Revascularization and Digestive Tract Repair in Secondary Aortoenteric Fistula Using a Single-Center in Situ Revascularization Strategy.

BACKGROUND: Information regarding optimal revascularization and digestive tract repair in secondary aortoenteric fistula (sAEF) remains unclear. Thus, reporting treatment outcomes and presenting comprehensive patient details through a structured treatment approach are necessary to establish a treatment strategy for this rare, complex, and fatal condition. METHODS: We performed a single-center retrospective review of consecutive sAEF managed based on our in situ revascularization and intestinal repair strategy. The primary endpoint of this study was all-cause mortality, and secondary endpoints were the incidence of in-hospital complications and midterm reinfections. RESULTS: Between 2007 and 2020, 16 patients with sAEF, including 13 men (81%), underwent in situ revascularization and digestive tract repair. The median follow-up duration for all participants was 36 (interquartile range, 6-62) months. Among the participants, 81% (n = 13), 13% (n = 2), and 6% (n = 1) underwent aortic reconstruction with rifampin-soaked grafts, unsoaked Dacron grafts, and femoral veins, respectively. The duodenum was the most commonly involved site in enteric pathology (88%; n = 14), and 57% (n = 8) of duodenal breaks were repaired by a simple closure. Duodenum's second part-jejunum anastomosis was performed in 43% of patients (n = 6), and 19% of the patients (n = 3) died perioperatively. In-hospital complications occurred in 88% patients (n = 14), and the most frequent complication was gastrointestinal. Finally, 81% patients (n = 13) were discharged home. Oral antibiotics were administered for a median duration of 5.7 months postoperatively; subsequently, the participants were followed up carefully. Reinfection was detected in 6% of the patients (n = 1) who underwent reoperation without any complications. The 1-year and 3-year overall survival rates of participants were 75% (n = 12) and 75% (n = 9), respectively, and no sAEF-related deaths occurred, except perioperative death. CONCLUSIONS: Surgical intervention with contemporary management based on our vascular strategy and digestive tract procedure may be a durable treatment for sAEF.

Prevention of Buttock Claudication by Preserving Antegrade Bilateral Superior Gluteal Arterial Blood Flow in EVAR for Aorto-Iliac Aneurysm Accompanied by Bilateral Internal Iliac Artery Aneurysms.

Buttock claudication (BC) is a complication of surgery for aorto-iliac aneurysms (AIAs) caused by sacrificing blood flow in the internal iliac artery (IIA). However, the preservation of antegrade blood flow of IIAs is often challenging when performing both open surgery and endovascular aneurysm repair (EVAR) for AIAs accompanied by IIA aneurysms. We performed EVAR and successfully preserved the antegrade blood flow of bilateral superior gluteal arteries using the GORE EXCLUDER iliac branch endoprosthesis with the VIABAHN endograft. BC did not occur, both subjectively and objectively, after surgery. This approach can be minimally invasive yet an effective procedure to prevent BC.

Successful Treatment of Giant Common and Proper Hepatic Artery Aneurysm Complicating Autosomal Dominant Polycystic Kidney Disease.

Hepatic artery aneurysms (HAAs) complicating autosomal dominant polycystic kidney disease (ADPKD) are extremely rare. On account of the large number of renal cysts in ADPKD, ingenuity is required to safely perform surgery for HAA. Here, we present the case of a 60-year-old man with a common and proper HAA of >60 mm complicated with ADPKD. In this patient, difficulty in maintaining the field of view was expected during surgery. Hence, we performed a hybrid approach with celiac-to-right hepatic artery bypass by puncturing the femoral artery and cannulating the splenic artery to allow celiac-splenic artery balloon occlusion in case of rupture. More than 5 years postoperatively, the graft is patent without intervention.

The Incidence of Para-Anastomotic Aneurysm After Open Repair Surgery for Abdominal Aortic Aneurysm Through Routine Annual Computed Tomography Imaging.

OBJECTIVE: Open repair surgery (ORS) for an abdominal aortic aneurysm (AAA) remains an important treatment option, but the incidence of para-anastomotic aneurysms is unclear. The purpose of this study was to estimate the incidence of para-anastomotic aneurysms and reveal secondary complications through routine annual computed tomography (CT) imaging. METHODS: One hundred and forty-seven patients who underwent ORS for AAA between January 2006 and December 2015 and received routine CT imaging surveillance were enrolled. RESULTS: The follow up period was 7.1 ± 2.7 years. The total follow up time of all patients was 1 041.1 years, and 958 CT images were collected (0.92 CT scans/year/patient). A proximal para-anastomotic aneurysm was detected in five patients (3.4%). Four of the five patients had aneurysmal dilation at the initial ORS (proximal diameter >25 mm), which enlarged during follow up; thus, a de novo proximal para-anastomotic aneurysm was observed in one patient (0.7%). The time between surgery and the diagnosis of all proximal para-anastomotic aneurysms was 5.7 ± 1.4 years, and the de novo proximal para-anastomotic aneurysm was detected at 11.8 years. The incidence of all para-anastomotic aneurysms at five and 10 years was 2.2% and 3.6%, and the incidence of the de novo para-anastomotic aneurysm was 0% at five and 10 years. Nine synchronous thoracic aortic aneurysms (TAAs) and seven metachronous TAAs were detected, and 16 patients (10.9%) had a TAA. Neoplasms were detected in 18 of 147 patients (12.2%), and the most dominant neoplasm was lung cancer. CONCLUSION: The incidence of para-anastomotic aneurysms was low; thus, abdominal and pelvic CT imaging every five years may be sufficient and consistent with the current AAA guidelines. In contrast, TAAs were diagnosed in a high percentage of patients, and based on these observations, routine CT imaging should be expanded to include the chest.

The Epidemiology of Micro-arteriovenous Fistulas in the Lower Legs.

BACKGROUND: Patients presenting with edema, skin redness, pain, and itching in their lower legs are common and encountered often in daily practice. However, although commonly recognized diseases such as deep venous thrombosis, stasis dermatitis due to varicose veins, lymphedema, and cellulitis are diagnosed correctly in most cases, micro-arteriovenous fistulas (AVFs) may often be overlooked due to low awareness and rarity. This study was carried out to evaluate the prevalence of micro-AVF in patients presenting with foot skin symptoms. METHODS: A total of 134 patients (184 limbs) visited the Department of Vascular Surgery at Kesennuma City Hospital with edema, skin redness, pain, and itching in their lower legs from January to September 2017 and were enrolled and followed up until November 2017. All patients received ultrasonic inspection of their symptomatic limb, and a blood test (white blood cell count, C-reactive protein, and d-dimer) was performed if needed. When micro-AVF was detected in one limb, the other limb was routinely inspected by ultrasonography. A computed tomography scan was performed with the patient's consent. Patients diagnosed with micro-AVF started compression therapy immediately and were followed up for at least 2 months. A surgical procedure was considered if the symptoms worsened. RESULTS: Micro-AVFs were detected in 24 limbs (13%, 24/184) of 14 patients (7 males and 7 females; age 70 ± 11.7 years). Four patients had unilateral skin symptoms with unilateral micro-AVFs and 7 patients had unilateral skin symptoms and bilateral micro-AVFs. Three patients had bilateral skin symptoms and bilateral micro-AVFs. Asymptomatic micro-AVFs were detected in 7 limbs. Subjective symptoms disappeared and skin appearance normalized in 14 limbs of 12 patients during the first 2 months with compression therapy only. Compression therapy was not effective in 3 limbs of 2 patients and they underwent vein ligation surgery. None of the patients had a surgical history or history of trauma in their lower legs. CONCLUSIONS: Among the lower legs presenting with skin symptoms, we detected micro-AVFs in 13% of limbs; therefore, micro-AVF of the lower leg is not as rare as previously thought. In addition, 10 of 14 patients (71%) had micro-AVFs of the lower leg bilaterally.

Mortality rates and walking ability transition after lower limb major amputation in hemodialysis patients.

OBJECTIVE: The number of hemodialysis patients with peripheral artery disease is increasing, and critical limb ischemia develops in some of these patients. The clinical outcomes in such patients after major amputation remain unclear. We therefore examined the mortality rates after major amputation in hemodialysis patients. METHODS: The study enrolled 108 hemodialysis patients undergoing their first major amputation at Community Health Care Organization Sendai Hospital between January 2005 and December 2014 and monitored them until June 2015. All-cause mortality and additional amputation-free survival were evaluated by Kaplan-Meier analysis. RESULTS: The most dominant primary disease of renal failure was diabetes mellitus (77%), and the duration of hemodialysis was 8.5 ± 6.8 years. During the median follow-up period of 11.5 months (20.3 ± 22.6 months), 80 patients (74%) died, and the survival rates were 83% at 30 days, 56% at 1 year, and 15% at 5 years. The median time to death was 19.9 months (95% confidence interval, 9.8-30.0 months), and the causes of death were cardiac (45%), sepsis (29%), cerebrovascular (4%), and others (22%). Thirty-one patients underwent additional amputation, and the additional amputation-free survival rates were 39% at 1 year and 9% at 5 years. The median time between the first and second amputations was 2.5 months (5.7 ± 7.6 months). Univariate analysis showed previous minor amputation (P = .04) and low hematocrit level (P = .04) were associated with the 30-day mortality rate, and age (P = .05) was associated with the 5-year mortality rate. On multivariate Cox proportional hazard analysis, only age was associated with mortality rate (hazard ratio, 1.02; 95% confidence interval, 0.99-1.02; P = .04). We also compared walking ability before and after major amputation among patients who survived >60 days. The rate changed from 34% to 12% for of ambulatory patients, from 45% to 48% for wheelchair use, and from 21% to 40% for bedridden patients. Ambulatory patients had a significantly better survival rate than the others (P = .02). CONCLUSIONS: The mortality rate after major amputation in hemodialysis patients was high, and major amputation had a huge negative effect on patients' walking ability.

Extracorporeal shock wave therapy improves the walking ability of patients with peripheral artery disease and intermittent claudication.

BACKGROUND: Despite the recent advances in bypass surgery and catheter interventional therapy for peripheral artery disease (PAD), the long-term outcome of revascularization therapy for infrapopliteal lesions remains unsatisfactory. We have previously demonstrated that low-energy extracorporeal shock wave (SW) therapy effectively induces neovascularization through upregulation of angiogenic factors and improves myocardial ischemia in pigs and humans and in hindlimb ischemia in rabbits. In this study, we thus examined whether our SW therapy also improves the walking ability of patients with PAD and intermittent claudication. METHODS AND RESULTS: We treated 12 patients (19 limbs) in Fontaine II stage (males/females, 10/2; 60-86 years old) with low-energy SW therapy to their ischemic calf muscle 3 times/week for 3 consecutive weeks. After 24 weeks, the pain and distance subscale scores of the walking impairment questionnaire were significantly improved (33±25 vs. 64±26, 27±16 vs. 64±23, respectively, both P<0.01). Maximum walking distance was also significantly improved at 4 weeks (151±37% from baseline, P<0.01) and was maintained at 24 weeks (180±74% from baseline, P<0.01). Moreover, the recovery time of the tissue oxygenation index in the calf muscle during a treadmill test, which reflects local O2 supply, was significantly shortened (295±222s vs. 146±137s, P<0.01). Importantly, no adverse effects were noted. CONCLUSIONS: Non-invasive SW therapy improves the walking ability of PAD patients.

Clinical characteristics of young-onset and medical treatment-requiring hypertension identified by targeted screening in university health check-up.

Based on targeted screening for hypertension at a university health check-up, we previously reported a high incidence of white-coat hypertension and estimated prevalence of hypertension requiring medical treatments (HT) as around 0.1% in young population aged less than 30. In spite of such low prevalence, continuous screening for seven consecutive years (2003-2009) increased the number of HT students to 20 (19 males and 1 female). We presently assessed the clinical characteristics of these HTs. Renovascular hypertension was found in the only female HT and aortic valve regurgitation in two HTs. Resting 17 HTs were diagnosed as having essential hypertension (EH). A father and/or a mother had EH in 16 out of 17 EHs, and blood pressure (BP) at home was slightly elevated (135-145 mm Hg in systolic) except three obese EHs (body mass index more than 30) who demonstrated more than 160 mm Hg in systolic. Plasma aldosterone-renin ratio (ARR) of EHs did not differ from that of normal controls, and Pearson correlation coefficient (R) between ARR and systolic BP (SBP) was -0.2. Its partial correlation coefficient, however, was statistically significant (R = -0.55, P = .026) after correcting for body mass index, which was significantly correlated with both SBP (P = .006, after correcting for ARR) and ARR (P = .004, after correcting for SBP). In conclusion, most of young-onset HTs are male EHs, and aortic valve regurgitation should be carefully checked. Excess plasma renin activity would be one of additional characteristics of young-onset EH to male gender, genetic background, and increased body mass.

Inflammatory popliteal aneurysm.

A 67-year-old man was referred to our department because of fever, right lower thigh swelling, and redness with pain. Laboratory tests showed slightly elevated leukocytes and markedly elevated C-reactive protein levels. Computed tomography confirmed a popliteal aneurysm with wall thickening, so-called mantle sign. Aneurysmorrhaphy with a reversed autologous saphenous vein reconstruction was performed. Aneurysm sac and perianeurysm tissue cultures were negative for aerobic and anaerobic bacteria. The microscopic appearance of the aneurysm showed thickening of the adventitia and infiltration of inflammatory cells. This report presents, for the first time, findings suggestive of an inflammatory aneurysm of the popliteal artery.