Angiographic and Clinical Impact of Novel Revascularization for Occluded Femoropopliteal Prosthetic Bypass Graft: A Combination of Surgical Thrombectomy and Drug-Coated Balloon Angioplasty.

Background: Previous reports have revealed various endovascular intervention techniques for prosthetic femoropopliteal bypass occlusion (PFPBO); however, treatment for PFPBO remains challenging for most interventionalists and vascular surgeons because the procedure is complicated. Most of the reported techniques involve device implantation. In the present study, we performed a combination of surgical graft thrombectomy and drug-coated balloon angioplasty for PFPBO without implanting any additional devices. Furthermore, we determined the favorable long-term results of this treatment using follow-up angiography. Case Presentation. A 77-year-old man with a history of chronic kidney disease and coronary artery disease presented to our clinic with rest pain on his left leg. Seven years prior to the current consult, he underwent femoropopliteal bypass (FPB) surgery using a prosthetic graft due to in-stent occlusion of the left superficial femoral artery (SFA). Four years after surgery, a duplex ultrasound scan revealed stenosis of the proximal anastomosis site; hence, medical therapy was continued. On the current consult, diagnostic angiography revealed occlusion of the FPB and infrapopliteal vessels. In the first attempt at recanalization, the guidewire was unable to pass through the occluded SFA. Therefore, another technique was performed to revascularize the FPBO and infrapopliteal vessels. We obtained an angiography of the left leg after inserting the guiding sheath via the right common femoral artery (CFA). First, surgical thrombectomy using a Fogarty catheter via the exposed left CFA was performed. Following endovascular therapy via the right CFA, we performed drug-coated balloon angioplasty for anastomotic stenosis and recanalized occlusive infrapopliteal vessels. Restenosis was not observed on follow-up angiograms. On further follow-up angiography, there was notable regression of the residual stenosis at the proximal anastomosis of the prosthetic graft. Conclusion: This novel revascularization strategy may be a viable treatment option for PFPBO.

Association of infective endocarditis caused by Abiotrophia defectiva with mycotic aneurysm formation: A case report and the review of the literature.

A 74-year-old woman with a history of mitral valve prolapse with mitral regurgitation was transferred to our hospital due to infective endocarditis. Blood culture revealed Abiotrophia defectiva which is known as a nutritional variant streptococcus. Transesophageal echocardiography revealed posterior leaflet (P2) prolapse due to rupture of tendon chordae with severe mitral regurgitation and vegetation on posterior leaflet. Magnetic resonance imaging (MRI) revealed multiple infarction lesions in left temporal lobe and parietal lobe and mycotic aneurysm formation of right middle cerebral artery. Because A. defectiva cannot be cultured on non-supplemented media, their prevalence may be underreported. Learning objective: A number of causative microorganisms of infective endocarditis have been identified. Streptococci and staphylococci account for 80 % of cases of infective endocarditis. Abiotrophia defectiva does not grow in ordinary growth media and its prevalence may be underreported. It is important to know A. defectiva causes infective endocarditis with mycotic aneurysm formation.

Characteristics of recurrent in-stent restenosis after second- and third-generation drug-eluting stent implantation.

BACKGROUND: In second- and third-generation drug-eluting stent (DES) era, in-stent restenosis (ISR) is not commonly seen. However, a few patients still need repeat revascularizations for recurrent ISR even after second- and third-generation DES implantation. METHODS: From January 2012 to March 2017, 2339 lesions underwent second- and third-generation DES (Nobori, Promus Element, Resolute Integrity, Xience, Ultimaster and Synergy) implantation, of which 95 lesions (4.1%) underwent revascularization for first ISR. All lesions were divided into two groups of recurrent ISR group and non-recurrent ISR group. After successful optical coherence tomography (OCT) guided revascularization for all lesions, we investigated characteristics of recurrent ISR, and 2 years follow-up were completed. RESULTS: The mean age was 70.8 ± 11.7 years, and 73.2% were males. Among 56 DES-ISR lesions which were assessed by OCT, recurrent ISR was seen in 33.9% (N = 19) at 2 years follow-up after revascularization for first ISR. Serum low-density lipoprotein-cholesterol (LDL-C) level was higher in recurrent ISR group compared with non-recurrent ISR group (114.1 ± 53.9 mg/dl vs. 90.9 ± 27.8 mg/dl, P = 0.04) and heterogeneous tissue pattern was more frequently found in recurrent ISR group compared with non-recurrent ISR group (63.2% vs. 27.0%, P = 0.03). Multivariate analysis identified a heterogeneous tissue pattern (odds ratio 3.71; 95% confidence interval 1.09-12.59; P = 0.03) as an independent predictor of recurrent restenosis. CONCLUSION: Recurrent ISR of second- and third-generation DES was associated with heterogeneous tissue pattern of first ISR, and high LDL-C level was associated with recurrence.

Obstructive shock with mediastinal hematoma caused by chest compressions after successful primary percutaneous coronary intervention.

A 75-year-old man with a history of hypertension was transferred to our hospital due to pulseless ventricular tachycardia. When return of spontaneous circulation was achieved, an electrocardiogram showed ST elevation in V1-4 leads. Successuful primary percutaneous coronary intervention was performed. However, on the next day, the patient's systolic blood pressure dropped to 60 mmHg despite using high-dose inotropic agents. Echocardiography and chest computed tomography revealed large mediastinal hematoma. A diagnosis of obstructive shock caused by massive mediastinal hematoma was made. Emergency surgical evacuation of hematoma and hemostasis was successfully performed. .

Left Ventricular Pseudo-aneurysm with Ventricular Septal Rupture Due to Anterior ST-segment Elevation Myocardial Infarction.

We report a case with the simultaneous occurrence of pseudo-aneurysm of the left ventricle and ventricular septal rupture, which was successfully surgically repaired. A 77-year-old woman with a history of aortic valve replacement and coronary bypass graft presented to our clinic due to chest pain. She was diagnosed with anterior ST-segment elevation myocardial infarction (STEMI) based on an electrocardiogram. Echocardiography revealed pseudo-aneurysm of the left ventricle and ventricular septal rupture. Coronary angiography revealed 99% stenosis with delayed contrast filling in the mid left anterior descending artery. Surgical repair with a bovine pericardium patch was performed, and the postoperative course was uneventful.

In-stent restenosis assessed with frequency domain optical coherence tomography shows smooth coronary arterial healing process in second-generation drug-eluting stents.

INTRODUCTION: The pathophysiology and mechanism of in-stent restenosis (ISR) after implantation of second-generation drug-eluting stents (DESs) are not fully clear. We compared the morphological characteristics of ISR between first- and second-generation DESs using frequency domain optical coherence tomography (OCT). METHODS: Patients who underwent follow-up coronary angiography (CAG) after first-generation (CYPHER™ and TAXUS™) and second-generation (Nobori®, PROMUS Element™, Resolute Integrity and XIENCE) DES implantations were examined. ISR was defined as lesions of over 50% diameter stenosis at follow-up CAG. Frequency domain OCT was performed at the time of revascularisation of ISR. Tissue morphology was assessed at minimum lumen area. OCT images of DESs at both early (≤ 1 year) and late (> 1 year) phase follow-up were compared. RESULTS: On qualitative OCT assessment, the ratios of homogeneous, layered, heterogeneous without-attenuation and heterogeneous with-attenuation morphologies were 57.1%, 17.1%, 20.0% and 5.7%, respectively, for second-generation DES ISR (n = 35), and 16.7%, 25.0%, 25.0% and 33.3%, respectively, for first-generation DES ISR (n = 36). At late phase follow-up, homogeneous morphology was significantly more common for second-generation DES ISR compared to first-generation DES ISR (first-generation: 8.0% vs. second-generation: 50.0%; p < 0.01) while heterogeneous with-attenuation morphology was significantly more common for first-generation DES ISR (first-generation: 44.0% vs. second-generation: 5.6%; p < 0.01). CONCLUSION: Homogeneous tissue morphology was more frequently found for second-generation than first-generation DES ISR, especially in the late phase. This suggested that neointimal hyperplasia was the main mechanism in second-generation DES ISR, and that the neointima was stabilised, much like in bare metal stent implantation.

Association of morphologic characteristics on optical coherence tomography and angiographic progression patterns of late restenosis after drug-eluting stent implantation.

OBJECTIVES: To gain insight into the pathophysiology of late drug-eluting stent (DES) restenosis. BACKGROUND: Restenosis of DES has a different time course from that of bare metal stents. METHODS: Patients who underwent follow-up coronary angiography (CAG) twice (six to nine months and 18 to 24 months) after DES implantation were examined using optical coherence tomography (OCT). All lesions with target lesion revascularization at first follow-up were excluded. Late catch-up was defined as lesions that progressed from less than 50% diameter stenosis (DS) at the first CAG to more than 50% DS at the second CAG. Lesions with the late catch-up were further divided into two groups; lesions with jump-up (less than 25% DS at the first CAG) and lesions with gradual progression (25-50% DS at the first CAG). RESULTS: Of the 25 patients who had late ISR, 23 patients (10 jump-up/13 gradual progression) were examined with OCT at late follow-up and enrolled in this study. In the qualitative OCT assessment, each ratio of homogeneous, layered, heterogeneous with or without attenuation tissue morphologies were in jump-up group, and gradual progression group were 0% and 15%, 0% and 23%, and 60% and 8%, and 40% and 54%, respectively. All of jump-up group showed heterogeneous restenotic tissue, while 62% of gradual progression group showed heterogeneous restenotic tissue (P = .04). CONCLUSIONS: These findings suggest different pathophysiology of the late catch-up after DES implantation between the jump-up and gradual progression groups.

Simple balloon dilation for drug-eluting in-stent restenosis: an optical coherent tomography analysis.

BACKGROUND: Although drug-eluting stent (DES) has significantly reduced restenosis, the treatment of DES-in-stent restenosis (ISR) remains a challenge with high restenosis rate. METHODS: We examined whether morphologic appearance of restenosis tissue by optical coherent tomography (OCT) had an impact on outcomes after balloon angioplasty for DES-ISR. The morphologic appearance of restenosis tissue was qualitatively assessed for tissue structures such as homogeneous, layered, and heterogeneous patterns. RESULTS: Using OCT, 50 patients with DES-ISR were divided into 2 groups: 25 lesions with homogeneous or layered patterns (homo/layered group) and 25 lesions with heterogeneous patterns (hetero group). Acute gain was larger in the hetero group (1.33 ± 0.41 mm vs. 1.06 ± 0.32 mm in the homo/layered group, P = 0.03). On intravascular ultrasound analysis, post-procedural percent neointimal area was smaller in the hetero group (27.4 ± 9.2% vs. 34.0 ± 11.2% in the homo/layered group, P = 0.05). Angiographic follow-up was performed in 37 lesions (74%). Follow-up minimal lumen diameter was larger in the hetero group (1.75 ± 0.89 mm vs. 1.01 ± 0.81 mm in the homo/layered group, P = 0.04). Target lesion revascularization rates tended to be lower in the hetero group (20% vs. 43% in the homo/layered group, P = 0.12). CONCLUSIONS: Balloon angioplasty was more effective for DES-ISR with heterogeneous tissue appearance than DES-ISR with homogeneous/layered tissue appearance. OCT assessment of DES-ISR morphology may be a useful adjunct in determining clinical strategies. Simple balloon dilatation is a possible treatment strategy for DES-ISR lesions with a heterogeneous appearance on OCT images.

Late regression of Cypher in-stent restenosis.

We encountered a case of late regression after sirolimus-eluting stent restenosis. We report this case with intravascular ultrasound imaging demonstrating an intraluminal echolucent tissue, which looks like a black hole.

Flaming portal vein as a new color Doppler sign of portal gas: report of two cases.

Portal gas is relatively rare, and the majority of reported cases have shown it to have a close relation to bowel diseases. At present, portal exploration usually begins with color Doppler sonography, and clinicians now possess a good understanding of color Doppler findings of a wide spectrum of portal abnormalities. However, the color Doppler sign we present in this article has not been reported before. We report two cases of ischemic bowel disease in which B-mode ultrasound showed multiple hyperechoic spots moving in the portal vein; the color Doppler appearance was as if the portal vein was on fire (flaming portal vein sign). Knowledge of this simple color Doppler sign helps to improve the diagnostic strategies in patients with portal gas.

R353Q polymorphism, activated factor VII, and risk of premature myocardial infarction in Japanese men.

BACKGROUND: The association between myocardial infarction (MI) and the R353Q polymorphism of the Factor VII (FVII) gene, which reportedly influences FVII concentrations, activated Factor VII (FVIIa), or FVII antigen (FVIIag), remains controversial. METHODS AND RESULTS: The present case - control study in 127 Japanese men with their first MI at or before 45 years of age and 150 matched healthy controls was designed to clarify this association in premature MI. R353Q polymorphism was determined by polymerase chain reaction, and plasma concentrations of FVIIa and FVIIag were assayed. The distribution of the RR, RQ, and QQ genotypes with respect to R353Q polymorphism was 117, 10, and 0 in the patients, and 131, 17, and 2 in the controls. The Q allele was negatively associated with premature MI (odds ratio =0.41, p=0.038). The plasma concentration of FVIIa was slightly higher in patients (55.1+/-40.9 U/L) than in controls (44.8+/-20.2 U/L), but not significantly (p=0.078); the plasma concentration of FVIIag did not differ between patients (88.7+/-15.7%) and controls (87.0+/-9.0%) (p=0.557). Plasma FVIIa concentrations were influenced by R353Q polymorphism (p<0.001). CONCLUSIONS: The Q allele may be protective against premature MI.

[Complete response in an elderly patient with advanced gastric cancer treated with TS-1].

The patient was an 89-year-old woman whose complaints were anorexia and weight loss. As a result of various examinations, she was diagnosed with advanced gastric cancer, Borrmann 3. TS-1 was administered at 75 mg/day for two weeks followed by one-week discontinvation during hospitalization; This course was then repeated after discharge. Anorexia and weight loss improved after two weeks, and complete response (CR) was obtained after 10 months of treatment. No cancer cells were confirmed by endoscopic biopsy. During this period no severe toxicities occurred. This TS-1 administration schedule appears to be a feasible and effective therapy for elderly patients with advanced gastric cancer.

[Usefulness of rapid quantitative cardiac troponin T and myoglobin assays for the diagnosis of acute myocardial infarction].

BACKGROUND AND OBJECTIVES: The rapid cardiac troponin T (cTnT) test is widely used to detect myocardial necrosis in the emergency setting. This assay system is rapid and myocardial-specific, but the plasma cTnT concentration is difficult to determine quantitatively. A recently developed bedside cTnT and myoglobin (Mb) analyzer (CARDIAC system) was evaluated. METHODS: The new CARDIAC system was used to measure plasma cTnT and Mb levels, and serum levels of creatine kinase MB isoenzyme (CK-MB), cTnT and Mb were measured by conventional assays in 160 consecutive emergency patients with suspected acute myocardial infarction. RESULTS: The sensitivity of cTnT for identifying acute myocardial infarction was 76%, significantly higher than that of Mb (67%, p < 0.01) and CK-MB (54%, p < 0.05). The diagnostic sensitivities in patients admitted < or = 3 hr and 3-6 hr after onset were 52% and 65% for cTnT, 60% and 90% for Mb, and 36% and 50% for CK-MB, respectively. These sensitivities of Mb were significantly higher than those of CK-MB but not cTnT. However, the sensitivity of cTnT (100%) was significantly higher than that of Mb (58%, p < 0.01) and CK-MB (70%, p < 0.001) in patients admitted > 6 hr after onset. The specificities of cTnT, Mb and CK-MB were 96%, 76% (p < 0.001 vs cTnT and CK-MB) and 95%, respectively. Therefore, cTnT (86%) had significantly (p < 0.001) higher diagnostic accuracy compared with Mb (71%) and CK-MB (75%). Combination diagnosis using cTnT and Mb showed the highest sensitivity (86%) compared with cTnT (p < 0.05) and Mb (p < 0.001). The correlation coefficients between the levels measured by CARDIAC system and those by ordinary assays were 0.98 in cTnT and 0.97 in Mb. CONCLUSIONS: Bedside rapid quantitative assays of cTnT and Mb are useful as a point of care test for the diagnosis of acute myocardial infarction.

Cerebrovascular disorders and genetic polymorphisms: mitochondrial DNA5178C is predominant in cerebrovascular disorders.

We studied polymorphisms of mitochondrial DNA 5178cytosine/adenine (mt5178C/A) and angiotensin I-converting enzyme (ACE) genes (DCP1) in 127 cerebrovascular disorder (CVD) patients and 294 age-matched normal controls to clarify the genetic background of Japanese patients with CVD. Mt5178C was predominant in CVD patients compared with controls (P<0.01). The frequency of DCP1 insertion (I) and deletion (D) alleles showed no significant difference between the CVD patients and controls or between each CVD subgroup. Although the number of CVD patients in the present study was too small to make a final conclusion, mt5178C might be one of the genetic factors to be considered in Japanese patients with CVD.