Comparison of Clinical Outcomes in Patients Undergoing Common Femoral Thromboendarterectomy With or Without Patch Angioplasty.

OBJECTIVE: Surgical thromboendarterectomy (TEA) is the standard treatment for an occlusive lesion of the common femoral artery (CFA). However, there is limited knowledge on the need for patch angioplasty in CFA TEA. The objective of this study was to compare the peri-operative and two year results of CFA TEA with or without patch angioplasty. METHODS: A multicentre retrospective observational study was performed at 34 Japanese centres. Comparisons were made between patients undergoing CFA TEA with or without patch angioplasty after propensity score matching (PSM). The primary endpoints were primary patency and freedom from target lesion revascularisation (TLR) of the TEA lesion. The secondary endpoints were hospital outcomes, limb salvage, and overall survival. RESULTS: Between 2018 and 2020, 428 TEA procedures (237 with patch angioplasty and 191 with primary closure) were performed. PSM extracted 151 pairs with no significant intergroup differences in baseline characteristics. Peri-operative death and complications occurred in 0.7% vs. 1.3% (p = 1.0) and 6.0% vs. 6.6% (p = 1.0), respectively. The follow up rate was 96% over a median follow up of 14.9 months (interquartile range 8.3, 24.3). Loss of primary patency occurred in 18 patients. The two year primary patency of patch angioplasty cases was statistically significantly higher than that of primary closure cases (97.0% vs. 89.9%; p = .021). TLR was performed in 14 patients. The two year freedom from TLR in patch angioplasty cases was also statistically significantly higher than in primary closure cases (98.6% vs. 92.9%; p = .003). During follow up, seven limbs required major amputation and 40 patients died. There was no statistically significant difference in limb salvage and survival between the two groups after PSM. CONCLUSIONS: This is the first report to show that patch angioplasty may decrease re-stenosis and target lesion revascularisation of CFA TEA lesions.

BubR1 insufficiency impairs angiogenesis in aging and in experimental critical limb ischemic mice.

OBJECTIVES: Budding uninhibited by benzimidazole-related 1 (BubR1), a cell cycle-related protein, is an essential component of the spindle checkpoint that regulates cell division. Mice in which BubR1 expression is reduced to 10% of the normal level display the phenotypic features of progeria. However, the role of BubR1 in vascular diseases and angiogenesis remains unknown. To investigate the influence of BubR1 on angiogenesis, we generated a low-null-BubR1-expressing (BubR1L/-) mouse strain with reduced BubR1 expression as low as 15% of the normal level without any abnormalities in appearance. METHODS: To elucidate the role of BubR1 in angiogenesis, we used a hind limb ischemia model induced in BubR1L/- mice and age-matched wild-type (WT) littermates. To evaluate the pathologic influence of BubR1 on angiogenesis, we measured the blood flow before and after hind limb ischemia surgery, and the expression of typical angiogenic factors in vivo and in vitro. RESULTS: In WT mice, blood flow in the ischemic left limb gradually recovered to approximately 80%, 14 days after surgery. Conversely, in the BubR1L/- group, blood flow in the left ischemic limb recovered to at most 30% (14 days after surgery, P < .01; immediately after the operation, and 5 and 9 days after surgery, P < .05). In adductor and calf muscles from BubR1L/- mice, regenerated muscle bundles, granulation tissue, and inflammatory cell invasion were more evident than in calf muscles from WT mice at 14 days after surgery. All WT mice at 14 days after surgery had complete limb salvage, but loss of limbs was observed in approximately 70% of BubR1L/- mice (P < .05). The vascular endothelial growth factor protein increase in ischemic hind limb muscles was lower in BubR1L/- mice compared with WT mice (P < .05), and vascular endothelial growth factor levels in human aortic smooth muscle cells treated with BubR1 knockdown siRNA were lower compared with scramble siRNA under hypoxic conditions (P < .01). HIF1α protein levels in the muscles after hind limb ischemia surgery were also significantly lower in BubR1L/- mice compared with WT mice (P < .05). CONCLUSIONS: BubR1 insufficiency impairs angiogenesis and results in limb loss in ischemic hind limbs. BubR1 may be a crucial angiogenic factor and might be beneficial for the treatment of limb ischemia.

Prognostic factor of the two-year mortality after revascularization in patients with critical limb ischemia.

Purposes The aim of this study was to evaluate the risk factors for the two-year survival after revascularization of critical limb ischemia. Methods Between 2008 and 2012, 142 patients underwent revascularization. A retrospective analysis was performed to measure the risk factor. Results A total 85 patients underwent surgical revascularization, 31 patients underwent endovascular therapy while 26 patients underwent hybrid therapy. By multivariate analysis, the following variables were considered to be risk factors: ejection fraction <50 % (HR, 3.14; 95% CI, 1.22-7.95; P = 0.02), serum albumin level <2.5 g/dL (HR, 3.45; 95% CI, 1.01-11.7; P = 0.04) and nonambulatory status (HR, 4.11; 95% CI, 1.79-9.70; P < 0.01). The two-year survival rate of the patients with no risk factors was 85.5%, while the patients with at least one risk factor had an unfavorable prognosis (one; 56.7%, two; 45.4%). Conclusions The nonambulatory status, serum albumin level <2.5 g/dL and ejection fraction <50% were the risk factors for the two-year mortality after revascularization in critical limb ischemia patients. These risk factors may be useful for the treatment strategy of critical limb ischemia patients.

Raison d'etre of Tibial Artery Bypass for Intermittent Claudication in the Era of Endovascular Therapy.

BACKGROUND: There is currently no positive opinion regarding infrapopliteal revascularization for intermittent claudication (IC) in any guidelines. The aim of this study was to analyze the outcomes of infragenicular bypass and verify the adequacy of tibial artery bypass for IC. METHODS AND RESULTS: Over a 21-year period, 58 below-knee popliteal artery (BKPOP) bypasses and 35 tibial artery bypasses were performed for IC caused by arteriosclerosis obliterans. Graft patency and major amputation (MA) were examined as primary endpoints and the predictor of each outcome was estimated by multivariate analysis. The primary patency (PP), secondary patency (SP), and freedom from MA (ffMA) rates of a prosthetic/vein graft in all cases at 5 years were 19/68%, 22/86%, and 78/100% (P<0.01 in all). Limited to vein graft cases, PP and SP rates of popliteal/tibial bypass at 5 years were 73/62% (P=0.32) and 92/80% (P=0.22), respectively. In tibial artery bypass with a vein graft, the PP and SP rates of a single saphenous vein/spliced vein graft at 5 years were 71/46% (P=0.11) and 89/61% (P=0.03). A prosthetic graft was a common negative predictor for graft patency and MA by multivariate analysis. CONCLUSIONS: Tibial artery bypass is an acceptable treatment option for IC when a single saphenous vein can be harvested as a graft conduit. (Circ J 2016; 80: 1460-1469).

Elective endovascular vs. open repair for abdominal aortic aneurysm in octogenarians.

PURPOSE: The purpose of this study was to investigate the operative mortality and short-term and midterm outcomes of treatment of abdominal aortic aneurysm in Japanese patients over 80 years of age. METHODS: Between January 2007 and December 2011, 207 patients underwent elective repair of infrarenal abdominal aortic aneurysms. Comorbidities, operative morbidity and mortality, midterm outcomes were analyzed retrospectively. RESULTS: The average age (endovascular aneurysm repair, 84.4 ± 0.3; open, 82.8 ± 0.3, P < 0.01) and the percentage of hostile abdomen (endovascular aneurysm repair, 22.2%; open repair, 11.1%, P < 0.05) were higher in the endovascular aneurysm repair group. Percentage of outside IFU was higher in open repair (endovascular aneurysm repair, 38.5%; open repair, 63.3%, P < 0.01). The cardiac complication (endovascular aneurysm repair, 0%; open repair, 5.6%, P < 0.01) and length of postoperative hospital stay (endovascular aneurysm repair, 10.3 ± 0.8 days; open, 18.6 ± 1.6 days, P < 0.05) were significantly lower in the endovascular aneurysm repair group. There were no differences in operative mortality (endovascular aneurysm repair, 0%; open, 1.1%, P = 0.43) and the aneurysm-related death was not observed. The rate of secondary interventions (EVAR, 5.1%; open repair, 0%, P < 0.01) and midterm mortality rate were much higher in the endovascular aneurysm repair group. CONCLUSIONS: Endovascular aneurysm repair is less invasive than open repair and useful for treating abdominal aortic aneurysm in octogenarians; however, open repair can be acceptable treatment in the inappropriate case treated by endovascular aneurysm repair.

Radial force measurement of endovascular stents: Influence of stent design and diameter.

BACKGROUND AND PURPOSE: Angioplasty and endovascular stent placement is used in case to rescue the coverage of main branches to supply blood to brain from aortic arch in thoracic endovascular aortic repair. This study assessed mechanical properties, especially differences in radial force, of different endovascular and thoracic stents. MATERIAL AND METHODS: We analyzed the radial force of three stent models (Epic, E-Luminexx and SMART) stents using radial force-tester method in single or overlapping conditions. We also analyzed radial force in three thoracic stents using Mylar film testing method: conformable Gore-TAG, Relay, and Valiant Thoracic Stent Graft. RESULTS: Overlapping SMART stents had greater radial force than overlapping Epic or Luminexx stents (P < 0.01). The radial force of the thoracic stents was greater than that of all three endovascular stents (P < 0.01). CONCLUSIONS: Differences in radial force depend on types of stents, site of deployment, and layer characteristics. In clinical settings, an understanding of the mechanical characteristics, including radial force, is important in choosing a stent for each patient.

Sarcopenia is a prognostic factor for overall survival in patients with critical limb ischemia.

BACKGROUND: Sarcopenia has been proposed as a prognostic factor for various diseases. Patients with critical limb ischemia (CLI) have a very poor prognosis, but sarcopenia has not been reported as a prognostic factor for CLI patients. If sarcopenia is associated with the prognosis of CLI patients, it could help select the treatment plan. Therefore, we examined whether sarcopenia is a prognostic factor for CLI patients. METHODS: We performed a retrospective study of CLI patients diagnosed with Fontaine III or IV peripheral artery disease who underwent preoperative computed tomography imaging and revascularization between January 2002 and December 2009. The presence of sarcopenia was defined as skeletal muscle area of <114.0 cm(2) for men or <89.8 cm(2) for women using transverse computed tomography scans at the third lumbar vertebra. We compared the 5-year survival rate and clinical characteristics between patients with or without sarcopenia. We also screened possible prognostic factors for overall survival using hazard ratios (HRs) with 95% confidence intervals (CIs). RESULTS: Of 64 eligible patients, 28 patients had sarcopenia and 36 did not. There were significant differences in age, skeletal muscle area, body mass index, and the presence of smoking, cerebrovascular disease, and hemodialysis between patients with and without sarcopenia (all P < .05). The 5-year survival rate was significantly lower in patients with sarcopenia (23.5% vs 77.5%, P = .001). Prognostic factors for overall survival were the presence of sarcopenia (HR, 3.22; 95% CI, 1.24-9.11; P = .02), requirement for hemodialysis (HR, 4.30; 95% CI, 1.60-12.2; P = .004), and postoperative complications (HR, 5.02; 95% CI, 1.90-13.7; P = .001). CONCLUSIONS: Our results suggest that sarcopenia is a prognostic factor for CLI patients. Exercise and nutritional interventions focusing on improving sarcopenia might be useful treatment options for CLI patients.

Thoracic endovascular aortic repair and coil embolization of the pulmonary artery for primary racemose hemangioma of the bronchial artery with a bronchial-pulmonary artery fistula.

A 69-year-old male visited a doctor with dyspnea. A bronchial-pulmonary artery fistula, which is called racemose hemangioma, and dilated pulmonary artery were detected by a computed tomography (CT) scan. The bronchial-pulmonary artery fistula can cause lethal hemoptysis, therefore, we performed thoracic endovascular aortic repair (TEVAR) to seal the bronchial artery and coil embolization of the pulmonary artery. Postoperative CT showed the thrombosed racemose hemangioma of the bronchial artery. TEVAR and coil embolization of the pulmonary artery is considered to be a useful treatment option for a racemose hemangioma.

Midterm outcomes of endovascular repair for abdominal aortic aneurysms with the on-label use compared with the off-label use of an endoprosthesis.

PURPOSE: Endovascular repair of an abdominal aortic aneurysm (EVAR) is sometimes not performed in accordance with the instructions for use (IFU) of the endoprosthesis ("off-label use"). We investigated whether the off-label use of the endograft affected the outcomes of EVAR. METHODS: Demographic, anatomical, intraoperative and follow-up data on 100 patients in whom the endograft was used on-label in EVAR were compared retrospectively with the corresponding data of 50 patients with off-label endograft use. RESULTS: The endograft IFU were most often not followed in patients with challenging aortic neck anatomy or iliac access or fixation, steep neck angulation or bilateral hypogastric artery embolization. Compared with patients in whom the device was used on-label, patients with off-label use had significantly higher rates of intraoperative type I or III endoleaks and proximal aortic cuff placement or other adjunctive procedures. However, there were no midterm differences between the two groups in the rates of type 1b or II endoleaks, sac enlargement, device-limb occlusion or patient survival. CONCLUSIONS: Most midterm outcomes of EVAR in which the endografts were used off-label were similar to those associated with on-label use of the devices. Off-label use of EVAR endoprostheses is feasible, but requires the use of special techniques in patients with challenging anatomical features.

Long-Term Results of a Hybrid Revascularization Procedure for Peripheral Arterial Disease.

OBJECTIVE: To evaluate the efficacy of hybrid procedure for peripheral arterial disease (PAD), we compared the cases treated using the hybrid procedure with those treated using open revascularization (bypass alone) in our facilities. MATERIALS AND METHODS: We retrospectively reviewed 204 patients who underwent revascularization for PAD between 2007 and 2013. We divided the patients into two groups based on the type of procedure. Group 1 included patients who underwent the hybrid procedure, that is, doing endovascular therapy (EVT) either femoral or iliac resion and added the bypass procedure (infragenicular vein bypass) to the below knee artery, and group 2 included patients who underwent only bypass procedure (used autovein), that is, central anastomotic region was femoral artery region and peripheral anastomotic region was below knee artery. We evaluated various factors between the two groups, including the primary patency rate, secondary patency rate, amputation-free survival rate, and determined the efficacy of the hybrid procedure for PAD. RESULTS: In the patient's characteristics, there was significant difference between the two groups in the cases with cerebrovascular disease, only (p = 0.03). There were no significant differences in the primary or secondary patency rates, and the amputation-free survival rate. CONCLUSIONS: Primary patency rate, secondary patency rate, and amputation-free survival rate of the hybrid procedure were comparable to those of bypass (alone) procedure. The hybrid procedure is therefore an acceptable strategy for patients with PAD.

Endovascular aneurysm repair for an abdominal aortic aneurysm and a left ruptured common iliac artery aneurysm in a patient with hepatocellular carcinoma: report of a case.

We performed an endovascular aneurysm repair (EVAR) for an abdominal aortic aneurysm (AAA) and a ruptured common iliac artery aneurysm (rCIAA) in a patient complicated by severe liver dysfunction due to obstructive jaundice resulting from hepatocellular carcinoma (HCC). A 68-year-old male presented with acute lower abdominal pain. Abdominal computed tomography (CT) showed a 4.5-cm infrarenal AAA, a 6.0-cm left rCIAA with retroperitoneal hematoma and a 13-cm mass in the liver, which was suspected to be HCC. His laboratory data showed severe liver dysfunction. An emergency EVAR was done under local anesthesia because of his liver dysfunction. He was transferred to another hospital without any complications.

Late type III endoleak of a Powerlink stent graft: report of a case.

We herein report a case of a late type III endoleak caused by disconnection of the aorta extension and main body of a Powerlink four years after implantation. Migration of the main body caused a disconnection of the main body and extension despite the fact that the size of the aneurysm had been decreasing. The endoleak was successfully repaired using the interpolation of an Endurant aortic extender. In case of necessity of implantation of the extension, first implantation of extension before deploying the main body may help to prevent type III endoleaks caused by disconnection of the stentgraft in patients treated with the Powerlink system. To our knowledge, this is the first reported case of a late type III endoleak caused by a Powerlink device.

Successful treatment of an abdominal aortic aneurysm with a severely angulated and large aortic neck using a modified Zenith.

This report presents the case of an abdominal aortic aneurysm (AAA), in which the aortic neck was severely angulated. Furthermore, there was moderate stenosis and a severe angle with calcification of the suprarenal aorta. EVAR was performed with a commercial Zenith stent-graft, with a slight modification, because an open aneurysm repair was risky in general condition. No complications occurred during the follow-up period.

Effectiveness of Thoracic Endovascular Aortic Repair for Blunt Thoracic Aortic Injury.

PURPOSE: Blunt thoracic aortic injury (BTAI) has a high mortality rate, and the occurrence of clinical complications is high. Several studies have reported the efficacy of thoracic endovascular aortic repair (TEVAR) for BTAI. This study aimed to clarify the use of TEVAR for BTAI. METHODS: We analyzed 10 cases of TEVAR for BTAI from July 2011 to December 2020 at our hospital. Five of 10 cases of BTAI were caused by road traffic accidents, while five were caused by falls from a height. RESULTS: The mean patient age was 59.3 years. When arriving at our hospital, seven of 10 patients were in shock. Nine of 10 cases of BTAI were at the aortic isthmus. With respect to BTAI severity, five of 10 patients were categorized as grade IV. Ps of non-survivors were extremely low. All patients underwent TEVAR. The mean surgical duration and volume of intraoperative blood loss were 77.5 minutes and 234 ml, respectively. CONCLUSION: The results of TEVAR for BTAI at our institution support previous reports, which show excellent clinical results. To further improve the outcomes, we must clarify the adaptation of nonoperative management (delayed repair), the optimal timing of invasive treatment, and the importance of long-term follow-up.

Optimal Duration of Compression Stocking Therapy after Endovenous Laser Ablation Using a 1470-nm Diode Dual-Ring Radial Laser Fiber for Great Saphenous Vein Insufficiency.

Objective: To investigate the optimal duration of compression therapy after endovenous laser ablation (EVLA) using a 1470-nm diode dual-ring radial laser fiber for great saphenous vein (GSV) insufficiency. Methods: Patients undergoing EVLA of GSV for varicose vein disease were divided into two groups based on the duration of subsequent compression after the procedure: short duration group (S group; 0-2 days) and long duration group (L group; 1-4 weeks). Patient-reported outcomes (pain and quality of life [QOL]) were set as the primary outcomes, and objective findings (venous clinical severity score [VCSS], leg circumference, and duplex ultrasound [DUS] findings) were set as the secondary outcomes. A follow-up examination was performed at 1 week and 1 and 6 months. Each variable between the groups was compared after a propensity score matching using the age, sex, Clinical-Etiological-Anatomical-Pathophysiological (CEAP) clinical class, job type, and target variable as covariates. A per-protocol analysis was performed. Results: The S and L groups included 98 and 99 patients, respectively. A propensity score matching analysis showed no significant differences between the groups in any outcomes at any follow-up intervals. Conclusion: Long-term compression showed little benefit; therefore, the prescription of compression stocking beyond 2 days after EVLA is unnecessary.

A Rare Complication of Spinal Cord Ischemia Following Endovascular Aneurysm Repair of an Infrarenal Abdominal Aortic Aneurysm with Arteriosclerosis Obliterans: Report of a Case.

We herein report a case of a rare complication of spinal cord ischemia (SCI) following endovascular aneurysm repair (EVAR). Computed tomography showed stenosis and calcification of bilateral iliac arteries and a saccular aneurysm of the terminal aorta. Paraplegia occurred soon after balloon angioplasty of iliac arteries and EVAR. Cerebrospinal fluid drainage was not performed because the patient was on dual antiplatelet drugs. The patient was treated with intravenous methylpredonisolone and naloxone; however, this did not improve his paraplegia. SCI after EVAR is extremely rare and unpredictable complication, however, physicians should be aware of SCI after EVAR in patients with atherosclerosis.

Emergency thoracic aortic stent grafting for acute complicated type B aortic dissection after a previous abdominal endovascular aneurysm repair.

We report a case of acute type B aortic dissection with the complication of bowel ischemia and abdominal stent graft compression treated by emergency thoracic aortic stent grafting after endovascular aneurysm repair (EVAR) for abdominal aortic aneurysm (AAA). A 69-year-old male was admitted to our hospital for sudden thoraco-abdominal pain. He had past treatment history of EVAR for AAA half a year ago. A computed tomography (CT) showed acute type B aortic dissection, and conservative treatment was initially performed. Three days after occurrence of aortic dissection, worsened abdominal pain and melena were observed. CT showed that the true lumen and abdominal stent graft was compressed by the false lumen. Emergency thoracic endovascular repair (TEVAR) was performed to close the entry tear. After the operation, the image views and the symptoms were improved. The state was still stable 6 months later. TEVAR for acute type B aortic dissection can become one of the effective treatments.

One-stage Procedure for Concomitant Abdominal Aortic Aneurysm and Gastric Cancer.

BACKGROUND/AIM: A concise surgical strategy for concomitant abdominal aortic aneurysm (AAA) and operable gastric cancer remains unknown. We assessed a one-stage procedure that included endovascular abdominal aortic aneurysm repair (EVAR) and gastric resection. PATIENTS AND METHODS: Forteen patients who underwent surgery for an infrarenal AAA and gastric cancer between 1990 and 2012 were retrospectively reviewed. Demographic characteristics, aneurysm size, comorbid conditions, length of postoperative hospital stay, complications within 30 days of surgery, and survival in patients in EVAR (n=4) were compared against patients who had an open AAA repair (n=10). RESULTS: Demographic characteristics, aneurysm size, and comorbid conditions were similar in the EVAR and open-AAA-repair group. The mean length of hospitalization was significantly shorter in the EVAR group (15.2 days vs. 34.9 days; p=0.005), and the rate of postoperative complications was significantly lower (p<0.05). The overall survival rates in the EVAR and open-AAA-repair groups were, respectively, 100% and 80% at 1 year and 75% and 60% at 3 years; the differences between groups were not significant (p=0.788). CONCLUSION: In patients with concomitant AAA and gastric cancer who are eligible for EVAR, use of a one-stage procedure including EVAR and gastric resection is feasible.

Thoracic stent graft with distal fenestration for the superior mesenteric artery for treatment of thoracic aortic aneurysm.

An 86-year-old man with a 75-mm TAA that terminated just above the celiac artery was treated with a customized Zenith stent graft that had a distal fenestration for the superior mesenteric artery (SMA). Because angiography demonstrated a type IB endoleak, an additional extension stent graft was deployed, and coil embolization of the aneurysmal sac was performed. Three months later, there was no endoleak and good visceral blood flow. Placement of a fenestrated thoracic stent graft with a scallop-like fenestration for the SMA is a promising procedure for the treatment of TAAs with a short distal neck.

Evaluation of the paramalleolar bypass for critical limb ischemia patients on hemodialysis with diabetes mellitus and chronic renal failure.

OBJECTIVE: To assess the influence of diabetes mellitus (DM) and end-stage renal failure on hemodialysis (HD) on the healing time of tissue lesions and blood flow to the foot following a paramalleolar bypass in patients with critical limb ischemia (CLI). METHODS: Consecutive patients with CLI and tissue loss (24 limbs) were followed up retrospectively after paramalleolar bypass, and the healing time of tissue lesions, graft patency, limb salvage and survival rates were analyzed. The blood flow to the foot was assessed by skin perfusion pressure (SPP) pre- and postoperatively. The delta SPP was calculated as the difference between the SPP before and after bypass. The patients were divided into 3 groups: diabetic (DM, n = 9); diabetic and end-stage renal failure on hemodialysis (HD, n = 10); or neither (n = 5). RESULTS: A total of 15 dorsal and 9 plantar artery bypasses were performed. The median follow-up was 7.3 months (range, 1-18 months). No patients required major amputations, and all tissue lesions healed. The mean duration to complete tissue healing of the DM, HD and neither groups was 2.2, 2.5 and 1.2 months, respectively, was and these were not statistically significant. A significant improvement in the delta SPP after paramalleolar bypass was observed in the neither group compared with both the DM and HD groups. CONCLUSION: Blood flow to the foot was not sufficiently improved in CLI patients with DM and HD, despite paramalleolar bypass. This may be the cause of the prolonged tissue healing duration of CLI patients with DM and HD. (English Translation of Jpn J Vasc Surg 2012; 21: 91-95).