Efficacy of Fusion Imaging in Endovascular Revascularization of the Superficial Femoral Artery.

BACKGROUND: The demand for endovascular revascularization (ER) to treat peripheral artery disease (PAD) has steadily increased. However, ER comes at the cost of increased contrast and radiation exposure, particularly in more complex cases. Fusion imaging is a new technology that may address these issues. The purpose of this study was to evaluate the efficacy of fusion imaging in ER of the superficial femoral artery (SFA). METHODS: Patients with PAD undergoing ER of the SFA from February 2016 to July 2020 were retrospectively evaluated. A group of patients treated using fusion imaging was compared with a control group treated without fusion imaging. The primary end points were the contrast dose, fluoroscopy time, radiation dose, and operative time. RESULTS: A total of 51 patients (fusion group, n = 26; control group, n = 25) underwent ER during the study period. Significantly lower iodinated contrast doses were observed in the fusion than in the control group (56.1 ± 23.7 vs. 87.9 ± 44.9 mL; P = 0.003), as well as significantly shorter fluoroscopy times (21.2 ± 11.1 vs. 44.9 ± 31.4 min; P = 0.001), lower radiation exposure (29.9 ± 8.9 vs. 122.2 ± 223.1 mGy; P = 0.04), and shorter operative times (88.3 ± 32.1 vs. 126.1 ± 66.8 min; P = 0.013). CONCLUSIONS: The use of fusion imaging technology during ER of the SFA can significantly reduce the contrast dose, fluoroscopy time, radiation dose, and operative time.

Early evaluation of the infrainguinal revascularization strategy selection tool of the Global Vascular Guidelines for chronic limb-threatening ischemia patients.

OBJECTIVE: The Global Vascular Guidelines (GVG) propose a novel Global Anatomic Staging System (GLASS) with the Wound, Ischemia, and foot Infection (WIfI) classification system as a clinical decision-making tool for interventions in chronic limb-threatening ischemia (CLTI). We assessed the validity of clinical staging and the relationship between the treatments recommended by the GVG and the outcomes of the actual procedures. METHODS: This retrospective, single-center, observational study included 117 patients with CLTI undergoing infrainguinal revascularization in our hospital between 2015 and 2019. Of those patients, 55 underwent open bypass (OB) and 62 underwent endovascular revascularization (EVR). Femoropopliteal, infrapopliteal, and inframalleolar GLASS grades were assigned based on angiographic images. These grades were combined to determine the revascularization strategy recommended by the GVG: "endovascular," "indeterminate," and "open bypass." The indeterminate category includes three subcategories: GLASS stage III, WIfI stage 2; GLASS stage II, WIfI stage 3; and GLASS stage II, WIfI stage 4. For the purposes of this study, we labeled these subcategories A, B, and C, respectively. The primary outcome was the correlation between the revascularization strategies recommended by the GVG and the actual procedures performed. The relationships between the actual procedures and overall survival, limb salvage, and patency were also examined. RESULTS: The femoropopliteal and infrapopliteal GLASS grades were higher in the OB group. EVR was performed more often for GLASS stages I and II and was more often classified as indeterminate B and C, whereas OB was performed more often in GLASS stage III and was more often classified as indeterminate A. There were no statistically significant differences in the inframalleolar/pedal disease descriptor or in the 30-day postoperative complication rates between the two groups. In higher GLASS stages, the technical success rate of EVR was lower, and lesion complexity was more severe. Patients for whom the recommended strategy according to the GVG would have been OB but who underwent EVR were associated with low limb salvage and patency rates. CONCLUSIONS: The GVG provide good guidance for the selection of the revascularization strategy. When the GVG indicate OB, it should be the treatment of choice, rather than EVR, for patients who are fit to undergo the procedure.

Preservation of the accessory renal arteries after endovascular repair of common iliac artery aneurysm using kissing stent grafts.

Exclusion of the accessory renal arteries (ARAs) is required during endovascular aneurysm repair if they arise from the sealing zone or aneurysm sac. Here, we report a case of successful endovascular treatment for a common iliac artery aneurysm located close to the aortic bifurcation and associated with nephrotic syndrome in a 51-year-old man. The bilateral ARAs were successfully preserved using kissing stent grafts. During surgery, the proximal ends of endografts inserted from the bilateral femoral arteries were adjusted so that they met at the same level in the aorta, and simultaneous balloon dilatation was performed. This method can be a useful treatment option for common iliac aneurysms in cases with large ARAs.

Favorable outcomes of very elderly patients with critical limb ischemia who undergo distal bypass surgery.

OBJECTIVE: To determine the midterm outcomes of distal bypass surgery for very elderly patients, and to determine the ideal candidates for this procedure. METHODS: Of 268 consecutive patients (328 limbs) with critical limb ischemia who were treated between 2006 and 2013, 106 (126 limbs) underwent distal bypass and were retrospectively reviewed. Nineteen patients (22 limbs) were aged ≥80 years (very elderly group) and 87 patients (104 limbs) were aged <80 years (control group). RESULTS: The baseline characteristics differed between the 2 groups in terms of regular hemodialysis rate (very elderly group, 4 [21%] vs control group, 60 [69%]; P = .0002) and the Charlson comorbidity index (very elderly group, 3.2 ± 1.7 vs control group, 5.0 ± 2.0; P = .0005). According to the Rutherford category of limb ischemia (4/5/6), the very elderly and control groups were classified as 5/17/0 and 11/87/6, respectively (P = .18). Before the surgery, 17 patients (77%) and 67 patients (64%) were ambulatory in the very elderly and control groups, respectively. At follow-up at 29 ± 22 months, the rates of primary (P = .33) and secondary patency (P = .14), limb salvage (P = .50), survival (P = .26), amputation-free survival (P = .42), major adverse limb event and also perioperative death (P = .11), and major adverse cardiovascular events (P = .36) did not significantly differ between the groups. In multivariate analysis, a history of coronary artery disease (hazard ratio [HR], 2.7; 95% confidence interval [CI], 1.3-5.9; P = .005), preoperative nonambulatory status (HR, 4.2; 95% CI, 2.1-8.1; P < .0001), and serum albumin levels <3 g/dL (HR, 2.7; 95% CI, 1.3-5.4; P = .01) were significantly related to poor amputation-free survival. Thirteen patients (59%) remained ambulatory at the latest follow-up. In 91 patients (110 limbs) with tissue loss, the Society for Vascular Surgery lower extremity threatened limb classification system: risk stratification based on Wound, Ischemia, and foot Infection classification stages 3 and 4 negatively affected complete wound healing, according to multivariate analysis (HR, 0.34; 95% CI, 0.20-0.61; P = .0005). CONCLUSIONS: A very elderly age should not preclude a patient from undergoing distal bypass surgery. A history of coronary artery disease, a nonambulatory status, and hypoalbuminemia, along with the Wound, Ischemia, and foot Infection classification for patients with tissue loss, should be carefully considered to obtain the most benefit from distal bypass surgery.

Therapeutic site selection is important for the successful development of collateral vessels.

BACKGROUND: Induction of collateral development to improve tissue perfusion is a promising approach for the treatment of arterial occlusive diseases. Several growth factors and cells have been reported to increase collateral circulation; however, the appropriate site for the delivery of these factors and cells is unclear. In this study, we identified the delivery site for growth factor in a rabbit model of limb ischemia and evaluated whether specific delivery of basic fibroblast growth factor (bFGF) to this site enhanced collateral augmentation. METHODS: The left femoral artery of Japanese white rabbits was excised to induce limb ischemia. Twenty-eight days thereafter, angiograms were obtained to identify the typical pattern of collateral development in this model. Subsequently, bFGF (100 µg) was selectively injected into the left coccygeofemoral muscle (coccygeo group) or adductor muscle (adductor group), major thigh muscles in proximity. Collateral development was evaluated at 28 days after injection, and its mechanism was assessed by immunologic and morphometric analyses of muscle samples. RESULTS: Angiographic evaluation of this model revealed that after femoral artery excision, collateral vessels generally developed in the left coccygeofemoral muscle, whereas few collateral vessels were detected in the left adductor muscle. At 28 days after injection, calf blood pressure ratio, defined as left pressure to right pressure, was significantly higher in the coccygeo group than in the adductor group (0.85 ± 0.05 vs 0.69 ± 0.05, respectively; P < .01). Similar results were observed in blood flow through the internal iliac artery (resting: 24.6 ± 6.1 vs 17.4 ± 8.0 mL/min, P < .01; maximum: 47.4 ± 12.3 vs 33.2 ± 10.7 mL/min, P < .01) and in the angiographic score (0.67 ± 0.13 vs 0.39 ± 0.11; P < .01). Immunologic analyses of the coccygeofemoral muscle at day 3 showed marked expressions of Ki-67, monocyte chemotactic protein 1, and FGF receptor 1 in the coccygeo group compared with the adductor group. Morphometric analyses of the same muscle at day 14 also revealed that collateral vessel density and wall thickness were significantly increased in the coccygeal group compared with the adductor group. CONCLUSIONS: These findings demonstrated that selective bFGF delivery to the coccygeofemoral muscle markedly improved collateral development and limb perfusion compared with delivery to the adductor muscle, suggesting that site selection is important in increasing therapeutic efficacy.

Effect of suprarenal aortic cross-clamping.

BACKGROUND: Renal insufficiency is the most frequent complication of surgeries that involve suprarenal aortic cross-clamping. Although some studies have assessed the risk of intraoperative renal ischemia by comparing juxtarenal abdominal aortic aneurysms (AAAs) and infrarenal AAAs, a critical limitation is the difference in these patients' clinical backgrounds and aneurysmal features. The present study evaluated the effect of suprarenal aortic clamping by comparing a juxtarenal AAA group with a subgroup of infrarenal AAAs (ie, short and/or large neck). METHODS AND RESULTS: Among patients who underwent open surgery for AAA, the 2 types of AAA were selected and compared: juxtarenal AAA (JR group: n=35) and infrarenal AAA with short (<15 mm) and/or large (>28 mm) aneurysmal neck that only required infrarenal aortic clamping (SL group: n=26). Postoperative renal function was evaluated using the RIFLE classification. There were no significant differences between groups in baseline characteristics, comorbidities, and intraoperative variables. There were no adverse events leading directly to in-hospital mortality in either group. The rate of postoperative renal insufficiency (estimated glomerular filtration rate decrease ≥-25%) was not significantly different between groups. CONCLUSIONS: The outcomes of the 2 groups were similar, indicating that intraoperative renal ischemia with no specific intraoperative protection would not adversely affect postoperative outcomes.

Three cases of fusion imaging in endovascular treatment of occlusive peripheral artery disease.

Endovascular treatment of peripheral artery disease has dramatically improved in the past decades; however, occlusive or stenotic lesions of the femoral-popliteal artery segment remain a significant challenge for vascular specialists. Real-time guidance based on vessel visualization might be helpful for successful recanalization. Herein, we present three successful cases of fusion imaging during endovascular treatment of the femoral-popliteal artery segments.

Risk factors for SARS infection within hospitals in Hanoi, Vietnam.

We investigated a nosocomial infection of severe acute respiratory syndrome (SARS) in Vietnam in 2003 and attempted to identify risk factors for SARS infection. Of the 146 subjects who came into contact with SARS patients at Hospital A, 43 (29.5%) developed SARS, and an additional 16 (11%) were asymptomatic but SARS-coronavirus (CoV) seropositive. The asymptomatic infection rate accounted for 15.5% of the total number of infected patients at Hospital A, which was higher than that of 6.5% observed at Hospital B, to where all patients from Hospital A were eventually transported (P<0.05). At Hospital A, the risk for developing SARS was 12.6 times higher in individuals not using a mask than in those using a mask. The SARS epidemic in Vietnam resulted in numerous secondary infections due to its unknown etiology and delayed recognition at the beginning of the epidemic. The consistent and proper use of a mask was shown to be crucial for constant protection against infection with SARS.

Targeting ability of self-assembled nanomedicines in rat acute limb ischemia model is affected by size.

Peripheral artery disease (PAD) is one of the most spreading diseases all over the world. The treatment strategies are limited to surgical or endovascular procedures for final stage chronic PAD or acute limb ischemia, and no pharmacological approaches have been achieved to prevent the worsening of chronic PAD or to regenerate the tissues of acute limb ischemia. Therefore, the improvement of therapeutic strategy is strongly demanded in clinics. Here, we adopted an acute hindlimb ischemia model in rats, which provides concomitant inflammatory response, to evaluate the application of drug delivery system against PAD. Through comparative experiments by using different-sized nanomedicine analogues, polyion complex (PIC) micelles with 30 nm diameter and PIC vesicles with 100- and 200-nm diameter (PICs-30, -100, -200 respectively), we found the size-dependent accumulation and retention in the collateral arteries. In contrast to PICs-30 and -200, histological analysis showed that PICs-100 were around the arterioles and co-localized with macrophages, which indicates that the PICs-100 can achieve moderate interaction with phagocytes. Our data suggests that controlling the size of nanomedicines has promise for developing novel angiogenic treatments toward the effective management of collateral arteries.

Useful predictors for critical limb ischemia in severely ischemic limbs.

BACKGROUND: The aim of this paper was to determine useful predictors for critical limb ischemia (CLI) occurrence in severely ischemic limbs. The contralateral limbs of patients with unilateral CLI were evaluated, with special respect to pulse volume recording (PVR). METHODS: Retrospective analysis of 102 consecutive patients (110 limbs) with unilateral CLI. We excluded patients with bilateral CLI, or without PVR data. PVR data were automatically quantitatively expressed as upstroke time (UT) and percentage mean artery pressure (%MAP). The role of PVR parameters was examined in relation to arterial occlusive disease in the lower limbs. Baseline characteristics and non-invasive laboratory data (including Ankle Brachial Index [ABI] and PVR data) were analyzed as predictors for CLI. RESULTS: After exclusion, 73 contralateral limbs of unilateral CLI patients (mean age, 70±12 years; 51 male, 70%) were investigated. Fifty patients (68%) had diabetes, and 41 patients (56%) were receiving hemodialysis. UT was longer in patients with crural arterial occlusive disease (214±55 versus 183±57 ms, P=0.02), although ABI was not different (P=0.31). In the follow-up of 19±12 months, 25 limbs progressed to CLI, and the cumulative incidence was 28% and 51% at 1 and 3 years, respectively. Multivariate analysis confirmed that abnormal %MAP (hazard ratio 5.9; 95% confidence interval, 1.8-27.0; P<0.01), coronary artery disease (CAD), and hypoalbuminemia were significant risk factors. CONCLUSIONS: %MAP, CAD, and hypoalbuminemia predicted CLI occurrence in the contralateral limbs of unilateral CLI patients.

Socioeconomic and reproductive factors associated with condom use within and outside of marriage among urban pregnant women in Zambia.

A cross-sectional questionnaire survey was conducted on 470 pregnant women in Lusaka, Zambia. Multivariate analysis revealed school attendance and child deaths as independently significant variables positively associated with HIV seropositivity. Among women with fidelity, HIV prevalence was not significantly lower, and condom use was much lower than among women who were having extramarital affairs. Factors significantly associated with condom use within and outside of marriage differed-age and number of live births within, and sexual transmission knowledge outside of marriage. School attendance was not effective for gaining knowledge on sexual transmission or condom use. Regular own earning was significantly effective for condom use in both groups, irrespective of school attendance. The following should be implemented intensively: effective education on HIV and sex in and out of school before early sexual debut, further implementation of family planning with emphasis on condom use, and empowering women by assisting with their economic independence.

Long-term results of combined aortoiliac and infrainguinal arterial reconstruction for the treatment of critical limb ischemia.

OBJECTIVE: This study was designed to investigate our long-term experience with combined iliac endovascular therapy (EVT) and infrainguinal bypass to treat critical limb ischemia (CLI) and compare outcomes to those of patients who underwent surgery for aortoiliac lesions. MATERIALS AND METHODS: From April 2000 to June 2013, 57 patients (58 limbs) underwent an infrainguinal bypass combined with aortoiliac reconstruction to treat CLI. Eighteen limbs were treated by bypass alone and 8 limbs were treated by bypass with EVT for aortoiliac lesions (Bypass group). Thirty-two limbs were subjected to EVT alone for iliac lesions (EVT group). RESULTS: Preoperative limb ischemia was more severe in the EVT group. There were no significant differences in major procedure-related complications (χ(2) test, P = 0.853), systemic complications (P = 0.853), and mortality (P = 0.916) between the 2 groups. The limb salvage rates were 92% at 1, 3, and 5 years in the Bypass group and 93% at 1, 3, and 5 years in the EVT group, with no significant difference observed between the groups (Kaplan-Meier, log-rank test, P = 0.616). CONCLUSION: Infrainguinal surgical reconstruction combined with an iliac EVT is an acceptable strategy for managing patients with CLI.

Adequate Selection of a Therapeutic Site Enables Efficient Development of Collateral Vessels in Angiogenic Treatment With Bone Marrow Mononuclear Cells.

BACKGROUND: Induction of angiogenic mechanisms to promote development of collateral vessels is considered promising for the treatment of peripheral arterial diseases. Collateral vessels generally develop from preexisting arteriolar connections, bypassing the diseased artery. We speculated that induction of angiogenic mechanisms should be directed to such arteriolar connections to achieve efficient collateral development. The aim of this study was to verify this hypothesis using autologous transplantation of bone marrow mononuclear cells in the rabbit model of chronic limb ischemia. METHODS AND RESULTS: The left femoral artery was excised to induce limb ischemia in male rabbits. In this model, arteriolar connections in the left coccygeofemoral muscle tend to develop into collateral vessels, although this transformation is insufficient to alleviate the limb ischemia. In contrast, arteriolar connections in the closely located adductor muscle do not readily develop into collateral vessels. At 21 days after ischemia initiation, a sufficient number of automononuclear cells were selectively injected in the left coccygeofemoral muscle (coccygeo group) or left adductor muscle (adductor group). Evaluation of calf blood pressure ratios, blood flow in the left internal iliac artery, and angiographic scores at day 28 after injection revealed that collateral development and improvement of limb ischemia were significantly more efficient in the coccygeo group than in the adductor group. Morphometric analysis of the coccygeofemoral muscle at day 14 showed similar results. CONCLUSIONS: Specific delivery of mononuclear cells to the coccygeofemoral but not the adductor muscle effectively improves collateral circulation in the rabbit model of limb ischemia and suggests that adequate site selection can facilitate therapeutic angiogenesis.

Protective roles of aldo-keto reductase 1B10 and autophagy against toxicity induced by p-quinone metabolites of tert-butylhydroquinone in lung cancer A549 cells.

tert-Butylhydroquinone (BHQ), an antioxidant used as a food additive, exhibits an anticancer effect at low doses, but is carcinogenic in rodents at high doses. BHQ is metabolized into cytotoxic tert-butylquinone (TBQ), which is further converted to 6-tert-butyl-2,3-epoxy-4-hydroxy-5-cyclohexen-1-one (TBEH) through 6-tert-butyl-2,3-epoxy-4-benzoquinone (TBE). Both TBQ and TBE are cytotoxic, but their toxic mechanisms have not been fully characterized. In this study, we have investigated the toxic mechanisms of TBQ and TBE, and the defense system against the two p-quinones using lung cancer A549 cells. TBQ and TBE, but not BHQ and TBEH, showed cytotoxicity to A549 cells. Neither caspase-3 activation nor an increase in the expression of endoplasmic reticulum stress-associating target genes was observed. TBQ and TBE reacted with reduced glutathione, and significantly decreased the glutathione level in A549 cells, suggesting that the cytotoxicity of the p-quinones is caused by their high electrophilicity reacting with biomolecules. The A549 cells treated with the p-quinones also showed increased levels of autophagic vacuoles and LC3-II protein, which are specific autophagy markers. An autophagy inhibitor, 3-methyladenine (3MA), decreased the LC3-II production by the p-quinones, but enhanced the cytotoxicity induced by TBQ and TBE, suggesting that autophagy contributes to alleviating the p-quinone-triggered cytotoxicity. In addition, the TBE-induced cytotoxicity and autophagy activation in the cells were significantly suppressed by overexpression of aldo-keto reductase (AKR)1B10 that efficiently reduces TBE into TBEH, and were augmented by pretreatment with a potent AKR1B10 inhibitor, C1. The effects of 3MA and C1 on the TBE-induced cytotoxicity were additive. The data provides evidence for the first time that autophagy and AKR1B10 contribute to the defense system against the cytotoxicity caused by the electrophilic p-quinone metabolites of BHQ.

Long-Term Results of Treatment for Critical Limb Ischemia.

From 2001 to 2012, arterial reconstruction was performed in 306 out of 497 limbs (62%) with critical limb ischemia. The reasons for non-vascularization include high operative risk (36%), extended necrosis or infection (20%), and technical issues (15%). Cumulative patency and limb salvage in collagen disease were significantly worse compared to arteriosclerosis obliterans. Cumulative limb salvage, amputation free survival (AFS), and major adverse limb event and perioperative death (MALE + POD) in patients with end-stage renal disease (ESRD) were significantly worse compared to patients without ESRD, but not significant with regards to graft patency. Our finding suggests that aggressive arterial reconstruction provides satisfactory long-term results in critical limb ischemia so long as case selection for revascularization is properly made. (This article is a translation of J Jpn Coll Angiol 2014; 54: 5-11.).

Purification and characterization of uridine phosphorylase from the ice-nucleating bacterium, Pantoea agglomerans NBRC12686.

The ice-nucleating bacterium, Pantoea agglomerans NBRC12686 responds to a decrease in temperature with the induction of proteins, which are classified as cold-induced proteins. When the temperature of the strain NBRC12686 culture was lowered from 30 degree C to 12 degree C, the viability after freezing treatment significantly improved. By the use of SDS-polyacrylamide gel electrophoresis and high-performance liquid chromatography (HPLC), we analyzed the cold acclimation response in strain NBRC12686. After a shift from 30 degree C to 12 degree C, several proteins and saccharides were synthesized. After 48 h of cold acclimation, the induction level of proteins increased. In addition, ribose-1-phosphate was fractionated by HPLC using a TSK gel Sugar AXG column. Cell-free extracts were prepared from a cold acclimation culture (30 degree C to 12 degree C) and a non-cold acclimation culture (30 degree C), and then subjected to SDS-PAGE. A protein of approximately 29.7-kDa was present in the cold acclimation culture but was not present in the non-cold acclimation culture. The 29.7-kDa protein was purified by various chromatographies. We found that apparent molecular mass of the protein was approximately 119-kD constructed of 4 subunits of 29.7-kDa each. Based on the analysis of the N-terminal amino acid sequences of proteins, the 29.7-kDa protein had 83 percent identity with that of uridine phosphorylase (UPase) obtained from Escherichia coli K-12. We confirmed that the 29.7-kDa protein was novel, judged by molecular mass different from the already-known UPase or cryoprotectants. The cryoprotective activity of UPase of 29.7-kDa protein for LDH was approximately 30 percent at 5.0 microgram per ml of the protein. Furthermore, UPase had a high level of cryoprotective activity even after treating at 70 degree C for 30 min, but had no activity after treating at 100 degree C. We could elucidate that UPase from strain NBRC12686 had a cryoprotective activity as well as an enzyme activity, and it seems that UPase works in two different mechanisms for freezing tolerance.

Treatment Strategies for a Pancreaticoduodenal Artery Aneurysm with or without a Celiac Trunk Occlusive Lesion.

OBJECTIVES: A true pancreaticoduodenal artery aneurysm (PDAA) is a rare disease, and has some unique characteristics: a high rupture risk and a strong correlation with celiac trunk stenotic lesions (CTSL). We showed here that our treatment strategy for PDAA. MATERIALS AND METHODS: Seven consecutive patients with PDAA at our institution from 1998 to 2011 were retrospectively reviewed. Of the 7 patients, five were male and two were female, with a mean age of 55 ± 9.7 years. Three aneurysms were diagnosed incidentally, and the remaining four ruptured. The locations of the aneurysm were the anterior superior pancreaticoduodenal artery (ASPDA) in 3 patients and the inferior pancreaticoduodenal artery (IPDA) in four. CTSL found 3 patients in the IPDA. RESULTS: Of four ruptured patients, emergency catheter coil embolization was performed in three, and a simple ligation was performed in one. Three patients with non-ruptured aneurysms in the IPDA with a CTSL underwent direct aneurysm resection with arterial reconstruction. Six patients were successfully treated without complications or the appearance of new aneurysms during the follow-up period. CONCLUSION: The treatment strategy for PDAA should be selected by the site of the aneurysm, the patients' condition, and the anatomical situation. A hybrid treatment could be considered a beneficial option for a CTSL.

Successful utilization of coronary covered stents to treat a common hepatic artery pseudoaneurysm secondary to pancreatic fistula after Whipple's procedure: report of a case.

A 73-year-old man underwent a pylorus-preserving Whipple's procedure for distal cholangiocarcinoma. His postoperative course was complicated by the formation of a pancreatic fistula, which was initially managed conservatively. On postoperative day (POD) 86, he lost 100 ml of blood from the site of the pancreatic fistula. Contrast-enhanced computed tomography (CT) showed a pseudoaneurysm, 12 mm in diameter, in the common hepatic artery. The diameter of the pseudoaneurysm increased to 15 mm on POD 89, so we implanted coronary covered stents to prevent massive bleeding from rupture and to retain hepatic arterial flow. Six days after implantation, computed tomography findings confirmed a thrombosed pseudoaneurysm as well as patent hepatic arterial flow. Follow-up CT 18 months after surgery showed patent hepatic arterial flow. There have been no signs of rebleeding or abnormal liver function.

Anabolic five subunit-type pyruvate:ferredoxin oxidoreductase from Hydrogenobacter thermophilus TK-6.

The thermophilic, obligately chemolithoautotrophic hydrogen-oxidizing bacterium, Hydrogenobacter thermophilus TK-6, assimilates carbon dioxide via the reductive tricarboxylic acid cycle. A gene cluster, porEDABG, encoding pyruvate:ferredoxin oxidoreductase (POR), which plays a key role in this cycle, was cloned and sequenced. The nucleotide sequence and the gene organization were similar to those of the five subunit-type 2-oxoglutarate:ferredoxin oxidoreductase from this strain, although the anabolic POR had been previously reported to consist of four subunits. A small protein (8 kDa) encoded by porE, which had not been detected in the previous work, was identified in the purified recombinant POR expressed in Escherichia coli, indicating that the enzyme is also a five-subunit type. Incorporation of PorE in the wild-type POR enzyme was confirmed by immunological analysis. PorA, PorB, PorG, and PorE were similar to the alpha, beta, gamma, and delta subunits of the four subunit-type 2-oxoacid oxidoreductases, respectively, and had conserved specific motifs. PorD had no specific motifs but was essential for the expression of the active enzyme.