Two-Stage Endovascular Aneurysm Repair with Preemptive Embolization: A Retrospective Study.

BACKGROUND: Type II endoleak is the most common complication of endovascular aneurysm repair. Retrograde perfusion from the aneurysmal sac side branch to the aneurysmal sac, including the inferior mesenteric artery and lumbar arteries, is associated with adverse events after endovascular aneurysm repair, such as aneurysm sac enlargement, reintervention, rupture, and abdominal aortic aneurysm-related death. Preemptive embolization of the aneurysmal sac side branch before endovascular aneurysm repair is an effective and safe procedure for preventing type II endoleak and reducing the size of the aneurysmal sac. Since 2019, we have been conducting preemptive embolization of the inferior mesenteric artery and lumbar arteries. Thus, we intended to work on a two-stage endovascular aneurysm repair in which embolization and endovascular aneurysm repair are performed on separate days, owing to concerns about prolonged operative time and increased contrast media use and radiation exposure from performing endovascular aneurysm repair simultaneously. This study aimed to evaluate the effects of a two-stage endovascular aneurysm repair. METHODS: This retrospective study included 114 cases of endovascular aneurysm repair (95 men and 19 women) for AAA performed at our hospital between January 2019 and December 2022. Inferior mesenteric artery and lumbar artery embolization were performed simultaneously with endovascular aneurysm repair (simultaneous group) in 49 cases, and two-stage embolization was performed (two-stage group) in 30 cases. The primary endpoints included the occurrence of T2EL during follow-up and the embolization rate of the IMA or LAs. RESULTS: Type II endoleak did not occur in the two-stage group (follow-up period: 35 ± 6.2 months), whereas it was observed in 8.2% of patients more than 6 months after EVAR in the simultaneous group (follow-up period: 28 ± 5.5 months). While the total operative time was 340 ± 111.2 min in the simultaneous group, the durations for embolization and endovascular aneurysm repair in the two-stage group were 169 ± 35.5 min and 135.0 ± 26.4 min (total time 304 ± 31.2 min, P = 0.21), respectively, indicating a reduction in the total time required for the 2 techniques. The total amounts of contrast media used in the simultaneous and two-stage groups were 200.0 ± 179.2 mL and 182.0 ± 51.2 mL (P = 0.42), respectively, and the corresponding total radiation doses were 2502.4 ± 690.5 mGy and 2114.6 ± 351.2 mGy (P = 0.28), respectively, showing a decrease in both in the two-stage group. The lumbar artery embolization rates were 74.3% and 87.9% (P < 0.01) in the simultaneous and two-stage groups, respectively, indicating a significant difference. CONCLUSIONS: Two-stage endovascular aneurysm repair with preemptive embolization of the inferior mesenteric artery and lumbar arteries may be an effective strategy for reducing type II endoleak occurrence, overall operative time, contrast use, and overall radiation exposure.

Development of a new surgical sheet containing both silk fibroin and thermoplastic polyurethane for cardiovascular surgery.

PURPOSE: The surgical sheets that are currently used for congenital cardiovascular surgery have several drawbacks, including material deterioration, calcification, and pseudo-intimal proliferation resulting in hemodynamic disturbance. The aim of this study was to evaluate a newly developed sheet made from a combination of silk fibroin (SF) and a synthetic polymer, thermoplastic polyurethane (TPU), for surgical use. METHODS: The hybrid SF/TPU sheet was a non-woven fabric with nanofibers that was made using the electrospinning method. The mechanical properties of the SF/TPU sheet were characterized. To determine its biocompatibility, part of the wall of the canine descending aorta was replaced with a SF/TPU sheet as a patch. The patches were removed after 3 months and a histological examination was performed. RESULTS: The flexibility, water permeability, and suture retention strength of the SF/TPU sheet were excellent and equivalent to those of existing sheets. The SF/TPU sheet had excellent handling properties and fit well into the vascular wall without needle hole bleeding. The histological examination revealed that the intimal tissue was restored well over the intraluminal surface of the explanted SF/TPU sheet, the absence of calcium deposition, and minimal inflammatory reaction, without signs of degradation. CONCLUSION: The SF/TPU sheet had excellent mechanical properties and tissue biocompatibility. These favorable features and possible biodegradability of the SF portion warrant a long-term follow-up study.

[Three Surgical Cases of Quadricuspid Aortic Valve].

Quadricuspid aortic valve is a rare congenital disease. We experienced 3 surgical cases of quadricuspid aortic valve. Patient 1 was a 72-year-old man who was noted to have a quadricuspid aortic valve associated with aortic regurgitation and an ascending aortic aneurysm(51 mm in diameter). He underwent replacement of the aortic valve and the ascending aorta. Patient 2 was a 71-year-old man with severe aortic stenosis, regurgitation, and coronary triple vessel disease. He underwent aortic valve replacement and coronary artery bypass grafting. Preoperative echocardiography revealed no abnormalities in the number of valve leaflets, but quadricuspid aortic valve was identified during surgery. Patient 3 was a 79-year-old man with severe aortic regurgitation, who underwent aortic valve replacement. In all patients, the 4 valve cusps were approximately of the same size. Multi-detector computed tomography is useful for evaluation of valve morphology. Indication of prophylactic ascending aorta replacement in patients with aortic dilatation requires further study.

Surgical treatment of a mycotic pseudoaneurysm of the transverse arch using a rifampicin-impregnated dacron patch in an infant.

We describe a case of successful treatment of mycotic pseudoaneurysm of the transverse aortic arch in a male infant. The aneurysm was resected and the defect was repaired using a patch made from a rifampicin-impregnated Dacron graft.

Trends in mortality rates and correlations between intracranial injuries and external causes: A Japanese population study.

The age-standardized incidence of head trauma in 2016 was 369 per 100,000 people worldwide. The Western Pacific region, including Japan, had the highest incidence. This study aimed to extract ICD-10 code data for intracranial injury (S06) and external causes of morbidity and mortality (V01-Y89), analyze their characteristics and interrelationships, and contribute to these diseases' prevention, treatment, and prognosis. The number of deaths according to injury type and external cause type of intracranial injury published by the Japanese government was statistically analyzed using JoinPoint, and univariate distribution and multivariate correlation were conducted using JMP Software. From 1999-2021, there was a downward trend in the number of deaths because of intracranial injuries: mortality from intracranial injuries was higher among those aged ≥65 years. Conversely, mortality from intracranial injuries was lower among those aged ≤14 years. Among deaths from intracranial injury, mortality from diffuse brain injury and traumatic subdural hemorrhage was more common. Among deaths from external causes of intracranial injury, mortality from falls, transport accidents, and other unforeseen accidents was more common. Mortality because of intracranial injuries increased significantly during the 2011 Great East Japan Earthquake. For some age groups and sexes, there were significant inverse correlations of mortality with traumatic subdural hemorrhage and traumatic subarachnoid hemorrhage for transport accidents, intentional self-harm and assault, and diffuse brain injury and focal brain injury for falls. We believe that the data presented in this study will be useful for preventing and treating intracranial injuries and for developing administrative measures to reduce intracranial injuries.

The left ventricular "lining" technique for repair of ischemic ventricular septal rupture.

We describe a technique to repair ischemic ventricular septal rupture via a left ventriculotomy. It employs a large endoventricular patch as a "lining" over the locally patched septal defect and the free wall defect which is going to be roofed with an external patch. Both defects are then closed in double layers, holding a single continuous patch. The technique enhances the advantage of the left ventriculotomy in the repair and minimizes ventriculotomy-related morbidity.

Temporal and regional variations in accidental deaths of elderly people in Japan.

To ascertain the characteristics of accidental deaths of elderly people in urban and rural areas, we analyzed the deaths of elderly people over the 10-year period from 2000 to 2009, in three geographic areas: nationwide, in the 23 wards of the metropolis of Tokyo, and in Saga prefecture. In addition, to assess the regional variation in accidental deaths of the elderly, we aggregated the numbers of accidental deaths of elderly people for each of Japan's prefectures in the year 2009 and categorized the deaths by accident type. The results showed that nationwide, deaths due to threats to breathing, falls, and drowning and submersion are increasing, while deaths due to transport accidents are decreasing, indicating a need for measures to prevent deaths from accidents other than transport accidents. In the urban areas of Tokyo's 23 wards, there is an increasing incidence of deaths due to falls, which is likely due to the high number of structures such as buildings and railway stations that elderly people need to negotiate. In urban areas, measures to reduce the incidence of accidental deaths need to focus on improving the physical environment to help prevent falls. In the rural locality of Saga prefecture, increasing numbers of elderly people are dying by drowning and submersion. The results of analysis of accidents in all prefectures of Japan by accident type show that the causes of accidental deaths of elderly people vary regionally, suggesting that accident prevention measures for elderly people need to consider the characteristics of the locality.

Surgical resection for accessory spleen torsion: A case report.

INTRODUCTION: Accessory spleen torsion is extremely rare, and surgery is often the emergency or elective treatment of choice. PRESENTATION OF CASE: A 20-year-old female with no specific medical history presented to our outpatient clinic with a chief complaint of abdominal pain. The patient was diagnosed with accessory spleen torsion by computed tomography. However, the abdominal symptoms and inflammatory reaction based on blood tests were mild, so a conservative treatment was selected. Subsequently, blood tests were normalized, and imaging studies showed that the accessory spleen was shrinking. Contrast-enhanced examination showed contrast enhancement in a portion of the infarcted accessory spleen region, indicating that the accessory spleen torsion had been released. Surgical resection was performed to prevent possible future re-torsion and hemorrhage of the accessory spleen. DISCUSSION: The removed specimen seemed to be normal accessory spleen tissue with clear infarcted foci edges. This artery showed evidence of luminal organization and untwisting of the occluded artery. CONCLUSION: This accessory spleen torsion was treated conservatively; however, the patient was referred for surgical treatment.

Postoperative results of the in situ fenestrated open stent technique for acute aortic dissection type A.

OBJECTIVE: Total arch replacement is commonly used for acute aortic dissection type A at some facilities, especially since open stent grafting became commercially available in Japan. Left subclavian artery (LSCA) reconstruction involves deep view manipulation, is difficult to expose and anastomose, and involves the risk of complications and surrounding vascular injury. METHODS: We evaluated 137 patients (mean age 73.8 ± 15.6 years) who underwent total arch replacement for acute aortic dissection type A, at our hospital between September 2014 and March 2022, and divided them into two groups: 70 patients for total arch replacement with fenestrated open stent technique (FeneOS), and 67 for conventional total arch replacement with the reconstruction of three-branch cerebral vessels. We performed FeneOS by deploying the graft from the entry of the left subclavian artery into the descending aorta and fenestrating the LSCA side of the stenting portion. The four-branched artificial vessel was then anastomosed between the left common carotid artery and LSCA. RESULTS: The surgical results of FeneOS were satisfactory and enabled significant reductions in operative time, selective cerebral perfusion time, cardiopulmonary bypass time, and lower body circulatory arrest time. Long-term observation (mean follow-up = 5.5 years) showed no left recurrent laryngeal nerve palsy or postoperative problems with left subclavian artery blood flow. CONCLUSIONS: FeneOS can minimize LSCA exposure because there is no need for LSCA reconstruction, reducing operation time and avoiding the risk of left recurrent laryngeal nerve injury and bleeding problems associated with LSCA exposure and anastomosis during left subclavian artery exposure.

Analysis of the pathogenesis of acute necrotizing esophagitis (black esophagus): A report of three autopsy cases.

Acute necrotizing esophagitis (ANE) is a rare condition characterized by black discoloration of the esophageal mucosa. We describe three autopsy cases of ANE, also known as black esophagus. The black discoloration was confined to the esophageal mucosa rather than to the gastric mucosa. The histological findings of brown pigmentation and acute inflammation led to an ANE diagnosis. The immediate cause of death was certified as ANE in all cases. In the three cases, one had hypertension, diabetes, and multiple cerebral infarctions, another had alcoholism, whereas the pre-existing condition was unknown in the remaining patient. Petechial hemorrhages were found on the gastric mucosa of all three patients as a finding of terminal hypothermia. In one case, frequent vomiting was observed prior to death. Blood alcohol was detected (the patient had been drinking immediately prior to death), and the onset of ANE was considered to have occurred several hours before death. The findings indicate that ANE occurs shortly before death in combination with frequent vomiting and terminal hypothermia in the setting of cerebrovascular disease or alcoholism.

Pubic Osteomyelitis in a Young Athlete.

We describe a case of pubic osteomyelitis in a 17-year-old Japanese male. The patient presented with acute left groin pain and left lower quadrant pain. He was evaluated at another hospital where pelvic X-ray/computed tomography was normal, and laboratory testing revealed only high C-reactive protein. Pelvic magnetic resonance imaging (MRI) on day three showed inflammation of the pubic attachment of the rectus abdominis muscle. Furthermore, a pelvic MRI performed 10 days after onset revealed a high signal on T2 short-TI inversion recovery in the left pubic bone, which was not found in the previous MRI, leading to a diagnosis of left pubic osteomyelitis. Symptoms improved rapidly after antibiotic therapy, and treatment was completed after six weeks. When a young athlete presents with fever and acute inguinal pain, osteomyelitis of the pubic bone should be considered as a differential diagnosis. This case report emphasizes the importance of taking a sports history during the interview and performing a repeat MRI for the early diagnosis of osteomyelitis of the pubic bone.

Analyses of physical factors that contribute to the blood carboxyhemoglobin saturation in autopsy cases of house fire fatalities.

The authors analyzed data from forensic autopsies of 75 patients who died as a result of house fires to clarify the physical factors that affect blood carboxyhemoglobin (COHb) saturation. Blood COHb saturation levels were significantly lower in patients who survived in the hospital. No significant differences were found in the blood COHb saturation levels between patients who died immediately at the scene and those who were pronounced dead at the receiving hospital without heartbeat being restored. The COHb saturation levels were significantly different among the groups of patients classified by the amount of soot. Although age, coronary artery stenosis, and blood alcohol concentration did not significantly affect blood COHb saturation, on comparing patients who died in the same fire, lower COHb saturation was observed in two patients, one with severe coronary artery stenosis and other with severe alcohol intoxication. To accurately interpret blood COHb saturation during forensic autopsy, the heartbeat status (present or absent) at the time of the rescue and the amount of soot in the trachea must be determined. Low levels of COHb saturation may be observed in fatalities with severe coronary atherosclerosis or severe alcohol intoxication.

A Nosocomial Outbreak Caused by Human Rhinovirus Species A Type 61 in a Welfare Facility in Gunma Prefecture, Japan.

Human rhinovirus (HRV) infections are generally referred to as the common cold, and are the main cause of mild symptoms. HRV is less frequently implicated in the development of severe respiratory infections. This study reports a nosocomial outbreak of bronchitis and pneumonia caused by HRV in a hospital during the COVID-19 epidemic in September 2022 in Gunma Prefecture, Japan. The patient continued to be symptomatic for nine days. During this outbreak, all 15 residents displayed respiratory symptoms. HRV-A was detected in 12 of the 12 samples, and phylogenetic analysis classified the strain as HRV-A type 61. HRV, COVID-19, and other respiratory infections cannot be differentiated based solely on clinical symptoms. A surveillance system to monitor them is thus needed.

Analysis of pituitary lesions in fatal closed head injury.

We analyzed forensic autopsy findings of 66 consecutive patients with fatal closed head injury who survived up to 48 days after trauma to ascertain the causal factors and the time course of development of posttraumatic pituitary lesions. Pituitary lesions were identified in 27 patients. In patients with pituitary lesions, posterior lobe hemorrhage was observed in 21 patients, followed by anterior lobe hemorrhage in 10 patients and anterior lobe infarct in 7 patients. Comparisons between patients with and without pituitary lesions showed that falls and subdural hematoma were significantly frequent in patients with pituitary lesions. Immunohistochemistry of neurophysin showed increased immunoreactivity in the hypothalamus of patients with pituitary lesions and brain edema, providing morphologic evidence of pituitary dysfunction. Hemorrhage in the anterior or posterior lobe was identifiable in patients with short survival periods, whereas infarct in the anterior lobe appeared in patients surviving at least 14 hours. These data further our understanding of the mechanisms of pituitary dysfunctions and help in the estimation of the survival period after head trauma.

Changes in the number of traffic collisions during the various waves of COVID-19 infection in Japan.

An analysis of the national traffic collision trends in Japan for the January 2018 to June 2022 period using existing statistical data indicates that the number of traffic incidents, injuries, and fatalities decreased over time. After the outbreak of COVID-19 in December 2019, traffic volume decreased. In this study, to explore how the COVID-19 pandemic correlates with traffic collisions, we used the Spearman rank correlation of non-parametric statistical test to compare the number of COVID-19 infections with the number of traffic collisions. The number of COVID-19 infections showed a significant inverse correlation with the number of traffic collisions nationwide, in some regions, and in some prefectures. When the number of COVID-19 infections increased, a State of Emergency or Semi-Emergency Spread Prevention Measures were repeatedly declared. We submit that these measures along with the restrictions on the population's autonomy and movement to prevent the spread of infection, reduces the number of traffic incidents, injuries, and fatalities owing to a decrease in traffic volume. Therefore, these lessons learned from the COVID-19 pandemic advocate that regulation of vehicle traffic volume is an effective means of reducing the occurrence of traffic collisions. These results can be applied to future policy development to support road safety improvements during unique events.

Gene expression in meningeal lymphatic endothelial cells following traumatic brain injury in mice.

Meningeal lymphatic vessels transport both the cerebrospinal fluid and interstitial fluid to the deep cervical lymph nodes. Traumatic brain injury (TBI) is accompanied by meningeal injury. We hypothesized that the TBI-induced meningeal injury would damage lymphatic vessels and affect brain function. We observed altered gene expression in meningeal lymphatic endothelial cells (LECs) in a mouse model of TBI. Through flow cytometry-based cell sorting, meningeal LECs were obtained from a mouse model of controlled cortical impact 3 days after TBI. Microarray analysis, real-time polymerase chain reaction assays, and enzyme-linked immunosorbent assays were performed to determine mRNA and protein expression levels in meningeal LECs. The number of meningeal LECs was significantly lower in the injury group than in the sham group 3 days after TBI. Additionally, the mRNA expression of lymphatic vessel endothelial hyaluronan receptor 1 (a specific marker of lymphatic vessels) in meningeal LECs was significantly lower in the injury group than in the sham group. The mRNA and protein expression of FMS-like tyrosine kinase 4 and neuropilin 2 (markers of lymphangiogenesis) in meningeal LECs was significantly higher in the injury group than in the sham group. Our findings indicate that TBI is associated with the impairment of meningeal LECs and meningeal lymphangiogenesis, which implicates lymphatic vessel injury in the pathogenesis of this condition.

Distal aortic replacement followed by endovascular repair for the management of severe intra-pleural adhesions accidentally detected during open surgery for chronic type B aortic dissection: a report of two cases.

BACKGROUND: Open repair is the most promising curative treatment option for patients with chronic type B aortic dissection. However, based on our experience, following the accidental detection of intra-pleural adhesions during open surgery for chronic type B aortic dissection, complete replacement of the diseased aorta cannot be accomplished. To overcome this problem, we switched the procedure to create a distal landing zone for subsequent endovascular repair by replacing the distal aorta with a vascular graft. CASE PRESENTATION: We report two cases in which open repair was attempted; however, the proximal descending thoracic aorta could not be exposed due to the presence of severe adhesion in the pleural cavity. In these patients, we accessed the lower descending thoracic aorta or thoracoabdominal aorta and created a distal landing zone for subsequent endovascular repair by replacing the aorta with a vascular graft. Thereafter, endovascular repair was performed with good outcomes. CONCLUSIONS: Replacement of the distal aorta, which is typically easy to access despite the presence of intra-pleural adhesions, with a vascular graft serves as a reliable distal landing zone for subsequent endovascular repair. This method may be a viable option for the management of severe adhesions accidentally detected in the pleural cavity during open repair for chronic type B aortic dissection.

Frequent detection of stomach contents in accidental drowning.

We analysed forensic autopsies of 536 consecutive adults to determine the relationship between the presence of stomach contents and the manner of death. Stomach contents were identified in 27 (79.4%) of 34 accidental drownings and in 22 (43.1%) of 51 suicidal drownings (P < 0.01). Accidental drowning was the manner of death most frequently associated with the presence of stomach contents, and stomach contents were found significantly more often in this type of death than in suicidal drowning. These findings indicate that food intake is a factor possibly related to accidental drowning and suggest that fasting may be required before swimming or taking a bath to prevent accidental drowning.

Analysis of autopsy cases involving individuals who experienced cardiopulmonary arrest immediately after sustaining minor head injuries.

The authors report five forensic autopsy cases involving individuals who experienced cardiopulmonary arrest immediately after sustaining minor head injuries. Heartbeat was restored in two patients after resuscitation by paramedics. During autopsy, three patients exhibited high blood alcohol levels indicating severe intoxication, two had an unknown blood alcohol status, and all five exhibited parietal bruising of the head. In addition to alcohol intoxication, blunt force impact to the parietal area of the head was believed to be related to the occurrence of cardiopulmonary arrest immediately after head trauma. The absence of secondary brain damage in patients who die from cardiopulmonary arrest immediately after head trauma should be taken into account when diagnosing the cause of death. Additionally, indications for bystander cardiopulmonary resuscitation should be considered for individuals who experience cardiopulmonary arrest due to head trauma.

Effects of Preexisting Diabetes Mellitus on the Severity of Traumatic Brain Injury.

Falls and traffic accidents can cause traumatic brain injury (TBI). Assessment of the injury severity is essential to determine the prognosis or the cause of death. Diabetes mellitus (DM) is a common preexisting disease in elderly adults. We hypothesized that preexisting DM exacerbates TBI secondary to prolonged inflammation. In this study, we investigated TBI-induced changes in nerve function and inflammatory cell migration to the injury site, and the extent of brain contusion in KK-Ay (DM) and C57BL/6J (non-DM) mice. A controlled cortical impact device was used to induce TBI in each mouse. The brain contusion volume was measured using magnetic resonance imaging. Nerve function changes were assessed using the following animal behavior tasks: neurological severity score (NSS), Morris water maze, forced swim test, and beam walking. Immunohistochemical examinations of brain sections were performed to assess the infiltration of neutrophils, astrocytes, microglia, and macrophages, and to detect apoptosis. These experiments were performed on post-injury days 1-90 (over five experiments/time-points in each group). Compared with non-DM mice, DM mice showed significantly greater brain contusion volume, greater deterioration in the NSS, and a higher number of neutrophils, macrophages, and apoptotic cells in the brain tissue specimens. This study indicates that the prognosis of normal mice and DM mice differs, even if they acquire a TBI of the same severity. Therefore, it is important to evaluate patients with TBI for DM and other preexisting diseases in order to provide adequate treatment or to determine the correct cause of death.