Midterm outcomes of side branch embolization and endovascular abdominal aortic aneurysm repair.

OBJECTIVE: To analyze the effects of total side branch embolization at endovascular aneurysm repair (EVAR) for abdominal aortic aneurysms on the incidences of persistent type 2 endoleak (pT2EL), changes in sac diameter, and reintervention. METHODS: Between 2013 and 2021, all patients who underwent primary EVAR with a few exceptions were included. Side branch embolization was considered during EVAR for inferior mesenteric artery (IMA) or IMA plus lumbar artery (LA) when feasible for contrast agent use. Outcomes measured were pT2EL, sac diameters, reintervention, ruptures, and aneurysm-related mortality. Radiation exposure and safety outcomes were also reported. RESULTS: Among 732 patients who underwent EVAR, 616 (84.2%) were included. Of the 616 patients, 223 (36.2%) did not undergo side branch embolization (NO-E), whereas 228 (37.0%) underwent IMA only (IMA-E) and 165 (26.8%) underwent IMA+LA including median sacral artery (IMA+LA-E). The technical success rate of IMA and LA embolization was 97.0% and 74.7%, respectively. Crude incidences of pT2EL were significantly different from 6 months through 3 years (NO-E, 27.8%; IMA-E, 31.7%; IMA+LA-E, 9.4% at 3 years; P = .007). In the multivariate analysis adjusted for background differences, the incidences of pT2EL were significantly higher in the NO-E (odds ratio [OR], 3.21; 95% confidence intervals [CIs], 1.08-9.57; P = .004) and IMA-E (OR, 4.86; 95% CIs, 1.68-14.11; P = .004) compared with the IMA+LA-E group. Similarly, any reintervention until 3 years was significantly frequent in the NO-E (OR, 5.26; 95% CIs, 1.76-15.70; P = .003) and IMA-E group (OR, 4.19; 95% CIs, 1.38-12.67; P = .01). Surgical conversion and secondary rupture were seen only in 1 patient without any aneurysm-related mortality. Percent sac shrinkage from the baseline was significantly promoted in the IMA+LA group (NO-E, 12.1% ± 16.6%; IMA-E, 11.4% ± 16.7%; IMA+LA-E, 18.0% ± 18.8%; P = .047). Fluoroscopy time was significantly longer in the IMA+LA-E group (NO-E, 60.2 ± 47.4 minutes; IMA-E, 59.3 ± 39.5 minutes; IMA+LA-E, 75.5 ± 42.8 minutes; P < .0001), and so do the dose-area product (NO-E, 424.6 ± 333.4 Gy cm2; IMA-E, 477.7 ± 342.4 Gy cm2; IMA+LA-E, 631.8 ± 449.1 Gy cm2; P < .0001). No embolization-related complications or radiation-related adverse events were recorded. CONCLUSIONS: Pre-emptive embolization of IMA, LAs, and median sacral artery at the time of EVAR reduced the incidences of pT2EL and any reintervention and promoted sac shrinkage during the follow-up period of 3 years.

Outcomes of Clampless Real Chimney Technique with Dacron Graft and Sleeve Banding of the Ascending Aorta for Total Debranching Endovascular Arch Repair.

BACKGROUND: Hybrid aortic arch repair with debranching of the supra-aortic vessels carries a high risk of cerebral infarction and fatal complications associated with side clamping of the ascending aorta. A previous study had reported the "real chimney" technique, a novel method for clamp-free total debranching thoracic endovascular aortic repair with the ascending aortic sleeve banding with dacron. In this study, we aim to build upon this foundation by presenting our experience with the early and midterm outcomes of this technique. METHODS: We retrospectively reviewed the medical records of 61 consecutive older adult patients with aortic arch pathologies and a high risk of open repair who underwent total debranching thoracic endovascular aortic repair using the real chimney technique at our institution between January 2014 and June 2022. This technique was used to anastomose the ascending aorta with the main trunk of the triple-branched prosthetic graft. RESULTS: The mean patient age was 75.1 years, and 54% of patients were transferred from medical facilities with cardiothoracic surgery departments. The comorbidities included chronic obstructive pulmonary disease (49.2%), chronic kidney disease (63.9%), coronary artery disease (27.9%), and history of stroke (31.1%). No 30-day mortality was observed. Complications included postoperative renal failure requiring permanent hemodialysis (4; 6.6%), stroke (modified Rankin scale score: ≥2 in 5; 8.2%), permanent paraplegia (1; 1.6%), and permanent paraparesis (4; 6.6%). The median follow-up period was 40.5±28.5 months. The postoperative survival rates at 5 years were 66.8%. No patients experienced complications associated with the aorta or anastomosis site; only 1 patient required an additional procedure for stenosis of the anastomosis site (midterm). An aneurysmal diameter reduction of ≥3 mm was observed in 37 cases (60.7%), and the mean aneurysmal diameter reduction was 5.3 mm. CONCLUSIONS: The postoperative outcome of total debranching thoracic endovascular aortic arch repair is not only acceptable but also promising, particularly in patients at high risk of open repair. CLINICAL IMPACT: Our novel real chimney technique for total debranching thoracic endovascular aortic repair of aortic arch pathologies in patients who were at a high-risk for open repair resulted in no 30-day mortality and no complications related to the aorta or the real chimney anastomosis site.The real chimney technique is effective for managing aortic arch pathologies and enables less invasive total debranching thoracic endovascular aortic arch repair without the need for extracorporeal circulation and clamping of the ascending aorta.

Proresolving Lipid Mediators Resolvin D1 and Protectin D1 Isomer Attenuate Neointimal Hyperplasia in the Rat Carotid Artery Balloon Injury Model.

BACKGROUND: Specialized proresolving mediators from ω-3 polyunsaturated fatty acid may control resolution of inflammation. We evaluated the influence of two specialized proresolving mediators, resolvin D1 (RvD1) and protectin D1 isomer (PD1 iso) on neointimal hyperplasia after balloon injury. MATERIALS AND METHODS: Sprague Dawley male rats at 12-14 wk of age were injured as a model of balloon angioplasty. Then, 1 µg/rat of RvD1 or PD1 iso was administered intravenously via the tail vein immediately and 2 d after angioplasty. The proliferation of injured artery and the infiltration of leukocytes, monocytes, and macrophages at 3 d after injury were evaluated by immunostaining. The activity of the inflammatory transcription factor nuclear factor kappa-light-chain-enhancer of activated B cells (NFκB) in the injured artery at 3 d after injury was evaluated using an enzyme-linked immuno sorbent assay kit. The proliferation of the neointima was evaluated by calculating the ratio of the neointimal and medial areas using specimens at 14 d after injury. RESULTS: RvD1 and PD1 iso attenuated proliferation of medial cells (P < 0.05) and infiltration of leukocytes (P < 0.05) and monocytes/macrophages (P < 0.01). Although both RvD1 and PD1 iso mitigated NFκB activity (P < 0.01), RvD1 attenuated this activity more strongly (P < 0.01). RvD1 decreased neointimal hyperplasia by 37.3% (P < 0.01), whereas PD1 iso decreased neointimal hyperplasia by 31.8% (P < 0.05) (RvD1 versus PD1 iso: P = 0.51). CONCLUSIONS: RvD1 and PD1 iso reduced the activity of inflammatory transcription factor NFκB within the injured artery and attenuated inflammatory cell infiltration, leading to a reduction in early inflammation and subsequent neointimal hyperplasia.

Increase in skin perfusion pressure predicts amputation-free survival after lower extremity bypass surgery for critical limb ischemia.

The objective of this study was to determine how postoperative skin perfusion pressure (SPP) as a measure of blood flow after revascularization affects limb prognosis in patients with critical limb ischemia (CLI). We retrospectively reviewed 223 consecutive bypass surgery cases performed in 192 patients with CLI during a 10-year period. SPP was measured 1-2 weeks before and after the procedure. An SPP of 40 mmHg was set as the cut-off value for revascularization. Patients were grouped according to their postoperative SPPs, and amputation-free survival (AFS) was analyzed. An SPP of ≥ 40 mmHg was recovered in 75% of the patients, but no significant difference was found between this group and the group that did not reach 40 mmHg. On the other hand, the values increased by ≥ 20 mmHg from the preoperative values in 70% of the patients. This group had a significantly better AFS than the group that did not increase by 20 mmHg. Logistic regression analysis revealed that (1) a preoperative SPP of < 20 mmHg and (2) a high serum albumin level (> 3.0 g/dL) were significant factors in increasing SPP by 20 mmHg. These results showed that an increase in SPP of ≥ 20 mmHg after bypass surgery was associated with better limb prognosis.

The relationship between medical expenses and the severity of peripheral arterial disease in Japan.

The main objective is to examine whether the severity of peripheral arterial disease (PAD) affects the expenses and hospital stay of the patients who undergo bypass surgery below the inguinal ligament for PAD. Eighty consecutive patients who underwent infrainguinal bypass surgery for PAD between January 2012 and December 2014 were included in the study. Patients were divided into groups according to their critical limb ischemia (CLI) symptoms and the Wound, Ischemia, and Foot Infection (WIfI) classification. As endpoints, we assessed the duration of postoperative hospital stay and expenses during hospitalization. CLI was a significant factor for longer hospital stay and increased medical expenses (p = 0.009 and p = 0.001). In the patients with CLI, significant factors for longer hospital stay and increased medical expenses were (1) history of distal bypass (p = 0.33 and p = 0.003, respectively) and stage 4 local lower limb status in WIfI classification (p = 0.0007 and p = 0.053). PAD severity was associated with prolonged postoperative hospital stay and increased medical expenses. The presence or absence of CLI and its severity according to the WIfI classification correlated with medical expenses and hospital stay duration between the milder and severe groups.

Outcomes in Patients with Critical Limb Ischemia due to Arteriosclerosis Obliterans Who Did Not Undergo Arterial Reconstruction.

The prevalence of arteriosclerosis obliterans (ASO) and critical limb ischemia (CLI) is currently increasing, and arterial reconstruction is often attempted to salvage the limb. Some patients cannot undergo attempted revascularization because of contraindications, and they only receive conservative treatment. In this study, we investigate the comorbidities and survival rates of patients with CLI who receive conservative treatment. Thirty-five patients with CLI due to ASO, who had not undergone revascularization surgery (C group), were enrolled. As controls, 136 patients with CLI due to ASO who did undergo revascularization (R group), mainly via bypass surgery, were enrolled. Coronary artery disease, heart failure, and respiratory dysfunction were factors indicating conservative treatment. Limb salvage rates and survival rates were not significantly different between the two groups. Patients who had survived for less than two years after surgery had a higher prevalence of chronic heart failure, cardiovascular disease, and end-stage renal disease compared to patients who had survived for more than two years. The use of statins, dual antiplatelets, aspirin, or warfarin did not influence whether a patient survived for longer than two years. 77% of patients survived for more than two years after receiving only conservative therapies. Surgical revascularization did not improve the prognosis of patients with CLI as compared with the conservative therapy. Clinicians might start with conservative treatment while considering other treatment options for patients with CLI.

Hemodynamic benefits of celiac artery release for ruptured right gastric artery aneurysm associated with median arcuate ligament syndrome: a case report.

BACKGROUND: It has been reported that median arcuate ligament syndrome is closely associated with gastric or pancreaticoduodenal artery aneurysms. Hemodynamic state plays an important role in the formation of the aneurysms. These aneurysms are treated with open resection or endovascular exclusion. However, whether revascularization of the celiac artery can prevent the aneurysm formation is unknown. This report indicated a possibility that prophylactic revascularization for celiac artery stenosis resulted in decreased shear stress on the collaterals, which may otherwise be susceptible to new aneurysms. CASE PRESENTATION: This report describes a 51-year-old man who presented with epigastric pain at our hospital. According to contrast enhanced computed tomography (CT), he was diagnosed with a ruptured right gastric artery aneurysm and celiac artery stenosis caused by the median arcuate ligament (MAL). He had a vascular anomaly of the common hepatic artery arising from the superior mesenteric artery (SMA). His vital signs were stable. We informed him of the situation and he chose open surgery rather than endovascular treatment. Following, we resected the aneurysm and transected the MAL. Intraoperative angiography after transection of the MAL showed the antegrade blood flow to the splenic artery instead of the retrograde flow via the prominent collaterals. Follow-up CT confirmed narrowed collateral vessels between the SMA and the celiac artery without de-novo aneurysms. CONCLUSION: While the necessity of celiac artery release could be questioned, the present case supports the hemodynamic benefits of MAL transection in terms of de-novo aneurysm prevention.

The impact and optimal indication of non-curative gastric resection for stage IV advanced gastric cancer diagnosed during surgery: 10 years of experience at a single institute.

BACKGROUND: The survival benefit of non-curative gastric resection for patients with stage IV gastric cancer is still unclear. METHODS: Of the patients who underwent open abdominal surgery that was preoperatively intended to be a radical excision procedure for gastric cancer, 72 were diagnosed with stage IV during the operation. At this institution, non-curative gastric resection is performed whenever possible. RESULTS: Non-curative gastric resection was performed in 44 of the 72 patients. According to the survival analysis, the median survival times in the gastric resection and no-resection groups were 1.9 and 0.9 years, respectively (log-rank test, p = 0.014). Based on the multivariate analysis, we selected gastric resection (hazard ratio [HR] = 0.309; 95% confidence interval [CI] = 0.152-0.615) and postoperative chemotherapy (HR = 0.136; 95% CI = 0.056-0.353) as independent factors associated with overall survival (OS). In the subgroup analyses of OS, the factors that were associated with gastric resection having no survival benefit were the existence of distant lymph node or liver metastasis (p = 0.527) and the lack of postoperative chemotherapy (p = 0.589). CONCLUSIONS: For patients who have distant lymph node or liver metastasis and those who will not undergo postoperative chemotherapy, non-curative gastric resection has no survival benefit.

Family history of aortic aneurysm is an independent risk factor for more rapid growth of small abdominal aortic aneurysms in Japan.

OBJECTIVE: We aimed to investigate risk factors associated with more rapid growth of abdominal aortic aneurysms (AAA) <50 mm (small AAAs) in Japan. METHODS: We retrospectively investigated the clinical data of 374 patients with small AAAs (maximum diameter, ≤50 mm) who were referred to The University of Tokyo Hospital, Tokyo Medical University Hospital, or Saitama Medical Center, between 1995 and 2008. RESULTS: A total of 374 patients (321 men and 53 women) were followed up for a median of 66 months. The median diameter on initial examination was 40 mm, and the median growth rate of the AAAs was 2.1 mm/y. The growth rate of AAAs with an initial diameter ≥45 mm was significantly greater than those with an initial diameter <45 mm (3.3 mm/y vs 2.0 mm/y, respectively; P = .007). The growth rate of AAAs was significantly greater in patients with hypertension than in those without (2.3 mm/y vs 1.7 mm/y, respectively; P = .006) and in patients with a family history of aortic aneurysm than in those without (4.2 mm/y vs 2.0 mm/y, respectively; P = .009). Logistic regression analysis revealed that a large initial diameter and family history of aortic aneurysm were independent predictors of accelerated growth rate of small AAAs in Japan. CONCLUSIONS: In the present study, a large initial diameter and family history of aortic aneurysm were independent risk factors for more rapid growth of small AAAs. Although few studies have reported similar findings thus far, family history of aortic aneurysm should be carefully considered during follow-up of patients with small AAAs.

False reduction of an inguinal hernia treated by Kugel patch repair via an anterior approach.

BACKGROUND: Reduction en masse of inguinal hernia is a rare condition following manual reduction of an unrecognized incarcerated inguinal hernia. The preoperative diagnosis and surgical treatment via an inguinal approach has been considered difficult. CASE PRESENTATION: A 59-year-old man with lower abdominal pain was presented to our hospital. He was diagnosed reduction en masse of an inguinal hernia based on his CT findings which showed the presence a pre-peritoneal hernia sac containing the small bowel. An emergency operation via an anterior approach was performed and we found a hernial sac containing an incarcerated small bowel at the cranial and internal sides of the internal inguinal ring. Opening of the hernial sac revealed necrosis of the incarcerated small bowel and bowel resection was performed. Kugel patch was inserted into the pre-peritoneal space and the patient made an uneventful recovery. CONCLUSION: When it is accurately diagnosed, reduction en masse of an inguinal hernia can be treated with direct Kugel repair via an anterior approach.

Revascularization surgery for penile calciphylaxis.

Calciphylaxis, a systemic disorder seen in 1%-4% of patients with end-stage renal disease, is a cause of penile ischemic gangrene. We present a case of successful revascularization surgery for penile calciphylaxis. An arterial bypass to the deep dorsal penile vein relieved the rest pain and stopped expansion of the gangrenous lesion.

Modified adaption of iliac branch endografts in rare congenital anomaly of proximal origin of bilateral internal iliac arteries.

We report a case of 55 mm abdominal aortic aneurysm coinciding with a rare congenital anomaly of proximal origin of bilateral internal iliac arteries (IIAs). Because renal to iliac bifurcation lengths were bilaterally short (129 mm and 125 mm), a trunk-ipsilateral leg and an iliac leg were deployed before iliac branch component insertion into the iliac leg. With help of a pull-through wire, internal iliac component was delivered without migration of the main body. The left IIA was embolized, but the right IIA was successfully preserved with commercially available iliac branch endoprosthesis only from femoral approaches, and the patient fully recovered without any complication.

Clampless In-Situ Immobilized Branching (CLIMB) to Reconstruct the Internal Iliac Artery.

BACKGROUND: Surgical reconstruction of the internal iliac artery (IIA) or its branches is sometimes demanding because of difficulty in distal clamping and suturing in the narrow pelvic space. Here we present a hybrid technique of ClampLess In-situ imMobilized Branching (CLIMB) to reconstruct IIA. METHODS: in the CLIMB technique, an 8 mm artificial graft is sutured onto the surface of the common iliac artery (CIA) without clamping. Following puncture of the CIA wall, stent grafts are bridged from IIA to the graft. Finally, the graft is sutured to the ipsilateral external iliac artery (EIA). Concomitant endovascular aneurysm repair or IIA branch embolization can also be performed. We applied this technique to the patients unsuited for other IIA reconstruction. RESULTS: eleven patients underwent the current technique. All but one patient underwent contralateral IIA interruption. Seven patients had a history of aorto-iliac repair before the index surgery. Iliac extender, internal iliac component, Viabahn VBX or Fluency covered stent were used for bridging the graft. Simultaneous IIA branch embolization was performed in 2 patients. Distal landing zones were IIA in 7 grafts, superior gluteal artery in 4 grafts and inferior gluteal artery (IGA) in 1 graft. Technical success was achieved in all cases. No patient complained of buttock claudication or other ischemic symptoms on the treatment side. During a mean follow-up period of 38 months, 11 out of 12 grafts were patent without any related endoleak. One IGA graft occluded at 56 months after surgery. CONCLUSIONS: the CLIMB technique is a viable alternative to preserve IIA with an acceptable mid-term durability.

Aortoduodenal Fistula After Endovascular Abdominal Aortic Aneurysm Repair.

Aortoduodenal fistula after endovascular treatment of abdominal aortic aneurysm is a very rare but life-threatening complication. Herein, we describe 4 cases of aortoduodenal fistula diagnosed at 15 to 78 months after the index aortic intervention, all successfully treated by surgery. All patients underwent primary repair of the duodenal wall, creation of tube duodenostomy, stent graft removal, and in situ reconstruction using a rifampicin-soaked prosthesis. Patients received prolonged antibiotic treatment for at least 2 months postoperatively, and all were free of recurrent infection at follow-up. Prompt and appropriate surgical intervention is required to effectively manage this condition.

Wound healing after revascularization for critical limb ischemia.

BACKGROUND: Wound healing is one of the most important endpoints after revascularization for critical limb ischemia. The purpose of this study was to evaluate the risk factors for wound healing after revascularization for critical limb ischemia (CLI). METHODS: A retrospective study was conducted at a single university hospital, and data were collected retrospectively between January 2005 and September 2016. All admitted patients who were diagnosed with CLI and underwent revascularization for the first time were enrolled. The risk factors for wound healing were analyzed. RESULTS: The risk factors for wound healing were analyzed in 153 patients. The cumulative rate of wound healing at 12 months after revascularization was 79%. The independent risk factors for wound healing were non-ambulatory status (hazard ratio, 1.95; 95% CI [1.22-3.21], P=0.004), and wound, ischemia and foot infection (WIfI) stage 4 (hazard ratio, 1.89; 95% CI [1.25-2.91], P=0.002). CONCLUSIONS: In our study, non-ambulatory status and WIfI stage 4 were independent risk factors for wound healing after revascularization. WIfI criteria well reflected the prognosis of patients with CLI in wound healing, as well as limb salvage.

Increased Incidence of Cancer in Japanese Patients with Critical Limb Ischemia.

Objective: This multicenter observational study was conducted in order to investigate the incidence of cancer in patients with critical limb ischemia. Materials and Methods: We prospectively investigated the incidence of cancer in 68 patients with critical limb ischemia over a two-year period. Patients underwent an intensive examination at enrollment, which included tumor marker levels and chest and abdominal computed tomography, as well as one- and two-year follow-up examinations. We compared the observed incidence of cancer with the expected incidence calculated from national cancer rates by the standardized incidence ratio (SIR). Results: The majority (83.6%) of the patients were men, and 92.5% of the patients had a peripheral arterial disease that was classified as Fontaine stage III or IV. During enrollment, newly diagnosed cancers were detected in seven patients. Four additional cancers were detected during the follow-up period. All of the detected cancers were asymptomatic. We observed an increased risk of cancer (SIR, 4.04; 95% confidence interval, 1.31-9.42) in patients with critical limb ischemia. Conclusion: This study suggests that critical limb ischemia is associated with an increased risk of cancer. Our findings should be taken into serious consideration by future investigators considering the use of therapeutic angiogenesis.

Results of surgical interventions for critical limb ischemia due to vasculitis or collagen-tissue related disease.

BACKGROUND: In this study, we aimed to clarify both systemic and local prognosis after surgical interventions for critical limb ischemia (CLI) due to vasculitis or connective tissue related disease, and to search for any risk factors that can worsen the prognosis. METHODS: One hundred and ninety three patients that underwent surgical interventions for CLI between 2005 and 2014 were followed up for a median of 2.7 years. The patients were grouped into a group with vasculitis or connective tissue related disease (V) or with atherosclerosis (control: C). Two groups were retrospectively reviewed and compared. RESULTS: Thirty-one patients were grouped into the V group. At three years after intervention, V group showed significantly higher survival rate compared to C group (89% vs. 73%). On the other hand, limb survival rate after bypass surgery was significantly lower (74% vs. 94%), due to lower patency of the bypassed graft. Within V group, preoperative skin perfusion pressure of lower than 20 mmHg showed significantly worse prognosis of the limb. (HR 1.8; P=0.01) Regarding specific diseases, systemic scleroderma, rheumatoid arthritis and systemic lupus erythematosus tended to show worse prognosis. CONCLUSIONS: Patients with CLI due to vasculitis or connective tissue related disease have a longer life expectancy with lower limb salvage rate that can lead to low quality of the remaining life.

Stenotic lesion level did not affect outcomes of carotid endarterectomy.

Background Carotid endarterectomy is the established treatment for carotid artery stenosis, and remains the primary surgical option due to its superior outcomes compared to carotid arterial stenting. However, Japanese patients are known to have unfavorable anatomical conditions for carotid endarterectomy, with a relatively higher level of the carotid artery bifurcation than in the Western population. We investigated the outcomes of carotid endarterectomy in our institute and evaluated the procedural quality by comparing patients based on higher or lower lesion levels. Methods The clinical data of 65 patients who underwent carotid endarterectomy were collected retrospectively. The outcomes reviewed included stroke-free survival and stroke-free rate. The patients were divided into a higher group ( n = 25) and a lower group ( n = 40), based on lesion location in respect of the 2nd cervical vertebral level. Results There was no perioperative death and only one case of stroke in the higher group within 30 days after carotid endarterectomy. At 5 years after carotid endarterectomy, the stroke-free survival rates were 83.4% in the higher group and 87.8% in the lower group, while the stroke-free rates were 96.0% and 94.0%, respectively; there were no significant differences between groups. Conclusions Stenotic lesion level did not affect the outcome or procedural quality of carotid endarterectomy.