Reduced Muscle Mass and Muscle Quality in Patients with Intermittent Claudication due to Peripheral Artery Disease.

BACKGROUND: Peripheral arterial disease (PAD) is associated with reduced muscle mass and quality, but the effects of leg ischemia caused by PAD on muscle quality remain poorly understood. The purpose of this study was to evaluate leg muscle mass and muscle quality in patients with intermittent claudication due to PAD using bioelectrical impedance analysis (BIA). METHODS: One hundred forty-one patients with intermittent claudication due to PAD who visited Tokyo Medical University Hospital from April 2019 to April 2020 were retrospectively analyzed. Leg ischemia was assessed using ankle-brachial pressure index (ABI). The skeletal muscle mass (SMM) assessed leg muscle mass, while the phase angle (PhA) assessed leg muscle quality using BIA. RESULTS: A total of 282 legs in 141 patients were included in the analysis. Leg PhA and SMM showed a decreasing trend according to the severity of leg ischemia (borderline/no ischemia: 2.80 ± 0.50 kg/m2, 4.38 ± 0.94°; mild ischemia: 2.83 ± 0.49 kg/m2, 4.33 ± 1.03°; moderate/severe ischemia: 2.50 ± 0.40 kg/m2, 3.89 ± 0. 88°; P < 0.001 and P = 0.020, respectively). The ABI was moderately correlated with leg SMM (B = 0.347, ß = 0.134, P < 0.001) and leg PhA (B = 0.577, ß = 0.111, P = 0.013) after adjustment for all significant covariates. Leg PhA was moderately correlated with leg SMM (r = 0.318, P < 0.001). CONCLUSIONS: Leg ischemia, especially when moderate or severe, has an adverse effect on both muscle mass and quality in the lower extremities and is associated with skeletal muscle myopathy.

Influence of Lower Limb Ischemia on Skeletal Muscle Mass Depletion in Patients with Peripheral Artery Disease.

BACKGROUND: The aim of the study was to determine the change in skeletal muscle mass over time by bioelectrical impedance analysis (BIA) in patients with peripheral artery disease (PAD). METHODS: Patients with symptomatic PAD visiting Tokyo Medical University Hospital between January 2018 and October 2020 were retrospectively analyzed. PAD was diagnosed based on ankle brachial pressure index (ABI) < 0.9 with either leg and confirmed by duplex scan and/or computed tomography angiography as needed. Patients undergoing endovascular treatment, surgery, or supervised exercise therapy were excluded before and during the study period. Skeletal muscle mass of the extremities was measured using BIA. The sum of skeletal muscle masses in the arms and legs was calculated as skeletal muscle mass index (SMI). Patients were scheduled to undergo BIA at an interval of 1 year. RESULTS: Of 119 patients, 72 patients were included in the study. All patients were ambulatory and had symptoms of intermittent claudication (Fontaine's stage II). SMI significantly decreased from 6.98 ± 1.30 at baseline to 6.83 ± 1.29 at 1-year follow-up. Individual skeletal muscle mass of the ischemic leg was significantly reduced after 1 year, but not in the nonischemic leg. A decrease in SMI (defined as SMI ≥0.1 kg/m2 per year) was independently associated with low ABI. The optimal cut-off value of ABI for the decrease in SMI was 0.72. CONCLUSIONS: These results suggest that lower limb ischemia due to PAD, especially if ABI is < 0.72 or less, may result in a decrease in skeletal muscle mass that affects health and physical function.

Association of lower limb ischemia with loss of skeletal muscle mass in patients with peripheral artery disease.

PURPOSE: The influence of lower limb ischemia on the loss of skeletal muscle mass, which is a prerequisite for sarcopenia, remains poorly studied in patients with peripheral artery disease (PAD). We determined whether or not lower limb ischemia correlates with a loss of skeletal muscle mass in patients with PAD. METHODS: The data of 101 patients (202 legs) with PAD were retrospectively analyzed. Body composition was measured using a bioelectrical impedance analysis. Based on the Asian Working Group for Sarcopenia, low muscle mass (LMM) was defined as skeletal muscle mass index (SMI) < 7.00 kg/m2 (male) and < 5.70 kg/m2 (female). Both univariable and multivariable analyses of the risk factors for LMM were performed. RESULTS: There were significant differences in age, ankle-brachial pressure index (ABI) per patient, and the geriatric nutritional risk index (GNRI), between patients with and without LMM. Multivariable logistic regression analysis showed age (odds ratio [OR], 1.09; p = 0.009), GNRI (OR, 0.93; p = 0.003), and ABI per patient (OR, 0.02; p = 0.027) as independent risk factors for LMM. CONCLUSION: These data show a detrimental effect of lower limb ischemia on skeletal muscle mass loss, suggesting that PAD may affect the development of secondary sarcopenia.

Time Course of Leg Edema after Endovenous Radiofrequency Ablation for Saphenous Varicose Veins.

BACKGROUND: The objectives of the study were to quantitatively evaluate leg edema in patients undergoing endovenous radiofrequency ablation (RFA) for saphenous varicose veins using bioelectrical impedance analysis (BIA) and to elucidate the time course of leg edema after RFA. METHODS: The data of 87 patients with 128 limbs undergoing RFA for saphenous varicose veins in Eniwa Midorino Clinic from April 2018 to November 2019 were retrospectively analyzed. Saphenous vein reflux was evaluated by duplex scan. Extracellular water/total body water ratio (ECW/TBW) of the leg was measured by BIA. Moderate to severe leg edema (ECW/TBW ≥ 0.400) was defined as significant leg edema. Venous reflux was evaluated as a venous filling index (VFI) using air plethysmography. RESULTS: BIA revealed that 26 legs (20.3%) had significant edema and 102 legs (79.7%) did not before RFA. The proportion of patients with significant leg edema increased significantly from preoperative to 1 week after RFA (P < 0.05) and decreased 1 month after RFA (P < 0.01). The ECW/TBW increased significantly from preoperative (0.393 ± 0.008) to 1 week after RFA (0.394 ± 0.008, P < 0.05), whereas it decreased significantly before or 1 week to 1 month after RFA (0.391 ± 0.008, P < 0.05). There was a significant, moderate correlation between the decrease of the VFI and that of ECW/TBW (r = 0.34, P < 0.001). CONCLUSIONS: This is the first study to quantitatively elucidate the time course of leg edema after RFA. Leg edema worsens one week after RFA, but it is improved one month after RFA, compared with that preoperatively.

The Role of Common Femoral Artery Endarterectomy in the Endovascular Era.

BACKGROUND: The purpose of this study was to review our experiences treating peripheral artery disease (PAD) by common femoral artery endarterectomy (CFE) with and without endovascular therapy (EVT), and to describe the role of CFE in the endovascular era. METHODS: We retrospectively reviewed a contemporary series of 38 limbs from January 2010 to September 2014. Clinical outcomes of primary patency, assisted primary patency, limb salvage, and survival were analyzed with the Kaplan-Meier method. Multivariable perioperative predictors of primary patency were identified using the stepwise Cox proportional hazards regression model. RESULTS: Hemodynamic success was achieved in 36 of the 38 limbs (95%). The mean ankle brachial pressure index improved significantly, rising from 0.56 ± 0.04 preoperatively to 0.89 ± 0.04 postoperatively (P = 0.0001). Overall primary and assisted primary patency rates, respectively, were 90% and 100% at 12 months and 85% and 94% at 24 months. There was no significant difference in primary patency rate between isolated CFE and hybrid CFE plus EVT. Both limb salvage and survival rates were 97% at 12 months and 97% at 24 months. Multivariate Cox regression analysis revealed that no clinical or perioperative risk factors were predictive of decreased primary patency. CONCLUSIONS: CFE is a safe, effective, and durable procedure for common femoral artery disease, and hybrid CFE plus EVT can be a valid alternative to open surgical bypass for multilevel occlusive artery disease. These observations stress that CFE plays a vital role in the management of PAD even in the endovascular era.

Relationship Between Serum Eicosapentaenoic Acid to Arachidonic Acid Ratio and Atherosclerotic Risk Factors in Patients With Peripheral Artery Disease.

BACKGROUND: The eicosapentaenoic acid to arachidonic acid ratio (EPA/AA) is attracting attention as a risk factor for peripheral artery disease (PAD). However, there have been few studies investigating the relationship between the EPA/AA ratio and atherosclerotic risk factors in patients with PAD. The purpose of the present study was to analyze atherosclerotic risk factors in patients with PAD to identify those factors associated with a low EPA/AA ratio. METHODS.: The data of patients treated for symptomatic PAD at Tokyo Medical University Hospital and Eniwa Midorino Clinic between April 2014 and March 2018 were retrospectively analyzed. RESULTS.: A total of 149 patients were tested for blood levels of n-3 and n-6 polyunsaturated fatty acids, including EPA and AA. 73 patients had a low EPA/AA ratio (<0.4) and 76 patients had a high EPA/AA ratio (≥ 0.4). Univariate analysis showed that older age (≥ 75 years), female sex, smoking history, body mass index (BMI), and hemoglobin A1C (HbA1C) were associated with the low EPA/AA ratio. Multivariable analysis showed that older age (odds ratio [OR], 0.34; 95% confidential interval [CI], 0.15-0.76; p = 0.008), BMI (OR, 0.87; 95% CI, 0.77-0.98; p = 0.027), smoking history (OR, 2.67; 95% CI, 1.09-6.55; p = 0.007), and HbA1C (OR, 0.46; 95% CI, 0.29-0.72; p = 0.020) were independently associated with the low EPA/AA ratio. CONCLUSIONS.: The EPA/AA ratio was related to existing arteriosclerotic risk factors in patients with PAD; it was positively correlated with older age, increasing BMI, and higher HbA1C, whereas it was negatively correlated with smoking history. These results suggest that the EPA/AA ratio may be closely intertwined with other atherosclerotic risk factors and have an influence on cardiovascular health.

Endovascular revascularization of diseased native arteries following failed aortoiliac and femoropoliteal grafts: report of two cases.

Arterial reconstructions for lower-extremity ischemia, comprising aortoiliac, aortofemoral, and femoropopoliteal bypasses, and other procedures, have an intrinsic tendency to fail as time elapses. Surgical approaches to arteries in patients who have failed bypass grafts are often rendered more difficult, or even impossible to use, by surgical scarring or infection. The authors report two cases in which the diseased native arteries treated with failed aortoiliac and femoropopliteal bypass grafts were successfully recanalized with primary stent placement. Our cases show that stent placement of the diseased native arteries can represent a possible option for the treatment of failed bypass grafts.

Primary stent placement for iliac artery chronic total occlusions.

PURPOSE: The purpose of this study was to evaluate the technical and mid-term results of primary stent placement for chronic total occlusions (CTO) of the iliac artery, in comparison to stent placement for iliac artery stenosis. METHODS: A retrospective study was carried out on 114 consecutive limbs with 24 CTOs and 90 stenoses of the iliac artery that underwent primary stent placement. Primary, assisted primary patency, and limb salvage rates were determined in accordance with the Society for Vascular Surgery guidelines. RESULTS: Angiographic and intravascular ultrasonographic success was achieved in all 114 limbs (100%). Three major complications, including 1 distal embolism and 2 arterial ruptures, occurred in the CTO group. The 2-year primary patency rate in the CTO group was as high as that observed in the stenosis group (91% vs 89%). There were also no significant differences in the assisted primary patency, limb salvage, and survival rates between the two groups. CONCLUSIONS: Our results indicate that primary stent placement is a safe and effective treatment for iliac CTOs. However, major complications, including distal embolization and iliac artery rupture, remain a significant problem, and caution should therefore be exercised when performing this technique for iliac CTOs.

Bioelectrical impedance analysis of leg edema and its association with venous functions in patients with saphenous varicose veins.

BACKGROUND: To quantitatively evaluate edema of the lower legs in patients with saphenous varicose veins, and to determine the association between leg edema and venous hemodynamics of the lower legs. METHODS: The data of 140 patients with saphenous varicose veins in Eniwa Midorino Clinic from April 2018 to November 2019 were retrospectively analyzed. Body composition values, including Body Mass Index, extracellular water/total body water (ECW/TBW) ratio of each leg, and skeletal muscle mass of each leg, were measured by segmental multi-frequency bioelectrical impedance analyzer. Overall venous hemodynamics of the leg, including functional venous volume, venous filling index (VFI), and ejection fraction, were assessed using air-plethysmography. Saphenous and deep vein reflux were evaluated by duplex scan. RESULTS: A total of 140 patients (58 men and 82 women) with a mean age of 66.0 years (range, 21 to 84 years) were analyzed. On visual inspection, 204 legs had saphenous-type varicose veins, while 76 legs did not. The legs were divided into two groups according to the presence or absence of leg edema, which was defined as ECW/TBW ≥0.390 and <0.390, respectively; 178 legs had leg edema and the remaining 102 legs had no leg edema. In univariate analysis, there were significant differences in age, sex, the presence of saphenous varicose veins, hypertension, and VFI between legs with edema and those without edema. Multivariable logistic regression analysis for leg edema detected age, female, and VFI as an independent risk factor for leg edema. CONCLUSIONS: Leg edema was objectively evaluated by bioelectrical impedance analysis in patients with saphenous varicose veins. Older age, female, and increased venous reflux were identified as independent risk factors for leg edema.

Influence of Superficial Venous Ablation on Deep Venous Dilation and Reflux in Patients With Saphenous Varicose Veins.

BACKGROUND: To investigate the influence of superficial venous ablation on deep venous dilation and reflux in patients with saphenous varicose veins, and to elucidate the association between superficial venous reflux and deep venous morphology and hemodynamics. METHODS: The data of 154 patients with 223 limbs, who underwent endovenous radiofrequency ablation (RFA) of the great saphenous vein for primary varicose veins between September 2014 and March 2016 in Eniwa Midorino Clinic, were retrospectively analyzed. Overall venous hemodynamics of the leg, including functional venous volume (VV) and venous filling index (VFI), was assessed using air-plethysmography. Saphenous and deep vein reflux and diameter were evaluated with duplex scanning. RESULTS: Hemodynamic and morphologic changes were evaluated before and 1 month after RFA. The VV and VFI were significantly decreased in postoperative values than in preoperative values (P < .001). Limbs with deep venous reflux significantly decreased postoperatively than preoperatively (P < .001). There were significant differences in the diameter of the common femoral vein (CFV) and popliteal vein (PV) between the preoperative and postoperative values (P < .001). There were strong to moderate correlations between the VV and the diameter of the CFV or PV (CFV, r = 0.47, P < .001; PV, r = 0.35, P < .001), while there were moderate to weak correlations between the VFI and the diameter of the CFV or PV (CFV, r = 0.23, P < .001; PV, r = 0.33, P <.001). CONCLUSIONS: Superficial venous ablation significantly reduced deep venous dilation and reflux in patients with saphenous varicose veins. Significant correlations existed between the VV or VFI, which reflected superficial venous reflux, and the diameter of the deep veins. These findings reveal that volume overload due to superficial venous reflux is associated with deep venous morphology and hemodynamics.

Primary stent placement for late complete occlusion after aortoiliac reconstructive surgery: report of a case.

We report a case that was successfully treated by primary stent placement without thrombolysis or thrombectomy for graft thrombosis after aortoiliac reconstructive surgery. A 79-year-old man presented with a 2-month history of severe intermittent claudication of the right leg. He had undergone a surgical repair of abdominal aortic aneurysm with a bifurcated polyester graft 3 years before presentation. Digital subtraction angiography revealed total occlusion of the right limb of the graft. He underwent primary stent placement on the lesion, and completion angiography showed revascularization of the right limb. Primary stent placement can be performed to decrease the risks of surgery and increase the salvage of a graft with chronic total occlusion.

Deep venous thrombosis caused by congenital absence of the inferior vena cava: report of a case.

Although anomalies of the inferior vena cava (IVC) are seen frequently in a clinical setting, congenital absence of the IVC (AIVC) is rare. However, anomalies of the IVC should be considered in young patients suffering from recurrent and idiopathic DVT. We report a case of DVT possibly caused by AIVC in a 27-year-old man, and discuss the clinical features, diagnosis, and treatment of this unusual entity.

Venous hemodynamic improvement after endovenous radiofrequency ablation of saphenous varicose veins.

BACKGROUND: Endovenous radiofrequency ablation (RFA) has been a viable treatment option for patients with saphenous varicose veins. The purpose of our study was to assess venous hemodynamic change before and after RFA by using air plethysmography (APG). METHODS: We prospectively analyzed the data of consecutive 91 patients with 124 limbs who underwent RFA for primary varicose veins. Overall venous hemodynamics of the limb was assessed using APG. The Venous Filling Index (VFI) was determined as a measure of reflux (normal range, <2 mL). Duplex scanning were performed to evaluate saphenous vein occlusion, deep venous thrombus and endovenous heat-induced thrombosis (EHIT). RESULTS: The VFI were significantly reduced from 4.1±3.1 preoperatively to 1.4±1.0, 1.3±0.8 and 1.4±1.2 at 1 week, 1 month and 4 month postoperatively, respectively. The percentage of the VFI >2 mL/s was 77% preoperatively, while it significantly decreased to 17%, 16%, and 18% at 1 week, 1 month, and 4 month postoperatively, respectively. Duplex scanning showed 100% of saphenous vein occlusion and no significant EHIT II-IV. CONCLUSIONS: Correction or significant improvement of venous reflux was achieved by RFA. Together with duplex scanning findings, RFA is a safe and hemodynamically effective treatment for varicose veins.

Risk factors for adverse outcomes after endovascular therapy for critical limb ischemia with tissue loss due to infrainguinal artery disease.

BACKGROUND: The purpose of this study was to analyze the risk factors for an adverse outcome after endovascular therapy (EVT) for critical limb ischemia (CLI) with tissue loss due to infrainguinal artery disease. METHODS: We retrospectively reviewed the charts of patients with tissue loss (Rutherford class 5 and 6) due to infrainguinal artery disease who were managed with endovascular therapy (EVT) between January 2006 and December 2013. The primary endpoint was amputation-free survival (AFS), while the secondary endpoints were freedom from a major adverse limb event (MALE) plus perioperative (30 days) death (POD), limb salvage, and survival rates at one year. Multivariable perioperative predictors of AFS were identified using the stepwise Cox proportional hazards regression model. RESULTS: A total of 65 patients underwent EVT for infrainguinal artery disease on 72 limbs. The technical success rate was 94% (68/72), while the clinical success was attained in 54 of 72 limbs (72%). The AFS, MALE + POD, limb salvage, and survival rates at one year were 76%, 86%, 91%, and 81%, respectively. The multivariate analysis demonstrated that major tissue loss classified as Rutherford class 6 (HR, 5.68; 95% CI, 2.29-14.13; P<0.05) was negatively associated with decreased AFS, while clinical success (HR, 0.25; 95% CI, 0.11-0.60; P<0.05) was positively associated with increased AFS. CONCLUSIONS: EVT resulted in an acceptable rate of AFS, MALE+POD, limb salvage, and survival. However, we must keep in mind that there are significant limitations to be considered for EVT in patients with major tissue loss, and that, even if revascularization could be successfully performed, a significant number of the treated limbs are still in a critical situation, such as major amputation or death.

Endovascular Therapy for Femoropopliteal Artery Disease and Association of Risk Factors With Primary Patency: The Implication of Critical Limb Ischemia and TASC II C/D Disease.

The treatment of femoropopliteal artery disease remains controversial, without clear guidelines specifying the indications for endovascular therapy (EVT). Accordingly, we retrospectively examined our experience of using EVT to treat femoropopliteal artery disease. A total of 91 limbs in 82 patients underwent EVT for the treatment of femoropopliteal artery disease. Percutaneous transluminal angioplasty alone was performed in 20 limbs, and additional stenting was performed in 71 limbs. The 1-year primary patency, primary-assisted patency, limb salvage, and survival rates were 76%, 88%, 96%, and 92%, respectively. Multivariate Cox analysis of primary patency showed that critical limb ischemia (CLI; hazard ratio [HR], 2.53; 95% confidence interval [CI], 1.08-5.33; P < .01) and TASC II C/D disease (HR, 2.70; 95% CI, 1.14-6.39; P < .05) were independent predictors of decreased primary patency. In conclusion, patients with CLI or extensive lesions have reduced patency after EVT for femoropopliteal artery disease.

Surgical treatment of a dissecting aneurysm of the proper hepatic artery: report of a case.

Primary dissecting aneurysms of the hepatic artery are extremely rare and only 15 cases, including the present case, have been reported in the literature. Surgery was performed in 5 cases, of which 3 cases were successfully treated. This report presents a case of a dissecting aneurysm of the proper hepatic artery that was successfully treated by aneurysmorraphy and vein patch angioplasty.

Stent placement for superficial femoral arterial occlusive disease in high-risk patients: preliminary results.

PURPOSE: To report the preliminary results of primary stenting of the superficial femoral artery (SFA) in high-risk patients with symptomatic SFA occlusive disease. METHODS: Between February 2005 and April 2007, a collective 30 lower limbs in 28 high-risk patients with SFA occlusive disease were treated by primary stenting. Hemodynamic improvement was assessed by ankle brachial pressure index (ABI), before and after the procedure. Primary and primary-assisted patency and limb salvage were measured in concordance with the Society for Vascular Surgery guidelines. RESULTS: The technical success rate was 97%. The average ABI before and after stent placement increased significantly, from 0.41 +/- 0.33 to 0.82 +/- 0.20 (P < 0.001). The primary and primary-assisted patency rates were 86% and 90% at 6 months, 86% and 90% at 12 months, and 68% and 90% at 24 months, respectively. The limb salvage rate was 92% at 6, 12, and 24 months and the survival rate was 95% at 6, 12, and 24 months. CONCLUSION: Our results suggest that the primary stenting of SFA lesions is a feasible, safe, and effective procedure for high-risk patients with SFA occlusive disease.

Perigraft seroma after surgical aortoiliac aneurysm repair with knitted polyester grafts: report of two cases.

Perigraft seroma usually occurs both polyester and polytetrafluoroethylene (PTFE) graft which are placed superficially for axillofemoral and femorofemoral bypasses, while it is a rare complication of conventional abdominal aortic and iliac arterial aneurysm repair. The cause of the seroma has not been elucidated, and several hypotheses have been proposed such as immunologic response to graft materials, discharge of serous fluid through the graft wall, and so on. The seroma sac occasionally increases their size finally leading to rupture. The treatment of perigraft seroma has not been established so far; there have been various recommended procedures including aspiration, graft removal followed by other material graft replacement, cessation of antithrombotic drugs, and careful observation. We report two cases of perigraft seroma after conventional aortoiliac aneurysm repair with a knitted polyester graft via left pararectal retroperitoneal approach, which were gradually shrinking by theirselves.

Cilostazol suppresses neointimal hyperplasia in canine vein grafts.

PURPOSE: To investigate whether cilostazol, a cyclic adenosine monophosphate (cAMP) phosphodiesterase inhibitor, suppresses intimal hyperplasia in canine vein grafts, and to elucidate its mechanisms in terms of cell proliferation and apoptosis. METHODS: Bilateral reversed jugular vein interposition grafts of the common carotid artery were performed in 12 beagle dogs. Starting from 7 days before surgery, either cilostazol (30 mg/day; n = 6) or a placebo (n = 6) was given orally twice daily. Vein grafts were harvested at 1 or 4 weeks, and fixed under pressure for histological examination. RESULTS: By 1 week after implantation, the cilostazol group showed significantly less cell proliferation than the placebo group. By 4 weeks after implantation, intimal and medial thickness was significantly thinner in the cilostazol group than in the placebo group. There was significantly more apoptosis in the placebo group than in the cilostazol group at both time points. CONCLUSION: Cilostazol suppressed the development of intimal hyperplasia in canine autogenous vein grafts. Thus, it may be associated with the modulation of cell proliferation and apoptosis.

Acute submassive pulmonary embolism following varicose vein surgery in a patient receiving hormonal replacement therapy.

Acute pulmonary embolism following varicose vein surgery is reported in a patient receiving hormonal replacement therapy. A 45-year-old woman underwent partial stripping of the greater saphenous vein of her bilateral legs and division of the lesser saphenous vein of her left legs under spinal anesthesia. On the first postoperative day, she complained of severe chest discomfort and collapsed suddenly while walking to the toilet. Emergency spiral computed tomography and perfusion scintigraphy demonstrated multiple defects in the bilateral lower lobes. She recovered after aggressive anticoagulant therapy. Although acute pulmonary embolism occurs only rarely after varicose vein surgery, it is important to remember its possibility especially when a patient has known risk factors predisposing venous thromboembolism, such as hormone replacement therapy.