Automated rapid solid-phase extraction system for separation and preconcentration of trace elements using carboxymethylated polyethyleneimine-type chelating resin.

An automated system for the rapid separation and preconcentration of trace elements was developed. Carboxymethylated polyethyleneimine 600 (CM-PEI600), which is a partially carboxymethylated polyethyleneimine with a molecular weight of 600 Da, was used as a chelating resin to quantitatively recover trace elements under high-flow-rate conditions. For accurately and precisely determining trace elements, even with a rough control of the sample and eluent flow volumes, an internal standardization technique was employed for the solid-phase extraction and separation. A recovery test of the deionized water-based sample solution was conducted using this system, and good results, with a recovery of 92% or higher, were obtained for 11 elements (Cd, Co, Cu, Fe, Mn, Mo, Ni, Pb, Ti, V, and Zn). Eight elements present in certified groundwater and wastewater reference materials (ES-L-1 and EU-L) were separated and preconcentrated using this system. Almost all the determined values were within their tolerance intervals, and no significant differences were observed between the determined and certified values, demonstrating the validity of this method. The time required for the separation and preconcentration using approximately 100 mL of the sample solution was approximately 6.5 min, and theoretically, the system could be used to preconcentrate 17 samples in an hour because extraction and elution could be conducted simultaneously using two cartridges packed with the chelating resin. Using this system equipped with cartridges packed with CM-PEI600 resin, solid-phase extraction and the separation of multiple elements were performed simultaneously, automatically, and rapidly, enabling the accurate and precise determination of trace elements in environmental water and inorganic salts even by rapidly flowing the sample solutions using peristaltic pumps. Compared to NOBIAS Chelate PA-1, a commercially available chelating resin, the CM-PEI600 resin can recover trace elements even under an extremely high flow rate of approximately 50 mL min-1.

Hydrophilic interaction chromatography-type sorbent prepared by the modification of methacrylate-base resin with polyethyleneimine for solid-phase extraction of polar compounds.

Hydrophilic interaction chromatography (HILIC)-type sorbents were newly developed for the solid-phase extraction (SPE) of polar compounds. Two methacrylate-base resins with different cross-linking monomers and pore properties were synthesized, and three polyethyleneimines (PEIs) with different molecular weights were modified onto each base resin. In both cases, PEIs with a molecular weight of 10,000 (PEI-10,000) exhibited the highest adsorption properties for polar compounds (uracil, uridine, adenosine, cytidine, and guanosine). To control the water-enriched layer at the surface of the PEI-10,000-modified sorbents, the additive amount of PEI-10,000 in the modified reaction was also optimized. When 10 times the amount of PEI-10,000 to each base resin was added, an improvement in adsorption property was observed. Moreover, the use of a nonaqueous sample solution (100% acetonitrile) during the sample loading process drastically improved adsorption, especially for uracil (about 80%) and adenosine (100%). These results indicate that the formation of a strong water-enriched layer at the surface of sorbents with an effective expression of hydrophilic interaction was an important factor in the adsorption properties of polar compounds in HILIC mode-SPE.

Prediction Models for Two Year Overall Survival and Amputation Free Survival After Revascularisation for Chronic Limb Threatening Ischaemia.

OBJECTIVE: The aim of this study was to create prediction models for two year overall survival (OS) and amputation free survival (AFS) after revascularisation in patients with chronic limb threatening ischaemia (CLTI). METHODS: This was a retrospective analysis of prospectively collected multicentre registry data (JAPAN Critical Limb Ischaemia Database; JCLIMB). Data from 3 505 unique patients with CLTI who had undergone revascularisation from 2013 to 2017 were extracted from the JCLIMB for the analysis. The cohort was randomly divided into development (2 861 patients) and validation cohorts (644 patients). In the development cohort, multivariable risk models were constructed to predict two year OS and AFS using Cox proportional hazard regression analysis. These models were applied to the validation cohort and their performances were evaluated using Harrell's C index and calibration plots. RESULTS: Kaplan-Meier estimates of two year OS and AFS post-revascularisation in the whole cohort were 69% and 62%, respectively. Strong predictors for OS consisted of age, activity, malignant neoplasm, chronic kidney disease (CKD), congestive heart failure (CHF), geriatric nutritional risk index (GNRI), and sex. Strong predictors for AFS included age, activity, malignant neoplasm, CKD, CHF, GNRI, body temperature, white blood cells, urgent revascularisation procedure, and sex. Prediction models for two year OS and AFS showed good discrimination with Harrell's C indexes of 0.73 (95% confidence interval [CI] 0.69 - 0.77) and 0.72 (95% CI 0.68 - 0.76), respectively CONCLUSION: Prediction models for two year OS and AFS post-revascularisation in patients with CLTI were created. They can assist in determining treatment strategies and serve as risk adjustment modalities for quality benchmarking for revascularisation in patients with CLTI at each facility.

Remote simulator training of coronary artery bypass grafting during the coronavirus disease 2019 pandemic.

OBJECTIVES: The coronavirus disease 2019 pandemic presents in-person exposure risk during surgical education. We aimed to validate the feasibility of fully remote faculty-supervised surgical training sessions focused on coronary artery bypass grafting using a synthetic simulator and online videochat software. METHODS: This observational study organized 24 sessions of 2-hour remote training. Each session involved 3 trainees, 1 faculty member, and 1 host. A total of 70 trainees and 24 faculty members were enrolled. The participants joined the remote sessions via online videochat and performed focused training in coronary artery anastomosis using a commercially available simulator. A survey was conducted to validate the feasibility of the remote sessions. Performance improvement of the trainees who repeatedly participated (n = 13) were analyzed comparing initial and final scores of various performance indicators. RESULTS: All trainees and faculty members were satisfied with the efficacy of the remote session. Additionally, most trainees (79%) and faculty members (95%) agreed that the remote training sessions were equivalent to conventional onsite training seminars. A significant improvement between initial and last sessions was observed in the scoring components of near side (3.4 ± 1.0 vs 4.1 ± 0.9; P = .02), far side (3.3 ± 0.8 vs 3.9 ± 0.8; P = .03), external appearance (3.5 ± 0.8 vs 4.2 ± 0.7; P = .01), and internal appearance (2.8 ± 0.9 vs 4.0 ± 0.9; P = .004). CONCLUSIONS: Faculty-supervised remote surgical training sessions were executed with satisfactory results. This methodology may have important implications for surgical education during the coronavirus disease 2019 pandemic.

A novel technique of reimplantation of a radial artery that makes a hairpin turn to reduce the excessive vascular access flow in a dialysis patient.

We report a new technique called "reimplantation of an artery with a hairpin turn (RAHT)" to reduce excessive vascular access flow. A 73-year-old woman on dialysis consulted us for vascular surgery because of an increased cardiac preload. Chest radiography and echocardiography revealed an excessive shunt flow in the brachial artery (flow rate, 2336 mL/min). Vascular echo-Doppler of the left upper limb showed that the radial artery made a hairpin turn at the arteriovenous fistula (diameter, 9 mm). Diameters of the radial artery proximal and distal to the arteriovenous fistula were 5.4 and 3.7 mm, respectively. We ligated and divided the juxta-anastomosis proximal radial artery and subsequently created an end-to-side anastomosis between the proximal radial artery and the distal radial artery. The anastomosis ostium in the distal radial artery (the recipient) was formed with a 4-mm longitudinal and gently curved incision. We performed RAHT so that the small anastomosis between both arteries and the small diameter of the distal radial artery juxta-anastomosis segment could reduce the vascular access flow. The flow rates in the brachial artery were 500 mL/min just after surgery and 560 mL/min at 2 months after surgery. Postoperative chest radiography and echocardiography confirmed a decrease in cardiac preload. We believe that this RAHT technique could be useful as one of the options to reduce the flow in patients who have excessive vascular access flow with a radial artery that makes a hairpin turn.

Incidence, diagnosis and treatment of popliteal artery entrapment syndrome in current vascular practice in Japan.

Few data regarding popliteal artery entrapment syndrome (PAES) is available in Japan. In this study, we investigated incidence, diagnosis and treatment of PAES in current vascular practice. A retrospective analysis of all patients with PAES visiting 31 participating institutes between 2003 and 2015 was conducted. Thirty-five limbs (28 patients) were identified during the 13-year study period, and the incidence of PAES was 0.12% of all peripheral artery disease cases revascularized. Mean age was 32.0 ± 16.9 years old, and 60 and more years old was 10.7%. Also, 92.9% were male and 39.3% were athletes. Most frequent initial symptoms were intermittent claudication in 23 limbs (65.7%); 4 limbs (11.4%) had chronic limb-threatening ischemia. CT scan was most frequently (94.3%) used for the diagnostic imaging followed by MRI (45.7%) and duplex ultrasound (45.7%). Stress test such as dorsal flexion during duplex ultrasound was used only in 28.6%. Thirty-two limbs (91.4%) received surgical treatment, including 23 arterial reconstructions (71.9%); there were no major perioperative complications. All patients achieved improvement of their symptoms, and the average ankle brachial index increased from 0.69 ± 0.22 to 1.00 ± 0.14 post-surgery. The average postoperative follow-up period was 26.0 months with only one reintervention during the follow-up. In conclusion, PAES was a rare condition and traditional surgical treatment was solid. However, given a broad spectrum of clinical feature of PAES and less usage of diagnostic duplex ultrasound with stress test, there might be a miss- or delayed diagnosis of PAES even in the current vascular practice.

Evaluation of the adsorption properties of nucleobase-modified sorbents for a solid-phase extraction of water-soluble compounds.

We developed hydrophilic interaction chromatography (HILIC)-type sorbents modified with nucleobases for solid phase extraction (SPE). The synthesized hydrophilic base resins were modified by each nucleobase (adenine, guanine, and cytosine). The measurement of the amount of water content indicated that each nucleobase-modified sorbent had a water layer. To evaluate the adsorption properties in the HILIC mode, we chose two nucleobases (uracil and adenine) and four nucleosides (uridine, adenosine, cytidine, guanosine) as water-soluble analytes, which were loaded into an SPE cartridge packed with the nucleobase-modified sorbent. Firstly, 95% acetonitrile (ACN) solutions were used in the process of conditioning and sample loading of the above polar analytes. High recoveries of the analytes were observed in each nucleobase-modified sorbent, and the Diol-type sorbent (no modification with any of the nucleobases) did not adsorb each water-soluble analyte. On the basis of this result, a 98% ACN solution was used during the process of conditioning and sample loading to decrease the concentration of water in the sample, which potentially inhibited the formation of hydrogen bonding between each analyte and the modified nucleobase. Considerable improvements of recoveries were observed in Adenine- and Cytosine-modified sorbents. These results were possibly attributed to the effective expression of hydrogen bonding by decreasing water concentration in the sample solution. Although a non-aqueous (100% ACN) sample solution can be expected to obtain higher recoveries compared with the 98% ACN solution, a decrease in recoveries was observed in Adenine-modified sorbent. From these results, the highest adsorption property was observed in Adenine-modified sorbent using 98% ACN as a sample condition, and the combination of this sample condition and sorbent is effective for high adsorption under HILIC condition. Moreover, we also revealed that a balance between the thickness of water layer and the modification amount of nucleobase is important for retention in the HILIC-type sorbent.

Acute mitral valve endocarditis at the 24th gestational week.

Infective endocarditis during pregnancy and subsequent cardiac surgery are rare and carry a high mortality risk for both the mother and fetus. We report our experience with a previously healthy, 22-year-old woman affected by acute active mitral endocarditis due to Streptococcus gordonii at the 24th gestational week, who wished to continue with the pregnancy. Due to cardiogenic shock, an intra-aortic balloon pump was inserted. Our patient successfully underwent mitral valve replacement with normothermic high-flow cardiopulmonary bypass and continuous intraoperative fetus monitoring. She delivered a 2524-g baby vaginally at the 38th gestational week. Both the mother and child were confirmed to be doing well at the 1-year follow-up. Although this was the first case, urgent cardiac surgery and a subsequent childbirth went well by prompt decision of each department.

Venous thromboembolism complications after endovenous laser ablation for varicose veins and role of duplex ultrasound scan.

OBJECTIVE: A nationwide survey was conducted in Japan to determine the incidence of venous thromboembolism (VTE) after endovenous thermal ablation for varicose veins and to investigate its pathogenic background. METHODS: The survey targeted all cases of endovenous thermal ablation between January 2011 and December 2013. Based on this survey, a retrospective study of patients who developed endovenous heat-induced thrombosis (EHIT) of classes 2 to 4, no EHIT-related deep venous thrombosis (DVT), and pulmonary embolism (PE) was conducted. Lower extremity venous ultrasound was performed within 72 hours and at 1 to 3 months postoperatively in all institutions. We investigated factors associated with the occurrence of complications and the usefulness of postoperative ultrasound. RESULTS: Survey responses were collected from 213 institutions. Endovenous laser ablation was performed for 43,203 patients (EHIT 2 in 318 patients, EHIT 3 in 50 patients, EHIT 4 in 7 patients, other DVTs in 24 patients, and PE in 3 patients). The incidence of VTE complications was 1.0% for EHIT 2, 0.11% for EHIT 3, 0.013% for EHIT 4, 0.063% for other DVTs, and 0.0067% for PE based on the adjusted population. Sex, age, obesity, origin of the varicose vein, vein diameter, and preoperative Caprini score were not strong indicators of VTE complications. Of 50 patients with EHIT 3, there were 35 patients who had EHIT 3 during the first postoperative ultrasound session. In one patient, EHIT 3 progressed to EHIT 4 despite initiation of anticoagulant therapy. Of seven patients with EHIT 4, only one patient had EHIT 4 at the first postoperative ultrasound examination. Because ultrasound performed before the occurrence of EHIT 4 revealed that three patients had EHIT 2 or EHIT 3, EHIT 4 could have possibly been predicted by ultrasound. Of three patients with PE, two developed PE before ultrasound, and EHIT was not detected by ultrasound in one of those patients before PE developed. Anticoagulant therapy was administered in most patients with EHIT 3 and all patients with EHIT 4 and PE, with favorable outcomes. CONCLUSIONS: The incidence of VTE complications after endovenous laser ablation was low. Furthermore, the value of performing postoperative ultrasound for VTE management seems to be low because the occurrence of severe VTE complications could not be predicted by lower extremity venous ultrasound. Although the perioperative detection of VTE complications by this modality resulted in the early administration of anticoagulant therapy and may have contributed to improved prognosis, the number of those patients was limited.

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.

Effects of pendant-like hydrophilic monomers on the adsorption properties of reversed-phase-type sorbents for solid-phase extraction.

Solid-phase extraction (SPE) has been extensively employed as a pretreatment method. In SPE, reversed-phase-type sorbents have been widely applied for the pretreatment of environmental or biological samples. Hydrophilic-lipophilic balance (HLB)-type sorbents, constituting the copolymers used as reversed-phase-type sorbents, have been applied for various sample pretreatment methods. In HLB-type sorbents, the hydrophilic monomer contributes to the improved wettability of sorbents and increase of polar interactions. In this study, three pendant-like hydrophilic monomers, viz. N-vinylpyrrolidone (NVP), 4-acryloylmorpholine (AMO), and 4-vinyl-1,3-dioxolan-2-one (VDO), respectively, exhibiting different Log P values and possibly causing different polar interactions, were selected to improve the adsorption properties of polar compounds, and divinylbenzene (DVB)-based HLB-type sorbents containing each hydrophilic monomer were synthesized and examined. By the optimization of the molar ratio of DVB and the hydrophilic monomer (i.e. HLB), the inert diluent, and the degree of cross-linking, the developed sorbents exhibited higher recoveries for various polar compounds (viz. cytosine, uracil, cytidine, uridine, 2'-deoxycytidine, 2'-deoxyguanosine, adenine, thymidine, adenosine, and 2'-deoxyadenosine) compared to commercially available HLB-type sorbents.

3D microdevices that perform sample purification and multiplex qRT-PCR for early cancer detection with confirmation of specific RNAs.

MicroRNA expression analysis is an important screening tool for the early detection of cancer. In this study, we developed two portable three-dimensional microdevices for multiple singleplex RNA expression analysis by microRNA purification and qRT-PCR as a prototype for point-of-care testing. These microdevices are composed of several types of modules termed 'chemical IC chips'. We successfully reduced the heating area and fluorescence observation area, reduced the energy required for the reaction, and improved the portability of all systems in the devices. The purification microdevice could purify the microRNA from the sample using the FTA elute card system. The disposable reactor module mounted on both devices was easily fabricated by deforming a 100-µm-thick polypropylene film using an uncomplicated procedure. The qRT-PCR microdevice could perform reactions for samples of small volume. We purified microRNA from the HepG2 liver cancer cell line using the purification microdevice and confirmed the expression level of miR-224, which is a potential biomarker for liver cancer. Furthermore, we observed an increase in the fluorescence intensity when we performed qRT-PCR in the qRT-PCR microdevice. Therefore, the two developed microdevices show promise as a new portable tool for early cancer detection.

Effects of hydrophilic monomers on sorptive properties of divinylbenzene-based reversed phase sorbents.

Solid phase extraction (SPE) has been extensively used as a pretreatment method. In SPE methods, commercially available reversed phase type sorbents, which consist of macroporus styrene-divinylbenzene or copolymers including divinylbenzene (DVB) and hydrophilic monomers, have been applied to a variety of samples. The later sorbents are called hydrophilic lipophilic balanced (HLB) type sorbents. Hydrophilic monomers in hydrophilic lipophilic balanced type sorbents contribute to the increase in retention of polar compounds, because hydrophilic monomers improve the wettability and increase the interaction with polar compounds as analytes. In this study, three different methacrylate monomers (ethylene glycol dimethacrylate (EGDMA), glycerol dimethacrylate (GDMA) and trimethylolpropane trimethacrylate (TMPTMA)), which are expected to improve the retention of polar compounds, were chosen, and DVB-based copolymetric sorbents including the three monomers were newly synthesized. Among them, the sorbents including GDMA or TMPTMA gave higher recoveries to polar compounds such as uridine and adenine than that including EGDMA. The optimization studies of hydrophilic lipophilic balance, inert diluent and the purity of DVB improved the sorptive abilities of the sorbents. The developed sorbents have higher recoveries for variety of polar compounds (cytosine, uracil, cytidine, uridine, 2'-deoxycytidine, 2'-deoxyguanosine, adenine, thymidine, adenosine and 2'-deoxyadenosine) than commercially available hydrophilic lipophilic balanced type sorbents, while the recoveries for theophylline were comparable between the proposed sorbents and the commercial sorbents.

Multiple Recurrent Pseudoaneurysms after Endovascular Repair of Abdominal Aortic Aneurysm in a Patient with Behçet's Disease.

In Behçet's disease (BD) patients, endovascular repair is a reasonable alternative treatment for aortic aneurysms to avoid postoperative anastomotic pseudoaneurysms. However, there are some complications that may occur after endovascular repair. We herein report the case of a 40-year-old man with active BD developed recurrent aortic pseudoaneurysms at the proximal and distal margins of the stent graft and a femoral puncture site pseudoaneurysm 3 months after endovascular abdominal aortic aneurysm (AAA) repair. The aortic pseudoaneurysms were treated endovascularly, including the use of the chimney technique for the proximal pseudoaneurysm close to the renal arteries and the femoral pseudoaneurysm with surgical excision and reconstruction. Intensive immunosuppressive therapy was initiated immediately after the operation. The patient is in good condition without any complications at 8-month follow-up. This case suggests the utility of the chimney technique and postoperative immediate intensive immunosuppressive therapy in treating recurrent aortic pseudoaneurysms in emergency, active BD patients.

In Patients with Severe Peripheral Arterial Disease, Revascularization-Induced Improvement in Lower Extremity Ischemia Can Be Detected by Laser Speckle Contrast Imaging of the Fluctuation in Blood Perfusion after Local Heating.

BACKGROUND: We previously reported the utility of the perfusion value (PV) fluctuation slope for detecting severe ischemia in the lower limb. Our approach was based on a thermal load test mimicking the well-known physiological reaction termed "cold-induced vasodilation," which is known to occur as a 3-phase phenomenon. The slope parameter quantifies the decrease in PVs accompanying the relative cooling (third phase) following the transient increase in blood flow (second phase) induced by the applied thermal load. This phenomenon of "relative" cold-induced vasodilation (rCIVD) can be monitored using laser speckle contrast imaging (LSCI) after applying the thermal load (LTL test). Here, we aimed to determine whether the slope parameter obtained via the LTL test also reflects the improvement in hemodynamics after revascularization. METHODS: The study enrolled 16 patients (18 limbs), who underwent revascularization for peripheral arterial disease (PAD). The measurements were performed at 2 sites in each limb (in total, 34 sites; 2 sites in one patient were excluded because of significant movement during the measurement). For each site, we recorded the slope describing the behavior of PVs (decrease or plateau) in the third phase of rCIVD, following the initial, heating-induced increase in perfusion (second phase of rCIVD). The plateau group (group P), which included patients with an abnormal rCIVD, and the decrease group (group D), which included patients with a normal rCIVD, were defined based on perfusion slope values of <0.20 and ≥ 0.20 perfusion units/min, respectively. We also quantified the transient increase in perfusion (from baseline to peak) as a descriptor of perfusion behavior during the second phase of rCIVD. RESULTS: In group P, the change in median values (25-75%) of the slope, transcutaneous oxygen tension, and ankle-brachial index (ABI) from before to after operation was (-0.02 [-0.04 to 0.02]; 4 [1-11]; and 0.08 [0-0.27]) to (0.39 [0.32-0.59]; 46 [37-54]; and 0.81 [0.72-0.90]). Conversely, in group D, the change in the median values of the slope, transcutaneous oxygen tension, and ABI between before and after operation was (0.38 [0.32-0.49]; 40.5 [35-45]; and0.58 [0.57-0.65]) to (0.44 [0.30-0.64]; 52 [43-56]; and 0.92 [0.81-0.99]). Sites exhibiting perfusion pattern of group D in the third phase of rCIVD showed no significant change in slope after revascularization (P = 0.21), whereas the slope in group P increased significantly after revascularization, becoming similar to the postoperative slopes in group D (P = 0.81). The amount of transient increase in perfusion, which quantified the behavior in the second phase of rCIVD, showed a similar behavior. Preoperatively, all patients in group P had rest pain and/or ulcer of the foot, whereas only few patients in group D had such symptoms. CONCLUSIONS: Normal rCIVD response in the LTL test indicates less-than-severe ischemia, while abnormal rCIVD response measured via the LTL test indicates severe ischemic symptoms, such as critical limb ischemia. Notably, patients with an abnormal rCIVD response can develop a normal rCIVD response following revascularization, thereby reflecting an improvement in blood flow. The LTL test assessing rCIVD response can be useful for detecting severe limb ischemia, such as critical limb ischemia (CLI), and determining the departure from severe limb ischemia by revascularization.

The evaluation of contralateral foot circulation after unilateral revascularization procedures using indocyanine green angiography.

The aim of the present study is to assess the effects of unilateral revascularization on the contralateral foot circulation using indocyanine green (ICG). From January 2016 to April 2016, a total of twenty-one patients were included in this study. The patients underwent elective unilateral revascularization at our institution and we evaluated the feet circulation by indocyanine green angiography (ICGA) tests preoperatively and postoperatively. The ICGA parameters included the magnitude of intensity from the onset of ICG to the maximum intensity (Imax), the time from the onset of ICG to the maximum intensity (Tmax), and the time required to reach the half maximum intensity from the onset of ICG (T1/2). There were significant differences in the treated limb Tmax (P = 0.016) and T1/2 (P = 0.013) values and in the contralateral limb Tmax (P = 0.013), and T1/2 (P < 0.001) values on the perioperative ICGA tests. These results reflect the increase in skin perfusion in the treated limb and the decrease in skin perfusion in the contralateral limb. Unilateral revascularization decreases contralateral foot circulation. The preoperative contralateral lesion should be evaluated when revascularization is performed.

Successful Complete Surgical Resection of a Large Venous Malformation of the Lower Extremity: A Case Report.

Venous malformations (VMs) are the most common type of vascular malformations, resulting from errors in vascular morphogenesis. Because of the wide variety in their presentations, selecting the appropriate treatment, especially for large VMs, may be challenging. Herein, we report a case of a 59-year-old man with a large VM in the lower extremity who achieved favorable outcomes by complete surgical resection. Even large VMs can be successfully treated with surgery when patients are properly selected. An accurate and careful evaluation is essential for achieving optimal outcome in patients with VMs.

The possibility of free tissue transfer as a nutrient flap for critical ischemic foot: A case report.

Microsurgical procedure of free tissue transfer in critical limb ischemia patients with large ulceration has already been established. The nutrient flap concept was that transferred tissue functioned not only to cover the skin defect but also as a supplementary blood supply to the ischemic lower leg. This report showed the justification for this concept, which was rarely discussed. A 58-year-old male patient with progressive forefoot gangrene caused by arteriosclerosis obliterans was presented. The distal bypass procedure was performed as revascularization surgery, and a latissimus dorsi (LD) myocutaneous flap was transplanted to cover ulceration. The arterial pedicle of the flap was anastomosed to the vein graft in an end-to-end manner, and the venous pedicle was anastomosed to the posterior tibialis vein in an end-to-end manner. Bypass graft blood flow went straight to the LD flap only. The postoperative course was uneventful. The free flap and right foot survived successfully and the patient was ambulatory with no recurrence of ulceration wearing order-made shoes more than three years after transplantation. Vessel-selective angiography was performed two months after surgery. An angiographic catheter was inserted into the bypass graft, which ran straight through the flap nutrient artery. The results obtained showed that not only the transferred flap area, but also the remaining original foot soft tissue (including the sole and heel) was clearly visualized radiologically only through the flap nutrient vessel. This findings of the angiography appear to provide direct evidence for the nutrient flap concept.