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.

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.

Randomized Controlled Trial of Oral Tranexamic Acid Intervention for the Prevention of Type II Endoleak after Endovascular Abdominal Aneurysm Repair.

PURPOSE: The purpose of this study was to evaluate tranexamic acid (TA) for the prevention of type II endoleak (EL2) at a high level of evidence by a randomized controlled trial. METHODS: Patients who underwent endovascular aneurysm repair (EVAR) between May 2017 and January 2020 were included. Patients in the TA group were given 750 mg of TA daily for a month after EVAR. The incidence of EL2, blood coagulation/fibrinolytic ability, and changes in aneurysm diameter were compared between two groups. RESULT: On the 7th day after EVAR, EL2 was found in 14 patients (34.1%) in the TA group and in 7 patients (15.9%) in the non-TA group. It was also found in 12 patients (29.3%) in the TA group and 6 patients (13.6%) in the non-TA group at 1 month after EVAR. There was no significant difference in the incidence of EL2 between the two groups (p = 0.051, 0.08). Blood tests revealed that fibrin degradation product and D-dimer were significantly suppressed in the TA group, there was no significant difference in the change of diameter regardless of the TA intake. CONCLUSION: This study proved anti-fibrinolytic effect of the TA, but it alone had not enough power to decrease EL2 after EVAR.

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.

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.

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.

A Case of Effective Balloon Fenestration for Localized Aortic Dissection Complicated with Acute Renal and Bilateral Limb Ischemia in a Thoracoabdominal Aortic Aneurysm.

An 85-year-old man visited our hospital with bilateral leg weakness. Blood tests revealed an abrupt deterioration of renal function. Computed tomography revealed a 53-mm aortic aneurysm at the level of the diaphragm with an aortic dissection after branching of the superior mesenteric artery. An emergency left axillary-left femoral artery bypass surgery was performed to secure blood flow to the kidneys and lower limbs. Five days later, a transcatheter balloon fenestration for the stenosis was performed, and the blood pressure of the infrarenal aorta was improved. Both the dorsal pedis and posterior tibial arteries became palpable, and renal function was improved.

Thoracic Endovascular Aortic Repair for Pseudoaneurysms After Repair of Patent Ductus Arteriosus.

BACKGROUND: Pseudoaneurysms that develop after surgical repair of a patent ductus arteriosus (PDA) are more likely to rupture, but open surgery including a repeat thoracotomy would be highly invasive. We report 2 cases of thoracic endovascular aortic repair (TEVAR) for such pseudoaneurysms. METHODS/RESULTS: A 59-year-old woman who underwent PDA surgical ligation at 13 years of age presented with sudden hemoptysis. She was diagnosed with a ruptured distorted pseudoaneurysm sized 26 mm; emergency TEVAR was performed. A 23-year-old woman with a history of Down syndrome, endocardial cushion defect, and PDA underwent 2 thoracotomy surgeries including PDA ligation. During a medical checkup, an abnormal shadow was detected on chest radiography. She was diagnosed with a 15-mm pseudoaneurysm after PDA surgical repair; TEVAR was performed. In both cases, the postoperative course was uneventful. CONCLUSIONS: To the best of our knowledge, this is the first report of emergency TEVAR for ruptured pseudoaneurysms after PDA ligation. Thoracic endovascular aortic repair is an important therapeutic option for such cases as it eliminates the need for repeat thoracotomy.

Popliteal Artery Entrapment Syndrome in Siblings.

Popliteal artery entrapment syndrome (PAES) is a rare disease. We treated siblings with this disease. An 18-year-old male consulted our hospital for intermittent claudication of the left lower limb. Contrast-enhanced computed tomography led to a diagnosis of type II PAES. After transection of the medial head of the gastrocnemius muscle, popliteal artery bypass was performed. His younger brother (6 years younger) was also diagnosed with type II PAES, and similar surgery was performed at the age of 19. These cases suggested the involvement of genetic factors in PAES in addition to embryological factors.

Spinal Subdural Hematoma owing to the Removal of Cerebrospinal Fluid Drainage Tube During Thoracic Endovascular Aortic Repair.

BACKGROUND: Cerebrospinal fluid (CSF) drainage during the treatment of aortic disease is commonly performed to prevent spinal cord ischemia. Spinal subdural hematoma (SDH) has never been reported after CSF drainage during thoracic endovascular aortic repair (TEVAR). We present a case of concurrent intracranial subarachnoid hemorrhage (SAH) and spinal SDH after CSF drainage tube removal in a patient with TEVAR. CASE DESCRIPTION: A 73-year-old man was hospitalized to undergo TEVAR. The day before the procedure, a lumbar CSF drainage tube was inserted. Continuous CSF drainage was performed only during the procedure, and the tube was removed the following day. The patient complained of mild back pain on postoperative day 2; headache, bilateral lower limb paresis, and bladder and rectal disturbances developed on postoperative day 5. Brain and spinal magnetic resonance imaging revealed spinal subdural or subarachnoid hematoma and intracranial SAH. Lumbar laminectomies for spinal SDH removal were performed; lower limb strength improved immediately after surgery. At postoperative 2 years, the patient returned to his preoperative activity level; only mild right lower limb numbness persisted. CONCLUSIONS: We present a rare case of intracranial SAH and spinal SDH that developed after CSF drainage tube removal in a patient with TEVAR. CSF drainage should be carefully considered in patients undergoing aortic procedures, as SAH and spinal SDH may occur in addition to spinal cord ischemia.

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.

What Is Vascular Behçet's Disease?

Vascular Behçet's disease (BD) would keep risk of anastomotic pseudoaneurysm due to deterioration of the disease even after vascular surgery was successfully done. Therefore, it is one of the least-welcome diseases for vascular surgeons. There still exist several points on a concept and criteria of the vascular BD which not only general practitioners but also the vascular surgeons do not understand. Clinical findings strongly suspecting vascular BD are follows; saccular aneurysms without atherosclerosis developed in younger than 50-year-old patients, superior vena cava syndrome or deep vein thrombosis in bilateral legs without apparent causes, and multiple superficial thrombophlebitis, etc. It is very difficult to make a diagnosis of BD in the patients whose onset of the disease is a vascular lesion, because vascular BD combines few ocular lesions. In such case, it is very important to find out not only oral and genital ulceration, but also past history of arthritis. To establish the vascular BD, we vascular surgeons have to collect cases of the vascular BD and to revise criteria of the disease. (This is a translation of Jpn J Vasc Surg 2017; 26: 19-23.).

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.

A Case of Patent Ductus Arteriosus in an Elderly Patient Treated by Thoracic Endovascular Aortic Repair.

The patient described herein was a 75-year-old female. Echocardiography showed patent ductus arteriosus (PDA). Heart failure symptoms gradually appeared, and she was referred to our department for treatment. Contrast-enhanced computed tomography (CT) revealed a tubular structure communicating between the aortic arch and pulmonary artery trunk, suggesting adult PDA. Thoracic endovascular aortic repair (TEVAR) was performed to close PDA. Completion angiography confirmed the disappearance of PDA. Post-TEVAR CT revealed no endoleak. The patient was discharged from the hospital on the 11th day after surgery. TEVAR is more useful and less invasive for adult PDA than conventional open surgery.

[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.

[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.