Prospective, Multicenter Study of Rotational Atherectomy with Antirestenotic Therapy for Infrainguinal Arterial Disease.

BACKGROUND: Thrombi are common in steno-occlusive lesions of infrainguinal atherosclerotic diseases. Despite the easy passage of guidewires through these lesions, conventional ballooning or stenting cannot effectively treat them, and patients are at risk of distal embolization. This study aimed to investigate the clinical outcomes of using a rotational aspiration atherectomy system to treat infrainguinal atherosclerotic disease. METHODS: Patients underwent revascularization of target lesions using the Jetstream™ Atherectomy System. The primary endpoint was the freedom from clinically driven target lesion revascularization (CD-TLR) 12-month after the procedure. Outcomes were evaluated according to the clinical severity, lesion type, use of drug-coated balloons (DCBs), and lesion length, characteristics, and sites. Survival analysis for CD-TLR over time was plotted. All statistical analyses were performed using SPSS version 22 (IBM; Armonk, NY, USA). P-values <0.05 were considered statistically significant. RESULTS: In total, 150 patients (91.2% male; mean age, 69.8 years; 66.2% with diabetes) with de novo or restenotic infrainguinal lesions were enrolled. The mean lesion length was 17.2 cm, 75.0% were occlusive, and 38.2% had severe calcification. The lesion types were sclerotic (64.7%), thrombosclerotic (20.6%), thrombotic (8.8%), and in-stent (5.9%). Adjunctive DCB was used in 86.8% of patients. The 12-month primary patency rate (PPR) and CD-TLR rates were 81.6% and 90.1%, respectively. The 12-month CD-TLR rate was significantly better in the sclerotic and thrombosclerotic groups than in the thrombotic group (100% and 100% vs. 66.7%; P = 0.001). The 12-month PPR was significant better in TransAtlantic Inter-Society Consensus (TASC) A and B groups than TASC C and D groups (P = 0.02). The 12-month PPR is significantly better after using a DCB or stent placement than after using a simple balloon (P = 0.01). There were no major adverse events, including procedure-related death, myocardial infarction, or major amputation. CONCLUSIONS: The results of this study demonstrated the safety and effectiveness of the Jetstream atherectomy device for complex infrainguinal lesions. This system functions optimally with TASC A/B lesions and sclerotic or thrombosclerotic lesions.

Predictive Factors of Severe Dissection after Balloon Angioplasty for Femoropopliteal Artery Disease.

BACKGROUND: Arterial dissection is one of the mechanisms of balloon angioplasty. Although some degree of dissection is unavoidable, severe dissection that impedes blood flow decreases patency and increases the need for additional procedures. To improve the results of angioplasty, it is necessary to understand the factors related to severe dissection and make efforts to reduce its occurrence. This study aimed to elucidate the predictive and protective factors associated with severe dissection in femoropopliteal balloon angioplasty. METHODS: This was a retrospective, single-center, nonrandomized study. A total of 409 limbs were studied in 334 patients with symptomatic femoropopliteal lesions treated between 2010 and 2019. Dissections after initial balloon angioplasty were classified according to the Kobayashi dissection classification (grade A: no dissection; B: mild dissection <1/3 of the lumen; C: severe dissection, ≥1/3 of the lumen) into the nonsevere dissection group (grades A and B), and severe dissection group (grade C). We compared clinical, procedural and lesion-related characteristics between the 2 groups. Factors with statistical significance in univariate analyses were entered into a multivariate logistic regression model to identify independent predictive factors of severe dissection. RESULTS: Severe dissection occurred in 237 limbs and nonsevere dissection in 172 limbs. In univariate analyses, the predictive factors of severe dissection were TransAtlantic Inter-Society Consensus II C/D grades (P < 0.001), lesion length ≥15cm (P < 0.001), chronic total occlusion (P = 0.004), and degree of stenosis ≥70% (P < 0.001). Protective factors for severe dissection were end-stage renal disease (P = 0.008), severe calcification >50% (P < 0.001), and the use of a scoring balloon (P = 0.001). In multivariate analysis, factors associated with severe dissection were lesion length ≥15cm (OR, 2.259; 95% CI: 1.417-4-3.601), occlusion or degree of stenosis ≥70% (OR, 1.931; 95% CI: 1.255-2.971), severe calcification (OR, 0.520; 95% CI: 0.338-0.800), and the use of a scoring balloon (OR, 0.467; 95% CI: 0.263-0.830). CONCLUSIONS: Lesion length ≥15cm and occlusion or stenosis ≥70% were identified as independent predictive factors of severe dissection in femoropopliteal artery balloon angioplasty. Conversely, severe calcification and the use of a scoring balloon appeared to be protective factors against severe dissection.

Ultrasound-Guided Direct Needle Engagement for Flush-Occluded Superficial Femoral Artery.

Flush ostial occlusion of the superficial femoral artery (SFA) is challenging for endovascular treatment. Neither ipsilateral nor contralateral access is easy. The drawback of ipsilateral common femoral artery (CFA) access is that the CFA is too short for catheter manipulation and sheath engagement. Contralateral retrograde CFA access could have merit, but it has the drawback of poor pushability and torquability in the manipulation of devices. The most challenging part of flush ostial occlusion is the difficulty of wire engagement into the SFA orifice. We describe a case of successful treatment of a flush-occluded long SFA lesion using ultrasound-guided direct ipsilateral ostial access.

Pseudostenosis of the External Iliac Artery after Common Iliac Artery Occlusion: 2 Case Reports.

We report 2 cases of pseudostenosis of the external iliac artery (EIA) combined with aortoiliac occlusive disease. Both cases were treated successfully by aortobi-iliac bypass surgery instead of aortobi-femoral bypass. Pseudostenoses of the EIA disappeared in the postoperative computed tomographic angiography. We are not aware of previous reports of similar findings. Pseudostenosis should be considered if the EIA shows diffuse narrowing without wall irregularity in combination with severe stenosis or occlusion of the common iliac artery.

Clinical course and angiographic changes of spontaneous isolated superior mesenteric artery dissection after conservative treatment.

PURPOSE: The aim of this study was to evaluate the clinical course and angiographic changes of spontaneous isolated superior mesenteric artery dissection (SISMAD) after conservative treatment. METHODS: Twenty-four patients with SISMAD admitted from September 2006 through March 2013 were included in this study. The clinical characteristics, type and location of the dissection, clinical outcome and angiographic changes were analyzed retrospectively. RESULTS: The median follow-up was 18.7 months (range 1.4-67.5 months). Eighteen patients (75 %) were symptomatic, and the median duration of abdominal pain was 2.5 days. All of the patients were treated conservatively. Follow-up computed tomography angiography showed complete remodeling in six patients (25 %), partial remodeling in four patients (17 %), no changes in nine patients (38 %), progression to total occlusion in four patients (17 %) and aneurysmal changes of the false lumen in one patient (4 %). Endovascular intervention was performed in the patient with aneurysmal changes. There was no mortality or morbidity related to the dissection. CONCLUSION: SISMAD represented variable angiographic changes, and its clinical course was benign in this study. For patients with SISMAD, if there is no evidence of bowel infarction, bleeding or aneurysmal changes, conservative treatment with close follow-up is sufficient and could reduce unnecessary endovascular interventions.

Is Routine Screening Using Duplex Ultrasonography for Deep Vein Thrombosis Necessary after Shoulder Arthroplasty?

The aims of this study were to examine the incidence, risk factors, and outcomes of deep vein thrombosis (DVT) after shoulder arthroplasty in Korean patients. A total of 265 patients who underwent shoulder arthroplasty were included. The mean age of the patients was 74.6 years, and there were 195 females and 70 males. Clinical data including patient demographics, blood tests, and previous and current medical history were investigated. For screening of DVT, duplex ultrasonography of the operative arm was performed 2 to 5 days after surgery. Of the 265 patients, 10 patients (3.8%) were diagnosed with DVT using postoperative duplex ultrasonography. There were no cases of pulmonary embolism. There were no significant differences between the DVT and no DVT groups regarding all clinical data, except for the Charlson comorbidity index (CCI), which was significantly higher in the DVT group than in the no DVT group (5.0 vs. 4.1; p = 0.029). All patients had asymptomatic DVT that showed complete resolution after administration of antithrombotic agents or close observation without medications. The overall incidence of DVT was 3.8% during a period of 3 months after shoulder arthroplasty in Korean patients, and most cases were asymptomatic. Routine screening for DVT using duplex ultrasonography after shoulder arthroplasty may not be necessary except in patients with high CCI.

Perioperative Factors Associated With Postoperative Delirium in Patients Undergoing Noncardiac Surgery: An Individual Patient Data Meta-Analysis.

Importance: Postoperative delirium (POD) is a common and serious complication after surgery. Various predisposing factors are associated with POD, but their magnitude and importance using an individual patient data (IPD) meta-analysis have not been assessed. Objective: To identify perioperative factors associated with POD and assess their relative prognostic value among adults undergoing noncardiac surgery. Data Sources: MEDLINE, EMBASE, and CINAHL from inception to May 2020. Study Selection: Studies were included that (1) enrolled adult patients undergoing noncardiac surgery, (2) assessed perioperative risk factors for POD, and (3) measured the incidence of delirium (measured using a validated approach). Data were analyzed in 2020. Data Extraction and Synthesis: Individual patient data were pooled from 21 studies and 1-stage meta-analysis was performed using multilevel mixed-effects logistic regression after a multivariable imputation via chained equations model to impute missing data. Main Outcomes and Measures: The end point of interest was POD diagnosed up to 10 days after a procedure. A wide range of perioperative risk factors was considered as potentially associated with POD. Results: A total of 192 studies met the eligibility criteria, and IPD were acquired from 21 studies that enrolled 8382 patients. Almost 1 in 5 patients developed POD (18%), and an increased risk of POD was associated with American Society of Anesthesiologists (ASA) status 4 (odds ratio [OR], 2.43; 95% CI, 1.42-4.14), older age (OR for 65-85 years, 2.67; 95% CI, 2.16-3.29; OR for >85 years, 6.24; 95% CI, 4.65-8.37), low body mass index (OR for body mass index <18.5, 2.25; 95% CI, 1.64-3.09), history of delirium (OR, 3.9; 95% CI, 2.69-5.66), preoperative cognitive impairment (OR, 3.99; 95% CI, 2.94-5.43), and preoperative C-reactive protein levels (OR for 5-10 mg/dL, 2.35; 95% CI, 1.59-3.50; OR for >10 mg/dL, 3.56; 95% CI, 2.46-5.17). Completing a college degree or higher was associated with a decreased likelihood of developing POD (OR 0.45; 95% CI, 0.28-0.72). Conclusions and Relevance: In this systematic review and meta-analysis of individual patient data, several important factors associated with POD were found that may help identify patients at high risk and may have utility in clinical practice to inform patients and caregivers about the expected risk of developing delirium after surgery. Future studies should explore strategies to reduce delirium after surgery.

Treatment of arteriovenous malformations involving the hand.

BACKGROUND: Hand arteriovenous malformations (AVMs) are difficult to treat because of the necessity to maintain function and the high complication rate of treatment. The purpose of this study was to review the treatment of hand AVMs with embolo/sclerotherapy and the surgical procedures at a single institute. MATERIAL AND METHODS: We retrospectively reviewed the medical records and identified the patients who were referred to the vascular division owing to hand AVMs between 1995 and 2009. The lesions were classified according to their affected areas. The treatments used at the clinic included conservative treatment, amputation, and embolo/sclerotherapy. We investigated the clinical data and assessed the treatment results. RESULTS: Sixty-four patients were involved in this study. The median follow-up duration was 26.9 months (range: 3.5-141.8 months). The median age of the patients was 31.5 years (range: 0.3-75.0 years). All of the lesions were of the extratruncal (ET) form, and 37 cases (57.8%) were of the infiltrating type. Sixteen patients were treated conservatively. Primary amputation was performed in seven cases with previous complications such as ulcer, bleeding, or functional limitations. Embolo/sclerotherapy with ethanol was performed in 41 patients. Sixteen (39.0%) of them showed clinical improvement. The treatment of 20 (48.8%) of the 41 patients was interrupted owing to a variety of complications, and 2 (4.9%) of these patients failed with embolo/sclerotherapy. Skin necrosis was the major complication, and this occurred in 17 patients treated with embolo/sclerotherapy--14 of these cases were small and the skin necrosis healed with conservative treatment; 1 patient had autoamputation owing to necrosis; and 2 patients underwent amputation surgery owing to gangrene. The risk for skin necrosis was higher for the AVMs that involved the subcutaneous layer and the AVMs that extended diffusely (P = 0.021, P = 0.011). Seven neuropathic complications developed after embolo/sclerotherapy, and all of them were transient. CONCLUSIONS: The symptoms and characteristics of the lesions are important factors in devising a treatment plan for AVMs. AVM treatment, and especially embolo/sclerotherapy, is a long-term prospect, and it carries a potential risk for serious complications. After every treatment, the lesions must be reevaluated and new treatment plans must be made by the members of a multidisciplinary team.

Natural course of venous malformation after conservative treatment.

PURPOSE: To investigate the clinical course of patients with venous malformation (VM) treated conservatively. METHODS: We reviewed retrospectively the database of our Congenital Vascular Malformation clinic and interviewed 207 patients with VM, who had been managed only conservatively. The questionnaires asked about changes in size (no change, increase in proportion to growth, increase greater than in proportion to growth, decrease) and changes in symptoms (markedly worse, moderately worse, no change, moderately improved, markedly much improved). Progression of VMs was defined as an increase greater than in proportion to growth or worsening symptoms. RESULTS: Fifty patients (24 %) reported an increase in size greater than in proportion to growth and 25 patients (12 %) reported symptoms worsening from their initial symptoms. Overall, sixty-six (32 %) of the patients reported evidence of progression of their VM. A binary logistic regression model identified VM combined with capillary malformation (CM) or lymphatic malformation (LM) as an independent predictor of VM progression (OR 2.67, 95 % CI 1.29-5.53). CONCLUSIONS: Based on responses to the questionnaire, the size and symptoms of VM progressed in 32 % of patients over the course of their life. VMs combined with CM or LM were the only independent predictor of progression of a VM after conservative management.

Characteristics and Effect of Rivaroxaban on Venous Thromboembolism in Korean Patients Compared to Western Population: A Subgroup Analysis from XALIA(-LEA) Study.

Purpose: This study aimed to compare the characteristics of venous thromboembolic disease (VTE) in Korean to Caucasian population. Materials and Methods: XALIA-LEA and XALIA were phase IV non-interventional prospective studies with identical designs that investigated the effect of rivaroxaban versus standard anticoagulation for VTE. Koreans accounted for the largest proportion of the overall enrolled population of XALIA-LEA. However, in the XALIA study, most patients were Caucasian. Therefore, Korean data from XALIA-LEA and Caucasian data from XALIA were used in this study. This study compared the clinical characteristics and primary outcomes of the XALIA program, including major bleeding, recurrent VTE, and all-cause mortality. Results: The Korean population was older, was less obese, and had more active cancer at baseline than the Caucasian population. Provoked VTE was more common in the Korean population. Interestingly, Koreans showed less accompanying thrombophilia than Caucasians, and factor V Leiden mutations were not detected. Korean analyses comparing the effects of rivaroxaban and standard anticoagulation with primary outcomes showed a lower incidence of major bleeding, recurrent VTE, and all-cause mortality with rivaroxaban. Similar results were obtained in the propensity score matching analysis. Conclusion: Characteristic differences were found between Korean and Caucasian VTE patients. Despite these ethnic differences, the effectiveness and safety of rivaroxaban therapy in these patients were consistent.

Scoring Balloon Reduces the Severity of Dissection and Stent Implantation Rate in Superficial Femoral Artery Angioplasty Compared to Plain Balloon.

PURPOSE: The knowledge regarding the benefits of the scoring balloon (SB) in comparison to the plain balloon (PB) is limited. This study aims to elucidate the difference in efficacy between SB and PB as pre-balloon in superficial femoral artery angioplasty. METHODS: We retrospectively analyzed angiographic images of 113 lesions in 98 patients treated with endovascular surgery. 37 lesions were prepared by SB and 76 lesions by PB. Lesions without significant residual stenosis nor a flow-limiting dissection were treated by drug-coated balloon and the others by drug-eluting stent. Severity of dissection was evaluated by Kobayashi dissection grade and NHLBI classification. The rate of stent implantation was compared between the 2 groups. Kaplan-Meier analysis estimated freedom from target lesion revascularization (TLR) rate at 12 months. RESULTS: Severe dissections (>1/3 of lumen) occurred less frequently in the SB group (SB 40.5% vs. PB 75.0%, P = 0.001). Overall stent implantation rate was lower in the SB group (SB 27.0% vs. PB 55.3%, P = 0.005). In subgroup analysis for the complex lesions, the SB group had lower rate of severe dissection(>1/3 of lumen) in patients with long lesions(>15 cm) (SB 51.7% vs. PB 76.9%, P = 0.020) and lesions of calcium grade ≥2 (SB 43.8% vs. PB 72.5%, P = 0.009). SB group had lower stent implantation rate in patients with long lesions (SB 34.5% vs. PB 59.6%, P = 0.030), lesions of calcium grade ≥2 (SB 31.3% vs. PB 56.9%, P = 0.023), and total occlusion (SB 30.8% vs. PB 80.0%, P = 0.002). There were no procedure-related complications in either group except 1 case of puncture-site hematoma. There was no significant difference in TLR rate between both groups at 12 months (P = 0.509). CONCLUSION: SB reduces the incidence of severe dissection (>1/3 of lumen) and rate of overall stent implantation in comparison with PB. The use of SB is a safe and effective method of lesion preparation in SFA angioplasty.

Wound outcomes and factors associated with wound healing after first-time femoropopliteal artery intervention in patients with ischemic tissue loss.

BACKGROUND/OBJECTIVE: This study's goal is to describe wound outcomes at 2 years following intervention for atherosclerotic femoropopliteal lesions in patients with ischemic tissue loss. METHODS: A retrospective review of 135 first-time endovascular procedures for chronic femoropopliteal atherosclerotic lesions related to ischemic tissue loss was performed. The final wound outcomes were categorized according to the initial wound healing, recurrence and the need of major/minor amputation. RESULTS: At 2-years of follow up, 76 limbs (56.3%) showed complete wound healing without recurrence, however, wound development occurred at other sites on the same foot following complete primary healing in 11 limbs (8.1%). Tolerable wounds persisted or wounds recurred at the same site in 30 limbs (22.2%), and 18 limbs (13.3%) needed major amputations. Independent factors that prevented wound healing without recurrence at 2 years were renal insufficiency (HR = 0.225, 95% C.I. = 0.091-0.556, p = 0.001), ankle pressure < 50 mmHg or flat forefoot PVR (HR = 0.328, 95% C.I. = 0.124-0.867, p = 0.025) and functional performance < 4 metabolic equivalents (MET) (HR = 0.150, 95% C.I. = 0.063-0.360, p < 0.001). CONCLUSION: Wound outcome classifications showed detailed information regarding clinical outcomes in patients with ischemic tissue loss. Renal insufficiency, ischemia grade 3 and poor functional performance were independent risk factors that prevented wound healing.

Analysis of the postoperative hemodynamic changes in varicose vein surgery using air plethysmography.

OBJECTIVES: This study used air plethysmographic parameters to evaluate the changes in venous hemodynamics after the surgical treatment of primary varicose veins. METHODS: We retrospectively analyzed 1756 limbs of 1620 patients who had undergone surgery for great saphenous vein (GSV) reflux from January 1996 to June 2009 at Samsung Medical Center. Venous hemodynamic changes were evaluated by performing air plethysmography preoperatively and 1 month postoperatively and assessing the venous volume (VV), the venous filling index (VFI), the residual volume fraction (RVF), and the ejection fraction (EF). RESULTS: Preoperatively, median (interquartile range) values were VV, 121.6 (94.7-160.6) mL; VFI, 4.8 (2.9-7.6) mL/s; RVF, 40.6% (29.7%-50.0%); and EF, 53.5% (44.3%-64.1%). Postoperatively, the median (interquartile range) values were VV, 90.6 (69.1-116.8) mL; VFI, 1.4 (0.9-1.9) mL/s; RVF, 28.4% (17.5%-38.7%); and EF, 65.2% (54.5%-77.2%). VV, VFI, and RVF were reduced 25.2%, 71.5%, and 29.9%, respectively; EF was increased 20.3%. The results were significant for all four variables (P < .001). We compared the degree of hemodynamic changes according to the treatment modalities: the high ligation and stripping group , 1578 cases; the GSV valvuloplasty group, 124 cases; and the VNUS group (VNUS Medical Technologies Inc, San Jose, CA), 54 cases. The reduction of the VV, VFI, and RVF was greater in the GSV stripping group and in the VNUS group than in the valvuloplasty group (P < .001), yet no difference was noted in the EF increase among the surgical modalities (P = .157). CONCLUSION: Our results show that the venous hemodynamic parameters of primary varicose veins were improved after surgical treatment.

Prevalence of asymptomatic critical carotid artery stenosis in Korean patients with chronic atherosclerotic lower extremity ischemia: is a screening carotid duplex ultrasonography worthwhile?

This study aimed to investigate prevalence of asymptomatic carotid artery stenosis (ACAS) in Korean patients with peripheral arterial disease (PAD) and identify predictive factors of ACAS in patients with PAD. Between 1994 and 2008, 546 patients who underwent bypass surgery due to PAD were identified in a single tertiary teaching hospital. Of those, 409 patients underwent preoperative screening carotid duplex ultrasonography (CDUS). Patients who had an episode of cerebrovascular event or previous carotid artery intervention were excluded and then a retrospective analysis was made of 340 patients. The degree of internal carotid artery (ICA) stenosis was determined by the criteria of Society of Radiologists in Ultrasound Consensus Conference. To determine the risk factors of ACAS, demographic, coexisting medical condition and lesion characteristics were tested with binary logistic regression model. The prevalence of > or = 70% ICA stenosis was 14%. ICA occlusion was detected in 7.1%. Multivariate analysis revealed age > 65 yr (OR: 2.610, 95% CI: 1.197-5.691) and coronary artery disease (CAD, OR: 2.333, 95% CI: 1.169-4.657) are predictive factors of > or = 70% stenosis. A PAD patient who needs revascularization, particularly, > 65 yr or has a concomitant CAD, can be a good candidate of screening CDUS.

The Effect of Severe Femoropopliteal Arterial Calcification on the Treatment Outcome of Femoropopliteal Intervention in Patients with Ischemic Tissue Loss.

PURPOSE: We investigated the effect of severe calcification of the femoropopliteal artery on intervention outcomes in patients with ischemic tissue loss. MATERIALS AND METHODS: A retrospective review of the first endovascular treatment of the femoropopliteal artery for ischemic tissue loss between May 2010 and February 2018 was performed. The calcification of femoropopliteal lesions was estimated by the Compliance 360° score, and lesions with a score of 4 were defined as severe calcification lesions. RESULTS: Overall, 135 first femoropopliteal endovascular procedures on 135 limbs from 112 patients were included in this study. Among the 135 limbs that received treatement of the femoropopliteal arteries, 74 limbs had Trans-Atlantic Inter Society Consensus (TASC) A or B lesions and 61 limbs had TASC C or D lesions. Among 61 cases of TASC C or D lesions, 21 limbs (34.4%) had severe calcification; there was no statistically significant difference in limb salvage (P=0.75), and amputation-free survival (P=0.11) based on the degree of calcification. However, the survival rate in TASC C or D lesions was significantly different between the two groups (non-severe calcification group vs severe calcification group at 1-year, 2-years, and 3-years: 88.6%, 79.7%, and 61.0% vs 70.0%, 56.0%, and 28.0%, respectively, P=0.01). In multivariate analysis of influencing factors for poor survival in TASC C or D using the Cox proportional hazards model, severe calcification (hazard ratio, 2.362; 95% confidence interval, 1.035-5.391; P=0.041) was a statistically significant risk factor. CONCLUSION: Severe femoropopliteal artery calcification was associated with poor survival, especially in TASC C or D lesions.

Effect of Opt-out System for Organ Donation After Brain Death on Ethical Legitimacy and Potential Efficacy in a Mathematical Model.

OBJECTIVES: We aimed to compare the possible outcomes of the current (opt-in) system and an opt-out system for organ donation in South Korea using a mathematical model. MATERIALS AND METHODS: A structured questionnaire was used to investigate the decision on organ donation and family consent after brain death under the current system and an opt-out system. The survey was conducted in August 2018 by means of a voluntary survey of 100 opposite-sex married couples. RESULTS: Sixty-three percent of participants wished to self-donate their organs after brain death: 69.5% were positive and 30.5% were negative regarding the implementation of the opt-out system. Among 200 participants, the total number of possible donors increased from 110 (55.0%) in the current system to 139 (69.5%) in the opt-out system. Positive autonomy was defined as obtainment of consent from the donor and the spouse, and negative autonomy was defined as concordaence of refusal between the donor and the spouse. Comparisons between the systems showed that the rate of autonomy increased from 57.0% in the current system to 61.5% in the opt-out system. Although the achievement of positive autonomy increased from 59.5% in the current system to 74.6% in the opt-out system, the achievement of negative autonomy decreased from 52.7% in the current system to 39.2% in the opt-out system. CONCLUSIONS: An opt-out system can increase the number of organ donors; however, achievement of negative autonomy can decrease.

The effect of a mandatory choice systemfor organ donation after brain death onethical legitimacy and potential efficacyin a mathematical model.

Background: The "mandatory choice" system is an organ donation system that forces individuals to clearly express their choice about organ donation. Although this system is widely practiced in western countries, it has not yet been implemented in many Asian countries. This study aimed to compare the possible outcomes of a mandatory choice system and the current system in Korea. Methods: A mathematical model was used to predict outcomes under each system. A structured questionnaire assuming two systems (current opt-in and mandatory choice) was developed to investigate participants' decisions on organ donation and the family's consent after brain death in each system. Participants who enrolled in this survey were 100 couples (200 people). Results: The total number of donors decreased slightly from 102 (51.0%) in the current opt-in system to 93 (46.5%) in the mandatory choice system. The rate of achieving autonomy was increased from 62.5% (125/200) in the current system to 68.0% (136/200) in the mandatory choice system. The achievement of negative autonomy was relatively higher in the mandatory choice system (73.6% [67/91] vs. 63.2% [55/87]). Conclusions: The mandatory choice system can supplement the weak ethical point of the current system by increasing the achievement of autonomy.

Factors affecting outcomes after endovascular treatment for femoropopliteal atherosclerotic lesions.

BACKGROUND/OBJECTIVE: This study aimed to investigate the outcomes of femoropopliteal interventions in relation to various influencing factors. METHODS: A retrospective review of 243 endovascular procedures for femoropopliteal atherosclerotic lesions on 243 limbs of 197 patients was performed. RESULTS: In patients with claudication, the TLR free rates at 1-, 3-, and 5-year intervals were 89.1%, 82.2%, and 78.9%, respectively. Amputation-free survival rates in the claudicants at 1-, 3-, and 5-year intervals were 95.3%, 81.1%, and 65.2%, respectively. Freedom from ischemia at 1-, 3-, and 5-year follow-ups was 77.8%, 69.0%, and 61.3%, respectively. In patients with critical limb ischemia, the TLR free rates at 1-, 3-, and 5-year intervals were 91.3%, 87.4%, and 65.4%, respectively, amputation free survival rates were 72.5%, 44.2%, and 36.8%, respectively, and their freedom from ischemia was 64.6%, 63.4%, and 49.7%, respectively. In the multivariate analysis of influencing factors related to freedom from ischemia, renal insufficiency (hazard ratio [HR] 1.623; 95% confidence interval [CI] 0.999-2.636; p = 0.050), TASC C/D lesion (HR 1.903; 95% CI 1.151-3.148; p = 0.012), and poor tibial runoff (HR 1.770; 95% CI 1.037-3.023; p = 0.036) were statistically significant risk factors. TASC C/D lesion and poor tibial runoff were significant risk factors for recurrent or persistent ischemia in claudication (p = 0.015) and in critical limb ischemia (p = 0.05), respectively. CONCLUSION: Endovascular treatment for femoropopliteal atherosclerotic lesions showed acceptable intermediate-term and long-term outcomes. Renal insufficiency, TASC C/D lesions, and poor tibial runoff adversely affected freedom from ischemia.

Arterial Aneurysmal Degeneration With Venous Varicosity Following Ligation of an Arteriovenous Fistula in a Kidney Transplant Recipient.

Late occurrence of arterial aneurysms following ligation of a hemodialysis arteriovenous fistula (AVF) is rare. Here, we report the case of 51-year-old male patient with an AVF in which arterial aneurysms developed. The patient had undergone left arm radiocephalic (RC) AVF creation for hemodialysis in 2000. He had received a living related donor kidney transplantation from his father in the same year. His RC AVF was ligated in 2009. However, his arm continued to gradually grow in size even after ligation and he visited a hospital for acute pain and erythema around the left elbow in 2017. Since his renal allograft function had been deteriorating, duplex ultrasonography was performed. It revealed 2 giant aneurysms in the distal brachial artery and proximal radial artery with diameters of 3.0 and 2.8 cm, respectively. The superficial veins of the left upper arm showed varicosity and had multifocal thrombi. Microfistula between the artery and vein was revealed by contrast-enhanced ultrasonography and the contrast agent microbubbles flowed from the artery toward the superficial veins. The aneurysms were resected and the arteries were reconstructed with great saphenous vein. There were no perioperative complications and the patient was discharged on postoperative day 3. No complications in the arm or bypass conduit have occurred at 6 months after the surgery.

Survey for the Opinion of Medical Students and Medical Staff on a Financial Incentive System for Deceased Organ Donation in an Asian Country.

BACKGROUND: Financial incentives for deceased organ donation are associated with many controversial ethical issues. This study examines the perspectives of medical students and staff members on financial incentives for the families of brain-dead organ donors. METHODOLOGY: A structured survey form was used between December 7, 2017 and January 28, 2018 to elicit opinions on financial incentives for the families of brain-dead organ donors. Forty-three medical staff members and 81 medical students participated in the survey voluntarily. The opinions on the financial incentive system and the relationship between willingness to give information about organ donation to families and a financial incentive system were assessed. RESULTS: The majority of the participants (81.4%) had positive thoughts on organ donation. More than half of the participants (60.5%) thought that the financial incentive system did not erode the ethical purity of organ donation. As charge doctors, most respondents (84.6%) were willing to give information about organ donation to family members in the presence of financial incentives. However, the percentage decreased significantly to 60.5% when financial incentive was no longer factored into consideration (P < .001). LIMITATION: The study population is small, and the participants are not representative of the general population. CONCLUSION: The opinions of medical students and medical staff on financial incentives for deceased organ donation were generally positive. Financial incentives proved to be a potential influencing factor as an option of organ donation to be given to families.