Strategy for thoracic endovascular aortic repair based on collateral circulation to the artery of Adamkiewicz.

PURPOSE: Spinal cord ischemia (SCI) is a serious complication of thoracic endovascular aortic repair (TEVAR). The purpose of this study was to establish if preoperative identification of the artery of Adamkiewicz (AKA) can help prevent post-TEVAR SCI. METHODS: Of 74 post-TEVAR patients, 51 had the critical segmental artery (CSA) to the AKA pre-identified to help the surgeon deploy stent grafts. RESULTS: None of these 51 patients suffered permanent paraplegia postoperatively, but 5 (23.8 %) of the remaining 23 patients (2 of whom had pre-existing paraplegia) did suffer permanent SCI. The CSA/AKA was preserved in 43 patients with pre-identification of the CSA/AKA; however, in 8 patients, the CSA was completely or partially occluded by a stent graft. Transient SCI developed in one patient from each group, but both of these patients recovered fully before discharge. No change in the anatomical route was identified in 29 of the patients who had postoperative evaluation of the CSA/AKA. Five of eight patients whose CSA was completely occluded had new collateral circulation to the AKA. CONCLUSIONS: None of the 51 patients with the CSA/AKA identified before TEVAR suffered permanent paraplegia, whereas 5 of the 23 without pre-identification did suffer permanent SCI. Thus, careful identification of the CSA/AKA may prove useful for preventing postoperative SCI. Preservation of potential collateral circulation may also reduce the risk of postoperative SCI.

Right versus left coronary artery involvement in patients with type A acute aortic dissection.

BACKGROUND: Type A acute aortic dissection (AAD) complicated by coronary malperfusion is a life-threatening disease. In the present study, we compared the clinical characteristics and prognostic impact of treatment strategies including surgical treatment and percutaneous coronary intervention (PCI) in type A AAD patients with RCA and LCA involvement. METHODS: This multicenter registry included 220 patients with type A AAD and either RCA or LCA involvement. Treatment strategies were left to treating physicians. The primary endpoint was in-hospital death. RESULTS: Of 220 patients, 115 (52.3%) and 105 (47.7%) had RCA and LCA involvement. Patients with LCA involvement were more1 likely to present with Killip class IV on admission than those with RCA involvement. Coronary angiography was performed in 52 of 220 (23.6%) patients, among whom 39 (75.0%) underwent subsequent PCI. During the hospitalization, 93 (42.3%) patients died. Patients with LCA involvement had an increased risk of in-hospital mortality compared to those with RCA involvement (54.3% vs. 31.3%, p < 0.001). In patients with RCA involvement, multivariable analysis identified Killip class IV and no surgical treatment as predictors of in-hospital death, while PCI and surgical treatment were indicated as factors associated with lower in-hospital mortality in patients with LCA involvement. CONCLUSIONS: The rates of RCA and LCA involvement were similar in type A AAD. Immediate PCI as a bridge to subsequent surgical treatment might improve survival in patients with type A AAD complicated by coronary malperfusion, especially in those with LCA involvement.

[Strategies for prevention from spinal cord ischemia during thoracic endovascular aortic repair].

Spinal cord ischemia (SCI) is one of the most serious complications in patients who undergo thoracic endovascular aortic repair (TEVAR). The incidence of SCI after TEVAR has been supposed to be lower than the one after traditional open surgical repair. However, not a few cases regarding SCI after TEVAR have been reported recently. Since the detailed mechanism of the SCI is still not fully understood, preventive strategies against SCI including preoperative identification of critical segmental artery (CSA) applying the artery of Adamkiewicz, preservation of the CSA, motor evoked potential (MEP) monitoring, and cerebrospinal fluid (CSF) drainage are routinely performed during TEVAR in our practice.

Updates on Computed Tomography Imaging in Aortic Aneurysms and Dissection.

Computed tomography (CT) is a primary imaging modality for the diagnosis of aortic diseases, because of its minimal invasiveness and agility. Prompt and accurate diagnosis is crucial especially for acute aortic diseases, and the guidelines for acute aortic dissection recommend the use of CT for initial diagnosis. For the follow-up observation of longstanding aortic diseases, the strategy of imaging management by CT must be different from that for emergency and acute phases. In this review, we document the differences in characteristics and clinical course between aortic aneurysm and aortic dissection and explain the use of recent CT techniques in diagnosing short- and longstanding aortic diseases.

Efficacy of low-dose hydrochlorothiazide in combination with telmisartan on early morning blood pressure in uncontrolled hypertensive patients.

Hypertensive patients whose BP was uncontrolled despite the use of antihypertensive agents, including an ARB (candesartan 8 mg/day or valsartan 80 mg/day), were enrolled. The patients were randomly assigned to combination therapy with telmisartan 40 mg/day (changed from current ARB) and hydrochlorothiazide (HCTZ) 12.5 mg/day (T + H, n = 32) or to no change in their current drug regimen (CTL, n = 32). The observation period was 12 weeks. The office and home BPs were significantly reduced in the T + H compared to those in the CTL. A sufficient and long-acting BP lowering effect, as reflected in decreased early morning BP, was obtained with the combination of low-dose HCTZ and telmisartan without apparent metabolic deterioration.

Antegrade thoracic endovascular aortic repair via the left axillary artery in a patient with aortoiliac occlusive disease (Leriche syndrome).

We present the case of a 77-year-old man with a saccular descending thoracic aortic aneurysm who underwent successful antegrade thoracic endovascular aortic repair (TEVAR) via the left axillary artery. The patient had a history of axillo-bifemoral bypass grafting due to aortoiliac occlusive disease (Leriche syndrome), which precluded normal retrograde TEVAR. Upon successful procedure completion, no endoleak was noted on postoperative computed tomography. The patient was discharged from the hospital without any complications. The left axillary artery is useful as an alternative access site in cases wherein conventional retrograde TEVAR is not feasible.

Chronic contained rupture of abdominal aortic aneurism complicated with aortic occlusion: a case report.

BACKGROUND: Chronic contained rupture is a subtype of an abdominal aortic aneurysm rupture. Its diagnosis is sometimes difficult due to lack of typical symptoms. We would like to report the challenge of diagnosing chronic contained rupture of abdominal aortic aneurysm with a retroperitoneal tumor. CASE PRESENTATION: A 60-year-old man reported perceived lower abdominal pain 7 months earlier that spontaneously remitted. A contrast-enhanced computed tomography (CT) indicated an abdominal aortic aneurysm and a mass lesion surrounding the abdominal aorta and iliac arteries. Fluorine-18-fluorodeoxyglucose positron emission tomography (FDG-PET) showed an increased accumulation of FDG in the margin of the lesion, indicating a retroperitoneal tumor. A CT-guided biopsy revealed only retroperitoneal fibrous tissue with chronic inflammation. We were thus unable to reach a definitive diagnosis. At 1 month after the initial examination, intermittent claudication was newly observed. A follow-up contrast-enhanced CT scan revealed abdominal aortic occlusion. Mass resection and bypass surgery were performed for diagnosis and treatment. Intraoperative and pathological findings led to the diagnosis of chronic contained rupture of an abdominal aortic aneurysm. The patient was discharged 19 days after surgery. CONCLUSION: The mass peripheral to the abdominal aorta should be considered the possibility not only of tumor but also of chronic contained rupture of an abdominal aortic aneurysm.

Increased carotid artery stiffness without atherosclerotic change in patients with aortic dissection.

The arterial properties and pathogenesis of aortic dissection remain obscure. To examine the arterial properties of patients with aortic dissection, the authors studied the ultrasonographic characteristics of the carotid artery in patients with an aortic dissection (AD, n = 86), and compared these findings with data of patients suffering from arteriosclerosis obliterans (ASO, n = 151), coronary artery disease (CAD, n = 163), and with healthy controls (HC, n = 77). Atherosclerotic intimal changes, such as intima-media thickness (IMT) and plaque formation, were milder in AD than in ASO or CAD (IMT: 0.83 +/- 0.16 vs 0.93 +/- 0.20/0.86 +/- 0.17 mm, p < 0.05; plaque number: 0.6 +/- 1.1 vs 2.7 +/- 2.4/2.5 +/- 2.1, p <0.05). Luminal diameter in AD, ASO, and CAD was significantly higher than in HC. The luminal distensibility in AD was decreased compared with HC but was the same as in ASO and CAD. Intra-AD group analysis showed that in patients with an intramural hematoma (IMH) or a dissection with a thrombosed false lumen (TLF) the IMT was higher than in patients with a classic dissection. In addition, plaque formation was more severe in AD patients with a coexisting abdominal aortic aneurysm (AAA). Reduced distensibility without severe intimal disease was found in AD. These findings suggest that patients with AD may have several arterial alterations, including structural abnormalities. Patients with IMH, TFL, or coexisting AAA may differ from patients who have a classic type of dissection or who do not have AAA, in terms of arterial characteristics including intimal disease and wall elastic property, and the initiating cause of the dissection.

Subtraction CT angiography for the diagnosis of iliac arterial steno-occlusive disease.

PURPOSE: Accurate evaluation of stenosis in severely calcified arteries is a major challenge in conventional CT angiography (CTA) for peripheral arterial disease (PAD). The aim of this study was to evaluate the efficacy of subtraction CTA compared with conventional CTA and conventional angiography. MATERIALS AND METHODS: 175 arterial segments of 31 consecutive patients with PAD who underwent CTA and subsequent digital subtraction angiography (DSA) were evaluated. The percentage stenosis of diseased arteries was measured in iliac arteries with caliper methods on conventional CTA and subtraction CTA, and the concordance of each CTA method with DSA in the identification of >50 % stenosis was evaluated. Interpretation of CTA was always based only on maximum intensity projection (MIP). RESULTS: 174 (99 %) segments were interpretable on subtraction CTA and showed a good correlation with DSA (R (2) = 0.844), although 55 (31 %) segments were not evaluable on conventional CTA due to severe calcification. On subtraction CTA, the segmental accuracy, sensitivity, and specificity were 90.5, 78.9, and 80.0 %, respectively. CONCLUSION: Subtraction CTA is an accurate diagnostic tool for the evaluation of PAD. It may be easier to interpret stenosis in the presence of calcifications using subtraction CTA rather than with the conventional CTA approach. Also, subtraction CTA using only MIP presented a similar accuracy to DSA.

Usefulness of transesophageal echocardiography in diagnosis of hemolytic anemia post total aortic arch replacement using the elephant trunk technique.

We report a rare case of a patient with hemolytic anemia who underwent emergency total arch replacement using the elephant trunk technique for type A acute aortic dissection 3 years earlier. The 78-year-old woman was referred to our hospital for diagnosis of the cause of the hemolytic anemia, which required twice weekly blood transfusion. Although contrast-enhanced computed tomography could not provide sufficient information, transesophageal echocardiography (TEE) revealed graft flection with high velocity. After percutaneous balloon dilatation, the hemolytic anemia improved and follow-up TEE showed no re-stenosis of the dilatation site.

Influence of daily alcohol consumption on serum adiponectin levels in men.

BACKGROUND: The risk of cardiovascular diseases is lower among moderate alcohol drinkers than among both nondrinkers and heavy drinkers. However, factors that can account for the U-shaped or J-shaped relationship between daily alcohol consumption and incident cardiovascular diseases remain obscure. PURPOSE: The present cross-sectional study investigated the relationship between alcohol consumption and serum adiponectin levels. METHOD: Total adiponectin was measured in 527 males participating in health check-up programs (age range 40-86 years, mean 60.5 years). Based on questionnaire responses, alcohol intake was categorized into three groups: none or occasional (A1); <50 g/day and ≥3 days/week (A2); and ≥50 g/day and ≥3 days/week (A3). RESULTS: No significant differences in adiponectin levels were observed among the three alcohol consumption groups of subjects without the metabolic syndrome (MetS). In subjects with the MetS, the adiponectin level was significantly higher in the A2 (moderate drinker) group than in both the A1 and A3 groups. MetS subjects in group A2 had higher HDL-C levels than those in A1, but levels in group A3 were not significantly different from those in group A2. CONCLUSION: An increased adiponectin level in moderate alcohol drinkers who have MetS may contribute to the U-shaped relationship between alcohol consumption and risk of cardiovascular events, in addition to the involvement of HDL-C.

Association between metabolic syndrome and carotid atherosclerosis: relevance of combined criteria including the serum adiponectin level for the general population.

OBJECTIVE: The association between carotid atherosclerosis and the metabolic syndrome (MetS) was analyzed in the general population. The usefulness of the inclusion of the serum adiponectin concentration in the MetS criteria for the detection of atherosclerosis was also examined. PATIENTS AND METHODS: The 825 participants of a comprehensive health checkup who underwent carotid ultrasonography and the measurement of serum adiponectin levels were studied. RESULTS: The carotid plaque score (PLS) was significantly higher in the MetS group than in the non-MetS group in women, but not in men. In women, a significantly higher odds ratios was obtained for MetS, in terms of the current waist circumference criterion, and a high PLS (fourth quartile) (OR=2.64, p=0.040). In men, however, a waist circumference of around 85 cm did not reflect high a PLS, and even when the waist circumference criterion was varied, the odds ratio did not increase. When the waist circumference was replaced by hypoadiponectinemia in the current MetS criteria, the odds ratio was significantly increased in men (OR=1.82, p=0.032). CONCLUSION: The current MetS criteria seem appropriate for women. In men, there was no significant evidence for the validity of the inclusion of the waist circumference criterion as an essential component. Incorporating hypoadiponectinemia into the current criteria would be useful for the early detection of atherosclerosis in men.

Chronic kidney disease is associated with increased carotid artery stiffness without morphological changes in participants of health check-up programs.

BACKGROUND AND METHODS: Patients with chronic kidney disease (CKD) show a much higher risk of cardiovascular disease. However, the mechanisms underlying this association and the impact of CKD on behaviors of the vascular walls have not been fully clarified. Using ultrasonography, this study investigated associations of CKD (estimated glomerular filtration rate <60 ml/min/1.73 m(2) and/or presence of proteinuria) with both elasticity (stiffness ß index) of the carotid artery and intimal atherosclerotic changes in participants of health check-up programs (n=3406, 63% men; mean age, 58.8 years). RESULTS: Stiffness ß was significantly higher in CKD subjects (7.49 ± 0.14) than in non-CKD subjects (6.87 ± 0.05, P<0.001). This significant difference was maintained in a multiple adjusted model including conventional risk factors such as hypertension, diabetes mellitus, dyslipidemia, smoking and obesity (7.20 ± 0.14 vs. 6.91 ± 0.05, P=0.043). No significant differences in intima-media complex thickness or plaque score were seen between CKD and non-CKD subjects. CONCLUSION: In participants of health check-up programs, CKD was associated with increased carotid arterial stiffness without intimal disease, independently of conventional risk factors. These findings indicate that CKD may predispose the carotid arteries to earlier development of arteriosclerosis, characterized by increased arterial stiffness.

Low-density lipoprotein cholesterol to high-density lipoprotein cholesterol ratio as a useful marker for early-stage carotid atherosclerosis.

A higher ratio of low-density lipoprotein cholesterol (LDL-C) to high-density lipoprotein cholesterol (HDL-C) is associated with a greater risk of cardiovascular events in patients with coronary heart disease. However, the role of this lipid index during early-stage atherosclerosis has not yet been established. This study investigated relationships between LDL-C/HDL-C ratio and carotid plaque score as assessed by ultrasonography in 825 subjects from the general population (527 men, 298 women; mean age, 60.5 years). To identify factors strongly associated with plaque score, stepwise multiple regression analysis was performed using various clinical variables including conventional lipid indices. In both sexes, increased LDL-C/HDL-C ratio was associated with increased plaque score (men: beta = 0.132, P = .001; women: beta = 0.150, P = .012). This association was maintained in men with normal LDL-C level (<140 mg/dL). The highest quartile of LDL-C/HDL-C ratio (>2.9 in men, >2.6 in women) showed significantly increased plaque score even when adjusted by factors included in the final model of stepwise analysis (P = .007 in men, P = .033 in women). No association was seen between LDL-C and plaque score in the multivariate-adjusted model. These findings indicate that increased LDL-C/HDL-C ratio may also be associated with initiation of atherosclerosis. Assessment of this lipid ratio may thus facilitate early management of atherosclerotic risks better rather than assessment of LDL-C alone.

Diabetic state as a crucial factor for impaired arterial elastic properties in patients with peripheral arterial disease.

BACKGROUND: Increased arterial stiffness is associated with greater risk of cardiovascular events and mortality. However, in patients with peripheral arterial disease (PAD) who have severe atherosclerotic disorder or risk clustering, the major determinants of increased stiffness have been not clarified. METHODS: This study investigated the associations between elastic properties of the carotid artery as measured by ultrasonography and atherosclerotic risk factors, with particular focus on diabetes mellitus (DM), in PAD patients (n=481; mean age, 69.6 years). DM was defined as hemoglobin A1c >/=6.5%, administration of anti-diabetic agents, or DM pattern on 75-g oral glucose tolerance test. Stiffness beta index was calculated from luminal diameter changes measured by the M-mode method using a linear array imaging probe. RESULTS: Stiffness parameter beta was significantly increased in diabetic patients compared with non-diabetic patients (9.56+/-0.35 vs. 8.31+/-0.32; p=0.009) in an age- and gender-adjusted model. This significant difference was maintained in a multivariate-adjusted model including age, gender, hypertension, hyperlipidemia, obesity and smoking history (9.43+/-0.36 vs. 8.39+/-0.33; p=0.037). No significant differences in mean intima-media complex thickness or plaque score of the carotid artery were seen between diabetic and non-diabetic patients. CONCLUSION: Diabetic condition impairs the elastic properties of arteries, independent of other known atherosclerotic risk factors or excessive intimal diseases in PAD patients. This may support the notion that diabetic condition can worsen prognosis for PAD patients.

Effects of telmisartan on adiponectin levels and body weight in hypertensive patients with glucose intolerance.

Few studies have analyzed intraclass differences in angiotensin II receptor blockers (ARBs) with respect to antidiabetic or metabolic effects. We designed a prospective randomized study to compare a peroxisome proliferator-activated receptor-gamma (PPARgamma)-activating ARB with a nonactivating ARB to delineate the effects on metabolic factors associated with cardiovascular disease. Subjects initially comprised 153 hypertensive patients (72 men, 81 women; mean age, 67.9 +/- 7.8 years) with diagnosed glucose intolerance on the glucose loading test. Patients were randomly assigned to receive 6-month administration of telmisartan 47.0 mg/d (TEL) or candesartan 8.4 mg/d (CAN), or to have no change in drug regimen (control group, CTL). Fasting plasma glucose level was significantly reduced in TEL (n = 46) compared with CTL (n = 47) (percentage of change from baseline, -1.7% vs +2.2%; P = .045). Percentage of increase in adiponectin was significantly larger in TEL than in CTL (+10.5% vs +2.2%, P = .025), but not significantly larger in CAN (n = 44) than in CTL (+4.9% vs +2.2%; P = .13). Percentage of decrease in body weight from baseline was significantly enhanced in TEL compared with CTL (-2.2% vs -0.8%, P = .023) and CAN (-2.2% vs -0.3%, P = .007). Telmisartan decreased body weight while increasing serum adiponectin levels in hypertensive patients with glucose intolerance. Candesartan did not achieve similar improvements in these patients. Among ARBs, telmisartan may have a larger impact on obesity-related diseases that can lead to cardiovascular disorders.