2CO3 SEI to LiC24 showed barriers larger than 1.2 eV irrespective of the terminations and Li+ cases. We also clarified that the charges of Li ions did not change much upon the intercalation. Based on these results and the calculated Li chemical potential, we constructed the probable free energy profile of Li+ between the anode and cathode under charging and discharging. This profile model suggest a possible electric field approximation for the charging stage, and the resultant free energy profiles with such fields gave a ca. 0.5 eV barrier under charging, which was consistent with the experimental values. The present picture will give a crucial insight into Li-ion transport at the battery interfaces.

Outcomes of Chimney Thoracic Endovascular Aortic Repair for an Aortic Arch Aneurysm.

BACKGROUND: Chimney thoracic endovascular aneurysm repair (TEVAR) has advantages that include no requirements for special devices; however, problems have been identified such as gutter leaks. The aim of this study is to evaluate the short- and mid-term results of TEVAR with chimney technique including the safety, efficacy, and risk factors for occurrence of gutter endoleak in this technique. METHODS: A retrospective single-center study was conducted on 55 consecutive patients who underwent first-time chimney TEVAR for arch aneurysms in the past 7 years. This consisted of 33 cases of single-chimney (SC) TEVAR and 22 cases of double-chimney (DC) TEVAR. The outcomes of these 55 cases of SC-TEVAR and DC-TEVAR were retrospectively examined. Risk factors for endoleaks in chimney TEVAR were also examined. RESULTS: Operative mortalities of 3.0% and 4.5% were observed in SC-TEVAR and DC-TEVAR, respectively. Incidences of stroke were 12.1% in the SC-TEVAR and 4.5% in the DC-TEVAR, resulting in endoleaks in 16 patients (48.5%) in SC-TEVAR and 6 patients (27.3%) in DC-TEVAR. Only 1 of the 77 chimney grafts was occluded, with a patency rate of 98.7%. SC-TEVAR and small distance from the common carotid artery were the risk factors of type I endoleaks. Overall survival rates over a period of 1, 3, and 5 years were 82.3%, 78.0%, and 57.7%, respectively, in the SC-TEVAR group and 95.2%, 89.3%, and 76.5%, respectively, in the DC-TEVAR group. Freedom from aneurysm-related death over 1, 3, and 5 years was 82.3%, 69.0%, and 57.7%, respectively, in the SC-TEVAR group and 95.2%, 89.3%, and 89.3% in the DC-TEVAR group. Freedom from secondary intervention over 1, 3, and 5 years was 80.2%, 64.7%, and 47.2%, respectively, in the SC-TEVAR group and 95.0%, 74.0%, and 74.0%, respectively, in the DC-TEVAR group. CONCLUSIONS: The short- and mid-term results of chimney TEVAR were worse than expectation. Especially, the results of SC-TEVAR were not acceptable because of extremely high incidence of type I endoleak and high incidence of stroke.

Current status of endovascular treatment for thoracoabdominal aortic aneurysms.

Open surgical repair (OSR) for thoracoabdominal aortic aneurysms (TAAAs) is maximally invasive and associated with high rates of operative mortality and perioperative complications including spinal cord ischemia (SCI), despite improvements in surgical techniques and perioperative care. Elderly patients, patients with a history of aortic surgery, and patients with severe comorbidities are often considered ineligible for this surgery and endovascular treatment may be their only treatment option. Total endovascular aneurysm repair (t-EVAR) without debranching surgery does not require thoracotomy and laparotomy and could improve the outcomes of these patients. t-EVAR includes fenestrated EVAR (f-EVAR), multi-branched EVAR (b-EVAR), and physician-modified fenestration endograft (PMFG). Although these techniques have achieved lower mortality rates than OSR, there are concerns about perioperative complications including limb ischemia, SCI, and long-term outcomes such as endograft migration and endoleaks (ELs). This article provides an overview of available endovascular devices for TAAAs and reviews the short and mid-term results of t-EVAR, as well as alternative options.

[Thrombectomy for right atrial thrombosis complicating a pyogenic liver abscess].

Vascular complications from a liver abscess are rare but life-threatening. Herein, we report the case of a man in his 40s with a pyogenic hepatic abscess complicated by an inferior vena caval thrombus extending to the right atrium. His presenting complaint was a high fever. Blood tests revealed elevated inflammatory markers and liver enzymes. An abdominal CT demonstrated a 10cm abscess in the right hepatic lobe. A blood culture grew Streptococcus intermedius, which was sensitive to ampicillin sulbactam. He was diagnosed with a pyogenic liver abscess and treated with metronidazole and ampicillin sulbactam. Three days following admission, an abdominal CT scan revealed the thrombus extending from the liver abscess into the right atrium. He underwent thrombectomy and received antibiotic therapy. Postoperatively, abdominal ultrasound revealed a significant decrease in the size of the hepatic abscess. The patient was discharged in good condition on the 46th day of hospitalization. When encountering a hepatic abscess, it is important to consider that it may be associated with a thrombus extending from the inferior vena cava into right atrium.

Risk Factor Analyses of Abdominal Aortic Aneurysms Growth in Japanese Patients.

BACKGROUND: This study aimed to retrospectively demonstrate the growth rate (mm/year) of abdominal aortic aneurysm (AAA) diameters (ADs) and to analyze risk factors for AAA expansion. METHODS: We retrospectively investigated the clinical data of 319 patients with AAAs who were followed up as outpatients for >2 years after their initial visit and who underwent computed tomography >4 times. RESULTS: The mean follow-up period was 3.7 ± 1.5 years. The annual average growth rates according to varying ADs were as follows: 1.9 ± 0.8 (AD 30-34 mm), 2.6 ± 1.2 (AD 35-39 mm), 2.8 ± 1.1 (AD 40-44 mm), 3.1 ± 1.3 (AD 45-49 mm), 3.4 ± 1.6 (AD 50-54 mm), and 3.5 ± 1.4 mm (AD ≥55 mm). Factors associated with AAA expansion were smoking (P = 0.017), hypertension (P < 0.001), and ADs (P < 0.001). In the subgroup analysis, data regarding growth rates of ≥3 mm were extracted, and a statistically significant difference between smoking status and ADs of ≥40 mm was observed. CONCLUSIONS: Factors associated with AAA expansion in Japanese patients included smoking, hypertension, and ADs, and a statistically significant difference was observed between smoking status and ADs of ≥40 mm.

Result of Thoracic Endovascular Aortic Repair for Patients with Esophageal Cancer.

BACKGROUND: Bleeding from the thoracic aorta is potentially fatal in patients with advanced esophageal cancer. Thoracic endovascular aortic repair (TEVAR) was recently applied for aortic invasion by esophageal cancer. However, only a few case reports have been published. This study was performed to clarify the effectiveness and safety of TEVAR for patients with advanced esophageal cancer. METHODS: We retrospectively reviewed 18 patients who underwent TEVAR for esophageal cancer. We also performed a literature search and reviewed 21 similar cases. RESULTS: From 2007 to 2016, 10 patients were treated on an emergent basis for aortic hemorrhage (salvage group) and 8 patients underwent urgent prophylactic surgery (prophylactic group). Hemostasis was achieved in all cases. One (10%) patient in the salvage group died of aspiration pneumonia on postoperative day 1, while all patients in the prophylactic group survived for >1 month. The median survival period in the salvage and prophylactic group was 3.25 and 11.10 months, respectively. The longest survivor was still alive 9 years after TEVAR and chemoradiotherapy. No fatal adverse events or negative impacts on subsequent treatment for esophageal cancer occurred. CONCLUSIONS: TEVAR is feasible, safe, and effective in preventing fatal aortic hemorrhage secondary to esophageal cancer invasion, although it is palliative in most cases. Because the outcomes of emergent TEVAR after bleeding tended to be worse in the salvage than in prophylactic group, prophylactic TEVAR may be considered a viable treatment option for patients with aortic invasion by advanced esophageal cancer.

Clinical Outcomes of Total Endovascular Aneurysm Repair for Aortic Aneurysms Involving the Proximal Anastomotic Aneurysm following Initial Open Repair for Infrarenal Abdominal Aortic Aneurysm.

BACKGROUND: To evaluate initial and midterm clinical outcomes of aortic aneurysms involving the proximal anastomotic aneurysm (AAPAAs) following initial open repair for infrarenal abdominal aortic aneurysm. METHODS: Between July 2006 and August 2015, 24 patients underwent elective endovascular repair for the treatment of AAPAAs at our institution. AAPAA classification has been categorized as 3 types. Type I AAPAA is the most extensive, extending from the descending aorta to the prior proximal anastomosis as similar to Crawford type II or III thoracoabdominal aortic aneurysm. Type II AAPAA is limited to the aortic aneurysm below the diaphragm including the abdominal visceral arteries. Finally, similar to pararenal abdominal aortic aneurysm, type III AAPAA involves the renal origins, but does not extend to the celiac and superior mesenteric arteries. Total endovascular aneurysm repair (t-EVAR) consisted of fenestrated EVAR (f-EVAR), multibranched EVAR (t-Branch), and snorkel EVAR (s-EVAR) were performed for patients with high-risk open surgical repair. We retrospectively analyzed 24 cases, which were categorized with 3 types of AAPAA. RESULTS: F-EVAR, t-Branch, and s-EVAR for AAPAAs were performed in 15 patients (62.5%), 5 patients (20.8%), and 4 patients (16.7%), respectively. Type I and type II AAPAA were identified in 13 patients (54.2%) and 7 patients (29.2%), and type III AAPAA was identified in 4 patients (16.7%). Technical success was 95.8%, and clinical success was 79.2% with t-EVAR. Spinal cord ischemia was identified in 2 patients (8.3%) of type I AAPAA, the 30-day mortality rate was 4.2% (n = 1, type I AAPAA). Type II and III endoleaks occurred in 1 (4.2%, type III AAPAA) and 3 patients (12.5%, each case of type I, II, and III AAPAA), respectively. There was no open conversion or aneurysm rupture in the late follow-up period. The estimated overall survival rates of t-EVAR after 1 and 3 years were 95.6% and 76.2%, respectively. Rates of freedom from aneurysm-related death and secondary intervention of t-EVAR at 3 years were 90.1% and 89.7%, respectively. Finally, rates of target vessel patency at 1 and 3 years were 95.3% and 88.8%, respectively. CONCLUSIONS: Our initial to midterm results of t-EVAR for the treatment of AAPAA were generally good with low rates of perioperative mortality and aneurysm-related death. However, more attentions should be paid for the treatment of type I AAPAA with high incidence of major adverse events.

Accumulation of immunoglobulin G against Dermatophagoides farinae tropomyosin in dorsal root ganglia of NC/Nga mice with atopic dermatitis-like symptoms.

Atopic dermatitis (AD), a chronic inflammatory skin disease, manifests as intractable itch, but its underlying mechanisms are poorly understood. This study assessed the relationship between immunoglobulin G (IgG) and dorsal root ganglia (DRG) in NC/Nga mice, a model of AD that manifests AD-like symptoms including itch. Immunohistochemical analysis showed large amounts of IgG in DRG extracts of NC/Nga mice with AD-like dermatitis, with a large fraction of the IgG distributed in satellite glial cells of the DRG. Proteomic analysis showed that this IgG was reactive against tropomyosin of Dermatophagoides farinae. These findings indicate that the accumulation of anti-tropomyosin IgG in DRG of atopic NC/Nga mice may be associated with the pathogenesis of AD-like symptoms, including itch.

Analysis of Risk Factors for Early Type I Endoleaks After Thoracic Endovascular Aneurysm Repair.

PURPOSE: To evaluate risk factors for early (<30 days) type I endoleak following thoracic endovascular aortic repair (TEVAR). METHODS: A retrospective study was conducted of 439 consecutive patients (mean age 74.0±10.0 years; 333 men) who underwent TEVAR at a single center between June 2006 and June 2013. Pathologies included 237 aortic arch aneurysms and 202 descending thoracic aortic aneurysms (dTAA). Maximum TAA diameter was 63.6±13.7 mm. Among the distal aortic arch aneurysms, 124 required coverage of the left subclavian artery (LSA), while the remaining 113 arch aneurysms had debranching (n=40), the chimney technique (n=52), and a branched stent-graft (n=13). Eight patients with dilatation of the ascending aorta underwent arch replacement with elephant trunk prior to TEVAR. Predictive factors for type I endoleak were explored in univariate analysis and examined for each outcome using logistic regression models; results are given as the odds ratio (OR) and 95% confidence interval (CI). RESULTS: Among 439 TEVAR cases, 37 (8.4%) had type I endoleaks on imaging at 1 month; 31 were in the 237 arch cases (13.1%). Endoleak investigation by site indicated a low incidence (3.0%) for dTAAs and markedly low (1.4%) in zone 4. Significantly more endoleaks were observed in zones 0-2 than in zone 4 (p<0.001). On univariate analysis, significant associations were found between endoleak and LSA coverage (OR 5.8, 95% CI 2.4 to 14.4, p<0.001), operative time ≥240 minutes (OR 3.7, 95% CI 1.5 to 6.2, p=0.002), and ≥270 mL of contrast (OR 2.8, 95% CI 1.4 to 5.8, p=0.004). Among the aortic branch reconstruction procedures, the chimney technique was the only maneuver associated with a significant risk of endoleak (OR 5.3, 95% CI 2.3 to 11.2, p<0.001). Arch state was not correlated with endoleaks, but ≥38-mm proximal neck diameter (OR 3.6, 95% CI 1.2 to 10.8, p=0.023), stent-graft diameter ≥40 mm (OR 9.9, 95% CI 1.4 to 30.5, p=0.015), and excessively oversized (≥14%) stent-grafts (OR 3.5, 95% CI 1.2 to 10.3, p=0.020) were; the proximal neck length was not correlated with endoleaks if a proximal neck length >10 mm can be secured. CONCLUSION: Risks for early type I endoleaks after TEVAR for aneurysm were landing zone 0-2, LSA coverage, large proximal neck and stent-graft diameters, excessive oversizing, and the use of the chimney technique.

Concomitant Coil Embolization for Gutter Leak during Endovascular Aortic Repair with the Snorkel Technique.

Snorkel endovascular aortic repair (SEVAR) is reported to be effective for the treatment of pararenal or juxtarenal aortic aneurysms. SEVAR can be performed with an off-the-self device, which is applied for emergency cases. However, there is a concern that SEVAR lead to gutter leak due to insertion of multiple stents. Previously, we performed 2-staged treatment for gutter leak after SEVAR. However, the gutter leaks can also occur late, and it is often difficult to close. Therefore, if a significant gutter leak is identified intraoperatively, performing concomitant gutter coil embolization at the time of the initial surgery may be reasonable.

Comparison between Open and Endovascular Repair for the Treatment of Juxtarenal Abdominal Aortic Aneurysms: A Single-Center Experience with Midterm Results.

BACKGROUND: To evaluate the optimal treatment for juxtarenal abdominal aortic aneurysm (JAAA), we compared the outcomes of open surgical repair (OSR) with endovascular aortic repair (EVAR) using a variety of fenestrated and snorkel EVARs. METHODS: We evaluated overall survival, aneurysm-related death, reintervention, and renal impairment in 152 JAAAs retrospectively, excluding cases of aortic dissection and rupture. Cox models were used to assess survival and assessed postoperative dialysis rates following surgery. RESULTS: OSR and EVAR were performed in 81 and 71 patients, respectively. The mean age was significantly higher in the EVAR group (overall, 74.5 years; OSR, 71 years; and EVAR; 77 years). High preoperative serum creatinine levels, cerebrovascular disease, and chronic obstructive pulmonary disease were more prevalent in the EVAR group. Mean operative time, hospital stay, and perioperative blood loss were significantly greater in the OSR group (P < 0.001 for all). The overall 30-day mortality was 1.9% with no statistical difference between 2 groups. The reintervention rate was significantly higher in the EVAR group (P = 0.01). Overall survival rates at 1, 3, 5, and 7 years were 97.4%, 91.6%, 86.3%, and 82.9%, respectively, with no significant difference between groups. Mortality in EVAR was associated with over 3.0 mg/dL of postoperative creatinine, and postoperative dialysis following OSR was associated with operative time and volume of bleeding. CONCLUSIONS: Acceptable outcomes were observed with OSR and EVAR. However, reintervention was more frequently required following EVAR. OSR appears to be the most appropriate first-line treatment for JAAA in good-risk patients; however, EVAR may represent an alternative option in high-risk patients.

Clinical Outcomes of Spinal Cord Ischemia after Fenestrated and Branched Endovascular Stent Grafting during Total Endovascular Aortic Repair for Thoracoabdominal Aortic Aneurysms.

BACKGROUND: In this single-center study, we assessed the clinical outcomes of fenestrated endovascular aortic repair (f-EVAR) and branched EVAR on morbidity and mortality during total endovascular aortic repair for thoracoabdominal aortic aneurysms (TAAAs). METHODS: Between July 2006 and June 2015, elective f-EVAR and multibranched EVAR (t-Branch) for TAAAs were performed in 99 patients at our institution (Crawford classification types I [7], II [13], III [6], IV [55], and V [18]). We retrospectively analyzed 44 patients, excluding those with Crawford type IV TAAAs, and compared 30 patients treated with f-EVAR and 14 treated with t-Branch. Multivariate analysis was performed to determine the factors associated with perioperative spinal cord ischemia (SCI). RESULTS: Technical success was 96.7% with f-EVAR and 100% with t-Branch, and the 30-day mortality rate was 3.3% with f-EVAR and 7.1% with t-Branch (P = 0.646). The incidences of perioperative SCI were higher with t-Branch (n = 5, 35.7%) than those with f-EVAR (n = 2, 6.7%; P = 0.04). Endoleaks were more prevalent with f-EVAR (n = 9, 30.0%) than with t-Branch (n = 1, 7.1%; P = 0.046). Rates of freedom from aneurysm-related death after 1 year for f-EVAR and t-Branch were 96.7 and 92.9%, respectively, and those after 3 years were 88.8 and 92.9% (P = 0.982), respectively. The risk of SCI remarkably increased in the presence of risk factors such as procedure (t-Branch), maximum short axis of ≥65 mm, coverage length of ≥360 mm, internal iliac artery occlusion, and ≥ 5 sacrificed intercostal arteries. CONCLUSIONS: Our initial to mid-term results of f-EVAR and t-Branch were good with low rates of perioperative mortality and high rates of freedom from aneurysm-related death. SCI incidence with t-Branch was significantly high; it is important to develop additional SCI prevention methods for patients with high-risk factors.

Utility of the Ginza forceps for superficial phlebectomy during endovenous laser ablation of the great saphenous vein.

PURPOSE: To evaluate the efficiency of using the Ginza forceps (DVx, Tokyo, Japan), which have a long shaft and strong grip, for superficial phlebectomy with the stab avulsion technique, during simultaneous endovenous laser ablation (EVLA) of the great saphenous vein (GSV). METHODS: The subjects were patients treated with EVLA performed by a single operator at one institution. All patients had a GSV diameter of 4-10 mm and an EVLA length of the GSV of >20 cm. We compared 59 limbs treated only with the Varady hook (Group A) with 46 limbs treated with the Ginza forceps (Group G). RESULTS: The mean operative times for Groups A and G were 55.4 ± 17.1 vs. 48.5 ± 13.5 min, respectively (P = 0.002), and the number of stab incisions was 5.9 ± 2.9 (1-13) vs. 3.5 ± 2.3 (1-11), respectively (P < 0.001). The rates of nerve injury and thrombophlebitis were 1.7 vs. 0 and 3.4 vs. 0%, respectively. CONCLUSIONS: Performing superficial phlebectomy with the Ginza forceps reduced the operation time and the number of stab wounds. These initial results suggest that using the Ginza forceps for the procedure is safe and efficient.

Current surgical management of abdominal aortic aneurysm with concomitant malignancy in the endovascular era.

PURPOSE: The management of abdominal aortic aneurysm (AAA) with concomitant malignancy is controversial in terms of which treatment should come first. The aim of this study was to evaluate the outcomes of endovascular aortic repair (EVAR) as the initial treatment prior to the treatment of malignancy for patients with AAA and concomitant malignancy. METHODS: EVAR for AAA was performed in 1,175 cases between April 2007 and April 2014, of which 63 patients (5.4 %) who had AAAs and malignancy were identified. The clinical details and outcomes for patients with AAA and malignancy were evaluated. RESULTS: The mean age of patients with AAA and malignancy was 76.6 years. Thirty-three patients underwent EVAR before surgery for their malignancies, and 30 patients received chemoradiotherapy following EVAR. No significant differences in the length of stay (LOS), 30-day mortality, and morbidities were observed in all groups. However, the overall survival rate of the patients who had AAA and malignancy was lower than those who had only AAA (P < 0.0001). The mean intervals from EVAR to surgery and chemoradiotherapy for malignancy in our institution were 13.4 days (overall 38.1 days) and 5.8 days (overall 18.2 days), respectively. CONCLUSION: EVAR for patients with AAA and concomitant malignancy may be acceptable in terms of a short LOS and resulting in treatment for malignancy without delay.

25-Gb/s broadband silicon modulator with 0.31-V·cm VπL based on forward-biased PIN diodes embedded with passive equalizer.

We investigated the broadband operations of a silicon Mach-Zehnder modulator (MZM) based on a forward-biased-PIN diode. The phase shifter was integrated with a passive-circuit equalizer to compensate for the narrowband characteristics of the diodes, which consists of a simple resistance of doped silicon and a parallel-plate metal capacitance. The device structure was simple and fabricated using standard CMOS processes. The measured results for a 50-Ω driver indicated there was a small VπL of 0.31 V·cm and a flat frequency response for a 3-dB bandwidth (f(3dB)) of 17 GHz, which agree well with the designed values. A 25-Gb/s large-signal operation was obtained using binary signals without pre-emphasis. The modulator showed a linear modulation property to the applied voltage, due to the metal capacitance of the equalizer.

Sumoylated α-skeletal muscle actin in the skeletal muscle of adult rats.

Skeletal muscles are composed of two major muscle fiber types: slow-twitch oxidative fibers and fast-twitch glycolytic fibers. The proteins in these muscle fibers are known to differ in their expression, relative abundance, and post-translational modifications. In this study, we report a previously unreported post-translational modification of α-skeletal muscle actin in the skeletal muscles of adult male F344 rats in vivo. Using two-dimensional electrophoresis (2D-PAGE), we first examined the differences in the protein expression profiles between the soleus and plantaris muscles. We found higher intensity protein spots at approximately 60 kDa and pH 9 on 2D-PAGE for the soleus muscle compared with the plantaris muscle. These spots were identified as α-skeletal muscle actin by liquid chromatography-nanoelectrospray ionization-tandem mass spectrometry and western blot analyses. In addition, we found that the 60 kDa α-skeletal muscle actin is modified by small ubiquitin-like modifier (SUMO) 1, using 2D-PAGE and western blot analyses. Furthermore, we found that α-skeletal muscle actin with larger molecular weight was localized in the nuclear and cytosol of the skeletal muscle, but not in the myofibrillar fraction by the combination of subcellular fractionation and western blot analyses. These results suggest that α-skeletal muscle actin is modified by SUMO-1 in the skeletal muscles, localized in nuclear and cytosolic fractions, and the extent of this modification is much higher in the slow muscles than in the fast muscles. This is the first study to show the presence of SUMOylated actin in animal tissues.