Comparison of clinical outcomes, including the wound healing rate, between inframalleolar bypass to the pedal artery and that to the pedal branch artery in the modern endovascular era.

OBJECTIVE: Inframalleolar (IM) bypass has been reported to demonstrate acceptable patency and limb salvage in patients with chronic limb-threatening ischemia. However, wound healing after IM bypass and comparisons between pedal artery (PA) bypass and pedal branch artery (PBA) bypass are lacking. METHODS: We reviewed prospectively collected data from 208 consecutive patients after IM bypass performed over a period of 6 years. Patients were divided into two groups based on the distal anastomotic artery: the PA group (dorsal pedis artery or common plantar artery) and the PBA group (medial tarsal, lateral tarsal, medial plantar, and lateral plantar artery). The primary outcome was wound healing, and secondary outcomes included loss of patency and limb and life prognosis. RESULTS: Of the 208 patients, 174 (74%) had PA bypass, whereas 34 (16%) had PBA bypass. Patients in the PBA group were significantly younger than those in the PA group (69 ± 7 vs 73 ± 9; P = .03). Although early (30-day) graft failure was more common in the PBA group, late clinical outcomes, including the wound healing rate (79% in the PA group and 84% in the PBA group; P = .74), were similar between the two groups. The Global Limb Anatomic Staging System IM grade (hazard ratio [HR], 0.73; 95% confidence interval [CI], 0.58-0.93; P = .006); wound, ischemia, and foot infection wound grade (HR, 0.67; 95% CI, 0.51-0.89; P < .01); and wound, ischemia, and foot infection foot infection grade (HR, 0.79; 95% CI, 0.65-0.96; P = .02) were independent predictors of wound healing. CONCLUSIONS: The current study revealed that wound healing in patients after PBA bypass was acceptable and comparable with that after PA bypass. In the modern era, including a high prevalence of infrapopliteal angioplasty, our results could provide useful information to clinicians in actual clinical settings. Moreover, PBA bypass may be an alternative revascularization procedure to avoid major amputation when the PA is occluded, such as in the global vascular guideline IM P2 grade. Prospective multicenter larger studies are warranted to confirm the findings of this study and to compare PBA bypass and IM endovascular treatment in patients with anatomical no-option chronic limb-threatening ischemia.

Prognostic Significance of Preoperative Functional Independence Measure (FIM) on Long-Term Outcomes in Patients with Chronic Limb-Threatening Ischemia (CLTI).

BACKGROUND: The purpose of this study was to evaluate the effect of preoperative motor and cognitive activities of daily living (ADL) on long-term outcomes of patients with chronic limb-threatening ischemia (CLTI) after distal bypass. METHODS: A retrospective review was performed for patients who underwent distal bypass for CLTI from 2013 to 2019 at multiple centers in Japan. Comparisons were made among patients with high and low motor and cognitive ADL based on the functional independence measure (FIM). The primary endpoint was limb salvage and the secondary endpoints were survival, amputation free survival (AFS), major adverse limb events (MALE), readmission, and wound healing. RESULTS: A total of 226 distal bypasses were performed in 185 patients (169 males; median age, 76 years; diabetes mellitus, 70%; end-stage renal disease with hemodialysis, 40%). The patients were divided into high (n = 93, 50%) and low (n = 92, 50%) FIM-motor cases, and high (n = 157, 85%) and low (n = 28, 15%) FIM-cognitive cases. FIM-motor (high vs. low) and FIM-cognitive (high vs. low) were not significantly associated with limb salvage, freedom from MALE, freedom from readmission, and wound healing. The 1- and 3-year survival rates were significantly lower in low FIM-motor cases (93% vs. 70% at 1 year, 73% vs. 46% at 3 years, P = 0.0011); and in low FIM-cognitive cases (87% vs. 50% at 1 year, 63% vs. 45% at 3 years, P < 0.001). The 1- and 3-year AFS rates were significantly lower in low FIM-motor cases (92% vs. 67% at 1 year, 69% vs. 44% at 3 years, P < 0.001); and in low FIM-cognitive cases (85% vs. 49% at 1 year, 59% vs. 44% at 3 years, P < 0.001). In multivariate analysis, independent risk factors for survival were hemodialysis (HR = 2.17; 95% confidence interval (CI), 1.23-3.83; P = .0078), low FIM-cognitive (HR = 3.45; 95% CI, 1.78-6.71; P < 0.001), and ejection fraction (HR = 0.98; 95% CI, 0.95-0.99; P = 0.019). CONCLUSIONS: FIM-motor and FIM-cognitive were predictive factors for long-term survival and AFS of CLTI patients after distal bypass, but had no influence on limb salvage, MALE, readmission, and wound healing. These results suggest that the motor and cognitive status of ADL should be assessed using FIM before distal bypass for patients with CLTI.

The PETTICOAT-Snowshoe Technique Prevents Distal Stent Graft-Induced New Entry in Patients with Aortic Dissection.

PURPOSE: Distal stent graft-induced new entry (SINE) is a serious complication of thoracic endovascular aortic repair (TEVAR) for Stanford type B aortic dissection (TBAD). The PETTICOAT-snowshoe technique was developed to prevent distal SINE for double-barrel TBAD. Initially, a proximal stent-graft (SG) is deployed, followed by the extension of a bare stent above the celiac artery and deployment of a second SG within the bare stent. This study examined whether the PETTICOAT-snowshoe technique prevents distal SINE. MATERIALS AND METHODS: This was a single-center, retrospective study comparing 2 groups that underwent conventional standard TEVAR between January 2013 and September 2018 and TEVAR using the PETTICOAT-snowshoe technique after October 2018 for double-barrel TBAD. RESULTS: Twenty-seven patients (74% male) underwent standard TEVAR (group A), while another 27 (78% male) underwent the PETTICOAT-snowshoe technique (group B). TEVAR was performed in the chronic phase on 15 patients (55.6%) in group A and on 16 (59.2%) in group B. Aorta-related mortality occurred in 1 patient in group A (3.7%). Oversizing ratios at the distal edge of the SG diameter to the major axis of the true lumen were 25% ± 26% and 25% ± 21% in groups A and B, respectively. During the follow-up period, 5 patients (18.5%) in group A and none in group B (P = 0.02) developed distal SINE. 3 of 5 patients with distal SINE in group A were treated with additional TEVAR, one with thoracoabdominal aortic replacement, and one with conservative observation. The freedom from distal SINE rate was significantly higher in group B than in group A (P = 0.04). CONCLUSIONS: The PETTICOAT-snowshoe technique significantly prevented distal SINE during the mid-term period even with the same distal SG oversizing as conventional standard TEVAR.

A Case of Iliac Aneurysm with Persistent Sciatic Artery Treated by Endovascular Aneurysm Repair.

A persistent sciatic artery (PSA) is a rare congenital vascular anomaly that occurs in approximately 0.01 to 0.06% of the population. We encountered a patient with aneurysms in the common iliac-internal iliac artery continuous to an occluded right PSA. The patient was an 85-year-old male in whom intermittent claudication of the right lower limb appeared 3 months ago. The right ankle-brachial index (ABI) was 0.48. On contrast computed tomography, the right PSA was present and was occluded over the popliteal artery. The right superficial femoral artery was hypoplastic. Moreover, abdominal aortic (diameter: 42 mm) and right common-internal iliac (diameter: 46 mm) aneurysms continuous to the PSA were present. For the surgical procedure, endovascular aneurysm repair was selected. First, the right internal iliac artery was embolized, an aortouni-iliac stent graft was placed from the infrarenal aorta down to the left common iliac artery, and left common femoral-right deep femoral artery bypass was performed to achieve revascularization of the right lower limb. Postoperatively, the aneurysms were favorably excluded with stent grafts without endoleak. The right ABI markedly improved to 0.83, and claudication was resolved. There are few reports of iliac aneurysm with a concomitant PSA.

Multifocal angiosarcoma of the gastrointestinal tract:a case report.

An 80-year-old man presented to our hospital with complaints of tarry stool and shortness of breath. A blood test confirmed marked anemia. On abdominal contrast-enhanced computed tomography, neither hemorrhagic lesions nor tumorous lesions could be pointed out. Upper gastrointestinal endoscopy revealed multiple erythematous flat elevated lesions, which were about 10mm in diameter, located between the stomach and the horizontal part of the duodenum. Colonoscopy revealed similar lesions throughout the entire colon. Pathological examination of biopsy specimens demonstrated the proliferation of neoplastic cells positive for immunostaining of factor VIII-related antigen, CD31, and CD34. Accordingly, the patient was diagnosed with angiosarcoma of the gastrointestinal tract. Although the patient was transferred to another hospital for chemotherapy, he died shortly after the transfer because of deterioration of his bleeding symptoms. Angiosarcoma is a soft-tissue neoplasm of vascular endothelium origin, accounting for less than 2% of all sarcomas. It usually occurs in the skin of the head and neck and in soft tissues. Angiosarcoma of the gastrointestinal tract is rare and is described only in case reports and small series. These tumors are characterized by an extremely aggressive course, with a high tendency to metastasize, leaving patients with a poor prognosis. When angiosarcoma is found in multiple sites of the gastrointestinal tract, it is sometimes difficult to differentiate between primary and metastatic occurrences. We analyzed reported cases of multifocal angiosarcoma of the digestive tract, of which there are 43 so far. In 24 cases, the angiosarcoma was thought to originate from the gastrointestinal tract (primary angiosarcoma). In 13 cases, angiosarcoma of other organs metastasized to the digestive tract (metastatic angiosarcoma). In the remaining 6 cases, whether the multifocal angiosarcoma of the digestive tract was primary or metastatic was unclear. In the current case, no primary lesion was found outside the gastrointestinal tract. Therefore, he was diagnosed with primary multifocal angiosarcoma.

[Obstructive colitis following the ingestion of laxatives during bowel preparation for colonoscopy: a report of two cases].

The first case of obstructive colitis (OC) was observed in a 71-year-old man who presented to our hospital complaining of frank blood in the stool. After receiving a laxative for bowel preparation, he complained of lower abdominal pain. Colonoscopy revealed a circumferential tumor at the rectosigmoid junction. Diffuse erythema with erosion and ulceration was observed 5cm proximal to the tumor. The second case of OC was observed in a 73-year-old man. He was admitted to our hospital for endoscopic resection of a colonic polyp. After receiving a laxative for bowel preparation, he complained of lower abdominal pain. Colonoscopy revealed that the rectum was filled with feces. Diffuse erythema with ulceration was observed in the part beyond the feces. In both cases, although the cause of the obstruction differed, the obstructing lesions were located at the rectum, and the OC appeared to be induced by laxative ingestion.

[Neuroendocrine tumor of the terminal ileum observed by magnifying endoscopy with narrow-band imaging: a case report].

We report the case of an 88-year-old woman with localized intestinal obstruction caused by a midgut neuroendocrine tumor (NET) without endocrine symptoms. She was referred to our hospital for lower abdominal pain. Abdominal enhanced computed tomography revealed a thickened wall in the terminal ileum with dilated small bowel and multiple hepatic metastases upstream. Although the presenting symptoms resolved with short-term fasting and defecation, we performed further investigation. Colonoscopy confirmed the presence of submucosal tumors in the terminal ileum with a yellow-discolored surface but without ulceration or erosion. Magnifying endoscopy with narrow-band imaging clearly showed extended and dilated vessels, with the existing vessels maintained under the epithelium. Biopsies from these lesions were immunohistochemically positive for all neuroendocrine markers, and the Ki-67 index was 10%. Therefore, the patient was diagnosed with NET, and she underwent laparoscopic surgery to relieve the intestinal obstruction. Pathological examination of the resected specimen confirmed grade 2 NET with intramural metastasis and dissemination. After follow-up for a month, octreotide long-acting repeatable therapy was initiated and the patient was free of symptoms at the 6-month follow-up. This is the first report of midgut NET observed by magnifying endoscopy with narrow-band imaging.

[A case of gastric carcinosarcoma treated with surgical resection and irinotecan and mitomycin C combination therapy].

A 59-year-old man was admitted following episodes of melena. Upper gastrointestinal endoscopy revealed a type 2 carcinoid-like tumor in the cardium of the stomach. Histopathological analysis of a biopsy specimen revealed adenocarcinoma. Although hepatic metastases were detected, total gastrectomy was initially performed for hemorrhage control. The final histopathological diagnosis of the resected primary tumor was gastric carcinosarcoma with an osteosarcoma component. After ineffective first-line combination therapy with S-1 (tegafur, gimeracil, and oteracil) and cisplatin, irinotecan and mitomycin C chemotherapy was introduced. Although the hepatic metastases showed shrinkage after three courses of the chemotherapy, the patient succumbed seven months after surgery. This case report suggests that systemic chemotherapy using irinotecan and mitomycin C may be effective in the treatment of gastric carcinosarcoma with an osteosarcoma component and distant metastases.

Determination of Treatment Efficacy after Revascularization of Intermittent Claudication Patients by Physical Function Assessment.

PURPOSE: There have been few reports examining changes in physical activity (PA) after revascularization of lower extremities from the perspective of physical function at discharge. The purpose of this study was to clarify the effects of physical function before discharge on the amount of PA after discharge in patients who underwent revascularization. METHODS: The subjects were 34 Fontaine class II patients admitted for elective surgical revascularization or endovascular treatment at two hospitals from September 2017 to October 2019. Triaxial accelerometers were used to measure changes in sedentary behavior (SB) before admission and 1 month after discharge. Multiple regression analysis was performed on the 6-min walking distance (6MWD) at the time of discharge and the change in SB 1 month after discharge; the cutoff value was calculated from the receiver operating characteristic (ROC) curve. RESULTS: SB 1 month after discharge significantly decreased in the decreased SB group compared to the increased SB group (575.5 [400-745.2] vs. 649.5 [453.8-809.2], p <0.01). ROC curve was plotted with SB increase/decrease as the dependent variable and 6MWD at discharge as the independent variable; the cutoff value was 357.5 m. CONCLUSION: 6MWD measurement at discharge may help predict changes in SB after discharge.

Long-Term Outcomes of Simple Endovascular Aneurysm Repair Based on the Initial Aortic Diameter.

PURPOSE: We aimed to investigate the effects of initial abdominal aortic aneurysm (AAA) diameter on aneurysmal sac expansion/shrinkage, endoleaks, and reintervention postelective simple endovascular aneurysm repair (EVAR). METHODS: Overall, 228 patients monitored for >1 year after EVAR were analyzed. Male and female participants with initial AAA diameters <55 mm and <50 mm, respectively, composed the small group (group S), while those with initial AAA diameters ≥55 mm (men) and ≥50 mm (women) composed the large group (group L). Aneurysmal sac expansion of 10 mm and/or reintervention during follow-up (composite event) and its related factors were evaluated. RESULTS: The 5-year freedom from composite event rate was significantly higher in group S (92.4 ± 2.8%) than that in group L (79.1 ± 4.9%; P <0.01). Multivariate analysis revealed AAA diameters before EVAR in group S (hazard ratio, 0.38; 95% confidence interval, 0.18-0.81; P = 0.01) and type II endoleak (T2EL) at discharge (hazard ratio, 2.83; 95% confidence interval, 1.29-6.20; P <0.01) as factors associated with the composite event. The freedom from composite event rate decreased to 51 ± 13% at 5 years in group L with T2EL. CONCLUSIONS: Group S had high freedom from composite event rate; in group L, the rate decreased to 51% at 5 years with T2EL at discharge.

The prognosis of patients on hemodialysis with foot lesions.

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

Quality of life and the venous function of the lower limb after harvest of autologous external iliac vein grafts: a clinical follow-up study.

PURPOSE: To investigate the quality of life and venous function of the lower limbs after right external iliac vein (REIV) grafting for digestive surgery. METHOD: The study subjects included 66 patients treated surgically for hepatopancreatobiliary malignancy who underwent concomitant resection with REIV for use as autologous grafts. Fifteen patients completed the Chronic Lower Limb Venous Insufficiency Questionnaire (CIVIQ), and the venous function was assessed using air plethysmography (APG) and duplex ultrasound in 10 patients. The outcomes of the 15 patients were analyzed statistically. RESULTS: Postoperative morbidity related to graft harvest occurred in three of the 66 patients (5 %). The right legs of the follow-up patients were 6 ± 3 % larger than the left legs. The mean CIVIQ score was acceptably low at 27; however, moderate symptoms (e.g., pain upon long-time standing or walking) occurred in seven of the 15 patients. APG revealed moderate to severe outflow obstructions that did not improve during long-term observation. The blood flow depicted on duplex ultrasonography was significantly associated with the patients' symptoms. No deep venous reflux was encountered, and no right leg skin changes or venous claudication developed. CONCLUSIONS: The symptoms occurring after REIV resection can be unexpectedly prolonged. These unfavorable effects must be kept in mind and the possible sequelae should be carefully explained to patients preoperatively.

Recyclable Mitsunobu reagents: catalytic Mitsunobu reactions with an iron catalyst and atmospheric oxygen.

Aerobic recycling: A catalytic amount of a hydrazine reagent is sufficient to promote Mitsunobu reactions in the presence of triphenylphosphine, an iron catalyst, and air. The active form of the catalyst, an azo species, can be readily generated by iron-catalyzed aerobic oxidation. MS = molecular sieves, Pc = phthalocyanine.

Calf extra-Fascial compartment area affects calf muscle pumping action: an air plethysmography and computed tomography study.

OBJECTIVES: We aimed to elucidate whether lower limb extra-fascial compartment and muscle areas affect the calf muscle pumping action on lower limbs. METHOD: This study included 90 patients (180 limbs) who underwent preoperative air plethysmography (APG) and preoperative non-contrast computed tomography (CT) of the lower limbs for diagnosis of unilateral or bilateral primary varicose veins. A correlation between cross-sectional CT images and preoperative APG was confirmed. Cross-sectional CT was used to measure the extra-fascial compartment and muscle areas of the calf. The lower limbs were divided into two groups: those that were normal and those with primary varicose veins. RESULTS: The extra-fascial compartment area was significantly correlated with the ejection fraction in normal (r = 0.388, n = 53, p = 0.004) and varicose limbs (r = 0.232, n = 91, p = 0.027). CONCLUSIONS: In normal and varicose limbs, evaluation of ejection fraction, an indicator of muscle pumping, requires consideration of the extra-fascial compartment area.

Identification of a phenanthrene derivative as a potent anticancer drug with Pim kinase inhibitory activity.

Pim-3, a proto-oncogene with serine/threonine kinase activity, is aberrantly expressed in malignant lesions, but not in normal tissues, of endoderm-derived organs, including the pancreas, liver, colon, and stomach. Furthermore, the development of hepatocellular carcinoma is accelerated in mice expressing Pim-3 transgene selectively in the liver when these mice are treated with a hepatocarcinogen. These observations suggest that a chemical targeting Pim-3 kinase may be a novel type of anticancer drug. In the present study, we screened low molecular weight chemicals and observed that the phenanthrene derivative T26 potently inhibited Pim-3 and Pim-1, but only weakly inhibited Pim-2. Moreover, T26 markedly inhibited the in vitro growth of human pancreatic cancer cell lines by inducing apoptosis and G(2) /M arrest. The growth inhibitory effects of T26 were reversed by overexpression of Pim-3 cDNA in human pancreatic cancer cells, indicating that T26 acts primarily on Pim-3. Furthermore, T26 inhibited the growth of a human pancreatic cancer cell line in nude mice without causing apparent adverse effects when it was administered after tumor formation was evident. These observations imply that the chemical and its related compounds may be effective for the treatment of cancers in which there is aberrant Pim-3 expression.

Remodeling of proximal neck angulation after endovascular aneurysm repair.

OBJECTIVE: This study investigated the remodeling of proximal neck (PN) angulations of abdominal aortic aneurysms (AAAs) after endovascular aneurysm repair (EVAR). METHODS: A 64-row multidetector computed tomography scan of AAAs treated with EVAR was reviewed, and the PN angulation was measured on a volume-rendered three-dimensional image. The computed tomography scan was examined preoperatively, after EVAR at 1 week, 1 month, 6 months, 1 year, 1.5 years, 2 years, and then yearly. The study enrolled 78 patients, comprising 54 Zenith devices (Cook Medical, Bloomington, Ind) and 24 Excluder devices (W. L. Gore and Associates, Flagstaff, Ariz). RESULTS: PN angulation was 50° ± 20° preoperatively, and after EVAR was 36° ± 14° at 1 week, 32° ± 14° at 1 year, and 28° ± 13° at 3 years. PN angulations ≤ 60° (n = 70, 77%) were 41° ± 13° preoperatively, 31° ± 12° 1 week after EVAR, 28° ± 12° at 1 year, and 26° ± 13° after 3 years. An angulation >60° (n = 18, 23%) was 78° ± 14° preoperatively, 51° ± 11° 1 week after EVAR, 44° ± 11° at 1 year, and 40° ± 12° after 3 years. The greater the preoperative PN angulation, the greater its reduction immediately after EVAR (r = .72, P < .001). The diameter shrinkage of AAAs with a PN angulation >60° was 3 ± 6 mm after 1 year; a significantly smaller shrinkage than with a PN angulation ≤ 60° (7 ± 7 mm, P < .05). AAAs with a PN angulation >60° had a larger angulation reduction and a smaller diameter shrinkage after the EVAR procedure. The PN angulation of the 54 AAAs treated by Zenith was 49° ± 22° preoperatively, 34° ± 14° 1 week after EVAR, and 25° ± 13° after 3 years. The corresponding angulation of the 24 AAAs treated by Excluder devices was 52° ± 17°, 41° ± 14°, and 38° ± 9°, respectively. The PN angulation reduction of Zenith and Excluder was similar 1 week after the EVAR procedure. Unlike Excluder, however, the PN angulation in Zenith continued to reduce for a long period at a slow pace. There were no significant correlations between PN angulation reduction and diameter change and between PN length and diameter change (P = .86 and .18, respectively). CONCLUSIONS: Although the instructions for use of most commercially available stent grafts provide for a PN angulation of ≤ 60°, PN angulation was not a major issue in a midterm follow-up of AAAs with adequate PN length for patients in this series who received a Zenith or Excluder graft.

Demonstration of intrahepatic accumulated microbubble on ultrasound represents the grade of hepatic fibrosis.

OBJECTIVES: To examine the feasibility of perflubutane-based ultrasound for grading hepatic fibrosis. METHODS: This prospective study included 202 subjects; main study (controls:33, F0-1:35, F2:26, F3:23, cirrhosis:29) and subsequent study (controls:16, F0-1:7, F2:20, F3:7, cirrhosis:6). Diagnostic abilities for assessing fibrosis grade were compared between contrast findings and FIB4 (age × AST/[platelet count × ALT(0.5)]). RESULTS: High-power emission produced an intrahepatic band-like structure, and the three-layer appearance was less frequent and monolayer appearance was more frequent in cirrhosis than controls/chronic hepatitis (P < 0.0001). Intensity difference at 15-min phase showed most significant correlation with fibrosis grade (ρ = 0.79, P < 0.0001), and the best areas under the receiver operating characteristic curves are 0.88 for marked fibrosis, 0.95 for advanced fibrosis and 0.97 for cirrhosis, which were significantly higher than those of FIB4, 0.85 for marked fibrosis, 0.89 for advanced fibrosis and 0.90 for cirrhosis. Sensitivity, specificity and efficiency of the intensity difference were 88%, 72% and 81% for marked fibrosis, 85%, 91% and 89% for advanced fibrosis and 97%, 90% and 91% for cirrhosis, respectively. The subsequent study validated the main study results; significant correlation between the intensity difference and the fibrosis grade (ρ = 0.73-0.77, P < 0.0001). CONCLUSIONS: Perflubutane-based ultrasound accurately predicts the grade of hepatic fibrosis. KEY POINTS: • The behaviour of intrahepatic microbubbles depends on the severity of hepatic fibrosis. • Layer enhancement pattern simply represents the degree of chronic liver disease. • Parenchymal intensity change due to high-power emission predicts the hepatic fibrosis grade.

Prediction of the therapeutic effects of anticoagulation for recent portal vein thrombosis: a novel approach with contrast-enhanced ultrasound.

OBJECTIVE: To examine whether intra-thrombus enhancement on contrast-enhanced sonograms can predict the recanalization by anticoagulation for recent portal thrombosis. METHODS: This prospective study included 10 patients with a recent portal thrombosis and 20 controls (10 cirrhosis patients and 10 healthy subjects, all without thrombosis). The diagnosis of thrombosis was based on clinical and ultrasound findings. Pre-anticoagulation intra-thrombus enhancement on the contrast-enhanced sonogram was examined with respect to the post-anticoagulation results or portal enhancement in controls. RESULTS: Complete recanalization was obtained in 4 patients with positive intra-thrombus enhancement. However, in 4 other patients who had a thrombosis showing positive enhancement concurrent with one showing negative enhancement, anticoagulation recanalized the former and failed to recanalize the latter. Mean onset time of contrast enhancement measured from the beginning of hepatic arterial enhancement was significantly longer in the thrombus (6.6 ± 4.3 s, 3-16 s) than in the portal vein of controls (cirrhosis, 4.3 ± 1.4 s, 2-8 s, P = 0.0035; healthy subjects, 2.4 ± 0.6 s, 1-3 s, P < 0.0001). Anticoagulation failed to achieve recanalization in 2 patients with negative intra-thrombus enhancement. Sensitivity and specificity of contrast enhancement for the prediction of post-treatment recanalization was 100%. CONCLUSIONS: Intra-thrombus positive enhancement demonstrated on contrast-enhanced sonograms has promise as a successful predictor of recanalization for the recent portal thrombosis.

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

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