The effect of an initial catheter ablation with an adjunctive ethanol infusion into the vein of Marshall on persistent atrial fibrillation.

INTRODUCTION: Some previous studies have reported that a first-step ethanol infusion into the vein of Marshall (EIVOM) with touch-up radiofrequency (RF) ablation can facilitate mitral isthmus (MI) block and improves the ablation outcomes in persistent atrial fibrillation (PeAF) patients. However, the effect of an initial RF ablation with an adjunctive EIVOM has not been fully investigated. METHODS: This study enrolled 233 PeAF patients undergoing pulmonary vein isolation and linear ablation including an MI, roof line, and cavotricuspid isthmus ablation. An EIVOM was performed when endocardial ablation with or without coronary sinus ablation failed to create MI block. RESULTS: Bidirectional MI block was achieved in 224 patients (96.1%). Among them, MI block was obtained by only RF ablation in 174/224 patients (77.7%) (RF group) and an adjunctive EIVOM was needed in 50/224 (22.3%) (EIVOM group). During the follow-up, 113 (64.9%) RF group patients were free from AF/atrial tachycardia compared to 41 (82.0%) EIVOM group patients (log-rank p = .045). In a multivariate Cox regression analysis, an adjunctive EIVOM was associated with a lower recurrence rate (hazard ratio = 0.39, 95% confidence interval = 0.17-0.78, p = .006). CONCLUSION: An initial RF ablation with an adjunctive EIVOM strategy improved MI ablation's acute success rate and was associated with better clinical outcomes.

Abdominal Aortic Aneurysm Shrinkage up to 2 Years Following Endovascular Repair with PEmbolization for Preventing Type 2 Endoleak: A Retrospective Single Center Study.

BACKGROUND: The aim of the present study was to evaluate the efficacy of preemptive embolization of aneurysm side branches that cause type 2 endoleak (T2EL). METHODS: We performed a retrospective review of consecutive patients who underwent endovascular aneurysm repair (EVAR) in our facility between April 2009 and April 2019. All the patients underwent the preemptive embolization for preventing T2EL since April 2014. The patients were divided into the nonembolization group (between April 2009 and May 2014) or the embolization group (between April 2014 and April 2019). We used a support wire to improve a success rate of the preemptive embolization. The aneurysm sac shrinkage (≧5 mm), freedom from all-cause death and aneurysm-related death, T2EL-related reinterventions, aneurysm sac enlargement (≧5 mm), and complications related to the endovascular procedure were compared between the 2 groups. RESULTS: Two-hundred patients with abdominal aortic aneurysm were included. They were divided into the nonembolization group (N = 103) and the embolization group (N = 97). We successfully embolized 89% of all the patent aneurysm side branches in the embolization group. The characteristics of the 2 groups were similar except for hypertension, patent lumbar arteries, and the use of Zenith, Excluder, and Endurant. The preemptive embolization group showed better aneurysm sac shrinkage (73% vs. 42%; P < 0.0001), no aneurysm sac enlargement (0% vs. 5%; P < 0.05), and lower T2EL-related reintervention rate (hazard ratio, 0.11; 95% confidence interval, 0.0061-0.60; P < 0.01) up to 2 years after EVAR. There were no significant differences in freedom from all-cause death, aneurysm-related death, and complications between the 2 groups. CONCLUSIONS: The present study showed the high success rate of preemptive embolization of aneurysm side branches resulting in better anatomical changes in the aneurysm sac and lower T2EL-related intervention rate in the embolization group up to 2 years after EVAR.

Thoracic endovascular aortic repair with branched Inoue Stent Graft for arch aortic aneurysms.

BACKGROUND: Thoracic endovascular aortic repair (TEVAR) for thoracic aortic aneurysms (TAAs) is in rapid expansion due to its minimal invasiveness. However, TEVAR for an arch aneurysm with a straight stent graft needs surgical reconstruction for supra-aortic vessels. A branched stent graft pioneered by Inoue (branched Inoue Stent Graft [ISG]) has been expected to resolve this problem, but its utility remains to be established in the real clinical setting. This study evaluated the long-term clinical outcome of branched ISGs for TAAs. METHODS: Among 217 consecutive patients who underwent TEVAR with ISGs between March 2003 and September 2013, 89 patients with TAAs were treated with implantation of the branched ISG (single branch: n = 64; double branch: n = 18; triple branch: n = 7). The primary end point was freedom from aneurysm-related death. Secondary end points included periprocedural adverse events, freedom from all-cause death and major adverse events (composite of aneurysm-related death, surgical conversion, aneurysm rapture, persistent type I or III endoleak, graft infection, graft occlusion, graft migration, and aneurysm expansion), changes of aneurysm diameter, stroke, and any endovascular reintervention during follow-up. RESULTS: All deployments of branched ISGs were successful. The 30-day mortality was 4.5% (single branch, 3.1%; double branch, 0%; triple branch, 29%), and periprocedural stroke was 16% (single branch, 7.8%; double branch, 33%; triple branch, 42%). At 1 and 5 years, freedom from aneurysm-related death was 93% and 93%, respectively, and freedom from all-cause death was 85% and 59%, respectively. Survival free of major adverse events was 76% at 5 years. The cumulative incidence of stroke was 11% at 5 years. Three patients underwent surgical conversion because of persistent type I endoleak. One branch graft occlusion was observed at the left subclavian artery in a patient who received a double-branched graft. CONCLUSIONS: Periprocedural outcome of the single-branched ISG was acceptable, and long-term safety and efficacy were demonstrated. However, the procedural complications of the multibranched ISG leave room for improvement.

Rupture of Non-aneurysmal Mycotic Thoracic Aortic Arteritis Caused by Campylobacter fetus.

Campylobacter fetus (C. fetus) demonstrates a preference for vascular tissue and is an infrequent etiology of mycotic aortic arteritis (MAA), mostly occurring in the abdominal aorta. MAA characteristically has a rapid progression to aneurysm formation and subsequently, to aortic rupture. We present a 73-year-old woman with non-aneurysmal mycotic thoracic aortic arteritis (MTAA) complicated with a rupture caused by C. fetus. She presented after four days of pain in the lower abdomen. Contrast-enhanced computed tomography revealed non-aneurysmal descending thoracic aorta arteritis and an abdominal aorta aneurysm, and the blood cultures were positive for C. fetus. Antibiotic therapy relieved the abdominal pain. However, eight days after the antibiotic therapy, she died because of a rupture of the non-aneurysmal MTAA. The non-aneurysmal MTAA caused by C. fetus ruptured while the infection was being treated with appropriate antibiotics, and there was no sign of arterial dilatation. An early open or endovascular repair after a short pre-operative antibiotic therapy may be required for non-aneurysmal MAA caused by C. fetus. More cases of non-aneurysmal MAA caused by C. fetus are needed to determine the clinical course and to decide the treatment strategy.

Inter- and intra-observer variability for assessment of the synergy between percutaneous coronary intervention with TAXUS and cardiac surgery (SYNTAX) score and association of the SYNTAX score with clinical outcome in patients undergoing unprotected left main stenting in the real world.

BACKGROUND: The Synergy Between Percutaneous Coronary Intervention With TAXUS and Cardiac Surgery (SYNTAX) score was proposed as a method to evaluate the complexity of coronary anatomy. However, the reproducibility of assessment for the SYNTAX score in unprotected left main coronary artery (ULMCA) disease has not yet been adequately evaluated. The purpose of this study is to assess inter- and intra-observer variability for the assessment of the SYNTAX score in patients undergoing ULMCA stenting in daily clinical practice. METHODS AND RESULTS: The SYNTAX score of 101 consecutive patients who underwent ULMCA stenting with sirolimus-eluting stent was independently assessed by 2 experienced interventional cardiologists. One of the 2 cardiologists evaluated all the cases again 6 months after the initial assessment. The κ value for inter-observer variability in estimating the SYNTAX score was 0.62 according to the dichotomized analysis (≥ 33, < 33) and 0.58 according to the tertile analysis (< 23, 23 ≤ - < 33, ≥ 33), while the intra-observer variability was 0.78 and 0.69, respectively. Patients with a high SYNTAX score (≥ 33, n = 55) compared with those with low or intermediate score (< 33, n = 46) had a significantly higher rate of target-lesion revascularization (TLR) of the ULMCA lesion at 2 years (24% vs. 4.4%, P = 0.01). CONCLUSIONS: Both inter- and intra-observer variability for estimating the SYNTAX score were within an acceptable range and a high SYNTAX score showed a higher rate of TLR in patients undergoing ULMCA stenting in daily clinical practice.

Successful staged management of a spontaneous iliac vein rupture associated with May-Thurner syndrome: a case report.

BACKGROUND: Spontaneous iliac vein ruptures have only been reported in approximately 50 cases. An accurate preoperative diagnosis is difficult even with contrast-enhanced computed tomography (CT), and the operative mortality and morbidity rates are quite high. The cause of spontaneous iliac vein ruptures and their optimal diagnosis and management remain unclear. CASE SUMMARY: A 69-year-old woman without a history of prior trauma presented with low back pain, left lower limb swelling, and hypovolaemic shock. An initial contrast-enhanced CT revealed a large retroperitoneal haematoma without arterial extravasation. Her blood pressure dropped again under a noradrenaline administration. A second venous phase contrast-enhanced CT revealed venous extravasation in the external iliac vein with a suspected compression of the common iliac vein (May-Thurner syndrome) and deep vein thrombosis (DVT). Her haemodynamics were stabilized whilst a laparotomy was arranged. An inferior vena cava (IVC) filter was placed due to concerns about rebleeding with initiating anticoagulation therapy. Given the failed conservative management, elective endovascular treatment (EVT) was performed including percutaneous Fogarty venous thrombectomy and placement of self-expanding and covered stents. After the intervention, the lower limb swelling significantly improved under oral anticoagulation therapy, and the IVC filter was retrieved. At the 3-month follow-up, the lower limb swelling completely disappeared, and the contrast-enhanced CT demonstrated the complete disappearance of the retroperitoneal haematoma and DVT. DISCUSSION: This case provided not only the potential value of the venous phase contrast-enhanced CT in diagnosing a spontaneous iliac vein rupture but also the potential benefit of conservative management followed by elective EVT.

Characterization of the antiplatelet effect of aspirin at enrollment and after 2-year follow-up in a real clinical setting in Japan.

BACKGROUND: Aspirin is an antiplatelet drug widely used for the prevention of cardiovascular diseases. It has been reported that some patients who exhibit a reduced antiplatelet effect of aspirin have higher cardiovascular risk. It is still controversial whether the antiplatelet effect of aspirin diminishes after a few years of treatment. This study aimed to evaluate the antiplatelet effect of aspirin and its 2-year change in Japanese patients. METHODS AND RESULTS: Collagen-induced platelet-aggregability was measured at enrollment by conventional optical aggregometer in 239 patients undergoing antiplatelet therapy with aspirin alone. Among them, 167 patients were evaluated after 2 years. Whole blood aggregability based on the screen-filtration method was also evaluated. Optical aggregometer studies showed that 27% of patients were low-responders. Multivariate analyses revealed that female sex and non-use of calcium-channel blockers were associated with low responsiveness. The antiplatelet effect of aspirin did not decrease after 2 years. Similar data were obtained with the whole blood aggregometer. CONCLUSIONS: In this Japanese patient group, 27% were low-responders to aspirin, and the antiplatelet effect of aspirin did not decrease after a 2-year interval.

Correction to: A superficial femoral artery calcification: insights from a multi-imaging modality assessment with computed tomography, electronic high-resolution angioscopy, and optical frequency domain imaging.

In the original publication of the article, the first author name "Yuji Nishimoto" was repeated in the author group.

Successful recovery from transcatheter aortic valve embolization by thoracic endovascular stent-graft repair.

We report a case of an 84-year-old Japanese female patient with transcatheter valve embolization treated with thoracic endovascular stenting. She was diagnosed with severe aortic stenosis and referred to our hospital. Transapical transcatheter aortic valve implantation (TA-TAVI) was selected because she had multiple comorbidities and peripheral vascular disease. During TA-TAVI, the transcatheter valve (TV) came loose and lodged in the distal aortic arch. The TV was floating and unstable, thereby affecting her hemodynamics. After a second TV was placed in the appropriate position with no trouble, we tried fixing the TV using a thoracic endovascular stent-graft. The procedure was successful, and the patient recovered well. The cause of embolization seemed to be associated with a relatively mild calcification of the native aortic valve. Although this complication is rare, several recovery procedures should be prepared.

Effects of high-speed rotational atherectomy in peripheral artery disease patients with calcified lesions: a retrospective multicenter registry.

Calcified lesions still remain a technical challenge even in the treatment of infrainguinal artery disease. The aim of this retrospective, multicenter observational study was to investigate interventional outcomes of a high-speed rotational atherectomy device (Rotablator™) and to compare clinical outcomes in patients who underwent Rotablator and those who did not even after failed balloon angioplasty because of underlying calcified lesions. This study enrolled patients who underwent Rotablator (Rota group) and those who did not (Non-rota group) between January 2010 and 2014 December at 12 hospitals. A total of 67 limbs and 68 lesions in 65 patients were included (Rota group; 54 limbs and 55 lesions in 52 patients, Non-rota group; 13 limbs and 13 lesions in 13 patients). In the Rota group, a technical success rate was 94.5% with a complication rate of 1.8%, and all lesions underwent subsequent postdilatation following the adjunctive use of Rotablator, and approximately half of above-the-knee lesions underwent stent implantation. The Rota group had a significantly lower clinically driven reintervention rate at 12 months than the Non-rota group (26.5% vs. 58.3%, respectively, p = 0.046). In addition, Rota group showed a trend toward a higher amputation-free survival compared to the Non-rota group at 1 month (Rota; 98.0% vs. Non-rota; 84.6%, respectively, p = 0.10). Rotablator was used as an adjunctive device with a high technical success and a low complication rates, and Patients who underwent Rotablator yielded a significantly lower clinically driven reintervention rate at 12 months compared to those who did not even after failed balloon angioplasty.

Long-term outcomes of coronary-artery bypass graft surgery versus percutaneous coronary intervention for multivessel coronary artery disease in the bare-metal stent era.

BACKGROUND: Observational registries comparing coronary artery bypass graft (CABG) surgery and percutaneous coronary intervention (PCI) have reported long-term survival results that are discordant with those of randomized trials. METHODS AND RESULTS: We conducted a multicenter study in Japan enrolling consecutive patients undergoing first CABG or PCI between January 2000 and December 2002. Among 9877 patients enrolled, 5420 (PCI: 3712, CABG: 1708) had multivessel disease without left main involvement. Because age is an important determinant when choosing revascularization strategies, survival analysis was stratified by either age >/=75 or <75 years. Analyses were also performed in other relevant subgroups. Median follow-up interval was 1284 days with 95% follow-up rate at 2 years. At 3 years, unadjusted survival rates were 91.7% and 89.6% in the CABG and PCI groups, respectively (log rank P=0.26). After adjustment for baseline characteristics, survival outcome tended to be better after CABG (hazard ratio for death after PCI versus CABG [HR], 95% confidence interval [CI]: 1.23 [0.99-1.53], P=0.06). Adjusted survival outcomes also tended to be better for CABG among elderly patients (HR [95%CI]: 1.37 [0.98-1.92] P=0.07), but not among nonelderly patients (HR [95% CI]: 1.09 [0.82-1.46], P=0.55). Unadjusted and adjusted survival outcome for CABG and PCI were not significantly different in any subgroups when elderly patients were excluded from analysis. CONCLUSIONS: In the CREDO-Kyoto registry, survival outcomes among patients <75 years of age were similar after PCI and CABG, a result that is consistent with those of randomized trials.

Coronary risk factor profile and prognostic factors for young Japanese patients undergoing coronary revascularization.

BACKGROUND: The prevalence of coronary artery disease (CAD) is increasing in young adults. Risk factor profiling will help to prevent heart attacks in young patients. This study aimed to analyze the risk factor profile and predictors of major cardiovascular events (MACE) in young CAD patients. METHODS AND RESULTS: From the Coronary REvascularization Demonstrating Outcome study in the Kyoto (CREDO-Kyoto) registry of Japanese patients undergoing their first coronary revascularization, 6,320 patients with complete data for all variables for statistical analyses were divided into younger (< or =55 years; n=898; 14.3%) and older (>55 years; n=5,422; 85.7%) patients. The risk factors that were more prevalent in the younger patients than in the older patients included: male sex, body mass index of >25 kg/m(2), current smoker, family history of CAD, dyslipidemia and metabolic syndrome-like risk factor accumulation. Multivariate analyses revealed that chronic kidney disease (CKD) was the only significant predictor of MACE, the composite of cardiovascular death, myocardial infarction and cerebrovascular accident, in the younger patients. Importance of CKD as a prognostic factor was consistently shown by a multivariate analysis in the older patients. CONCLUSIONS: Accumulation of multiple risk factors is prevalent and CKD is associated with MACE in young Japanese CAD patients.

Angio-embolization of renal artery pseudoaneurysm after renal biopsy: a case report.

Renal artery pseudoaneurysm is a rare clinical entity that has been reported after renal biopsy, percutaneous renal surgery, penetrating trauma, and rarely blunt renal trauma. We present the case of a 37-year-old man with ruptured renal artery pseudoaneurysm accompanied by massive gross hematuria, urinary clot retention, and bladder tamponade, which were the presenting signs seven hours after renal biopsy. Abdominal CT scan showed a large perinephric, intracapsular hematoma of left kidney. His angiogram revealed a left renal segmental artery pseudoaneurysm that measured 1 cm x 1 cm. He was successfully treated by selective embolization of the arterial branch supplying the pseudoaneurysm.

Ruptured Abdominal Aortic Aneurysm Treated by Double-Balloon Technique and Endovascular Strategy: Case Series.

PURPOSE: Mortality in patients with ruptured abdominal aortic aneurysms (rAAAs) has remained high despite advances in interventions. Endovascular aneurysm repair (EVAR) was recently developed for treatment of rAAAs. In this study, we assessed our endovascular strategy including a double-balloon technique for rAAA. METHODS: We analyzed 12 consecutive patients with rAAAs who were treated by our double-balloon technique and endovascular strategy from March 2013 to July 2016. RESULTS: The 30-day and 1-year mortality rates were both 17%. The mean times from admission to arrival at the hybrid operating room, from admission to aortic occlusion, and from admission to completion of EVAR were 46.8, 63.5, and 110.0 minutes, respectively. CONCLUSION: This study indicates that the herein-described double-balloon endovascular technique is feasible for use in the management of rAAA.

Left ventricular functional analysis using 64-slice multidetector row computed tomography: comparison with left ventriculography and cardiovascular magnetic resonance.

OBJECTIVE: The progress in computed tomography (CT) has improved temporal resolution and shortened the acquisition time. We compared cardiac function using 64-slice CT with left ventriculography (LVG) and cardiovascular magnetic resonance (CMR). METHODS: A head-to-head comparison between CT, LVG and CMR was performed in 41 patients. In global LV function, CMR served as the reference. Regional wall motion was compared in a 5-point scoring system. RESULTS: CT had excellent intra- and interobserver reproducibility. Ejection fraction, end-diastolic and end-systolic volumes by CT were closely correlated with CMR (r = 0.95, 0.96 and 0.98, respectively), while LVG underestimated LV volumes (p < 0.01). The standard deviation of ejection fraction difference between CT and CMR was significantly lower than that between LVG and CMR (p = 0.0015). In regional function, there were good agreements of 94.8% (kappa = 0.82) between CT and LVG and 94.5% (kappa = 0.84) between CT and CMR. The intermethod agreements in mild hypokinesis using CT tended to be lower. CONCLUSION: An excellent correlation was observed between CT and CMR in the LV function over a wide range of heart rates. However, even though 64-slice CT tended to be less sensitive in detecting mild hypokinesis, it still showed excellent concordance in advanced regional abnormalities.

The deeper the pouch is, the longer the radiofrequency duration and higher the radiofrequency energy needed-Cavotricuspid isthmus ablation using intracardiac echocardiography.

BACKGROUND: The aim of this study was to explore whether the pouch depth influenced the radiofrequency (RF) duration and total delivered RF energy for cavotricuspid isthmus (CTI) ablation and define the cutoff value for a deep pouch-specified ablation strategy. METHODS: This study included 94 atrial fibrillation (AF) patients (56 males, age 68 ± 8.0 years). With intracardiac echocardiography, the isthmus length and pouch depth were precisely measured. After a standard AF ablation, all patients underwent the CTI ablation along the lateral isthmus. If bidirectional block could not be achieved, the ablation catheter was deflected more than 90 degrees to ablate inside the pouch (knuckle-curve ablation). RESULTS: Seventy-two patients (76.6%) had a sub-Eustachian pouch. Bidirectional block could be achieved in all patients. By a univariate logistic regression analysis, only the pouch depth was significantly correlated with the RF duration (P = .005) and RF energy (P = .006). A multivariate logistic regression analysis also revealed the pouch depth was the sole factor that influenced the RF duration (P = .001) and RF energy (P = .001). Among the 72 patients, 21 patients needed a knuckle-curve ablation. Using a receiver operating characteristic curve, the optimal cutoff value of the pouch depth for a knuckle-curve ablation was 3.7 mm with a sensitivity of 90% and specificity of 69%. CONCLUSIONS: The sub-Eustachian pouch depth was the sole factor that influenced the RF duration and energy in the CTI ablation. If the pouch was deeper than 3.7 mm, a deep pouch-specified ablation strategy would be needed.

A Simple Reproducible Method to Treat Acute or Subacute Arterial Obstruction When the Thrombus Is Adherent to the Arterial Wall.

We report three consecutive patients with limb ischemia, where symptoms appeared several days to weeks prior to presentation. In all cases, initial over-the-wire thrombectomy failed due to adherence of the thrombus to the arterial wall. We adopted a new approach of stretching the whole obstructed segment by a series of ballooning using a percutaneous transluminal angioplasty (PTA) catheter. A subsequent thrombectomy was successful in all three cases. No further intervention, such as stenting or bypass surgery, was required. The adhering thrombus was dissected by stretching the arterial wall at the site of obstruction.