Prognostic factors after open and endovascular repair for infected native aneurysms of the abdominal aorta and common iliac artery.

OBJECTIVE: Infected native aneurysms (INAs) of the abdominal aorta and iliac arteries are uncommon, but potentially fatal. Endovascular aneurysm repair (EVAR) has recently been introduced as a durable treatment option, with outcomes comparable to those yielded by conventional open repair. However, owing to the rarity of the disease, the strengths and limitations of each treatment remain uncertain. The present study aimed to separately assess post-open repair and post-EVAR outcomes and to clarify factors affecting the short-term and late prognosis after each treatment. METHODS: Using a nationwide clinical registry, we investigated 600 patients treated with open repair and 226 patients treated with EVAR for INAs of the abdominal aorta and/or common iliac artery. The relationships between preoperative or operative factors and postoperative outcomes, including 90-day and 3-year mortality and persistent or recurrent aneurysm-related infection, were examined. RESULTS: Prosthetic grafts were used in >90% of patients treated with open repair, and in situ and extra-anatomic arterial reconstruction was performed in 539 and 57 patients, respectively. Preoperative anemia and imaging findings suggestive of aneurysm-enteric fistula were independently associated with poor outcomes in terms of both 3-year mortality (hazard ratio [HR], 1.62; 95% confidence interval [CI], 1.01-2.62; P = .046, and HR, 2.24; 95% CI, 1.12-4.46; P = .022, respectively) and persistent or recurrent infection (odds ratio [OR], 2.16; 95% CI, 1.04-4.49; P = .039, and OR, 4.96; 95% CI, 1.81-13.55; P = .002, respectively) after open repair, whereas omental wrapping or packing and antibiotic impregnation of the prosthetic graft for in situ reconstruction contributed to improved 3-year survival (HR, 0.60; 95% CI, 0.39-0.92; P = .019, and HR, 0.53; 95% CI, 0.32-0.88; P = .014, respectively). Among patients treated with EVAR, abscess formation adjacent to the aneurysm was significantly associated with the occurrence of persistent or recurrent infection (OR, 2.24; 95% CI, 1.06-4.72; P = .034), whereas an elevated preoperative white blood cell count was predictive of 3-year mortality (HR, 1.77; 95% CI, 1.00-3.13; P = .048). CONCLUSIONS: Profiles of prognostic factors differed between open repair and EVAR in the treatment of INAs of the abdominal aorta and common iliac artery. Open repair may be more suitable than EVAR for patients with concurrent abscess formation.

Surgical Treatment for Popliteal Artery Entrapment Syndrome in Japan: a Retrospective, Multicentre Study Using a National Clinical Registry.

OBJECTIVE: Surgical treatment is an established method for popliteal artery entrapment syndrome (PAES), which, however, mainly derives from single centre experiences where PAES cases are centralised and treated periodically. This study evaluated clinical outcomes of surgical treatment for PAES in a clinical setting where PAES cases were not centralised. METHODS: Multicentre, retrospective cohort study using a national clinical registry. From a Japanese nationwide clinical registry, data for patients who underwent surgical treatment for PAES between 2013 and 2018, including 58 limbs from 41 institutes, were retrieved and evaluated. Patency was analysed using Kaplan-Meier curves. RESULTS: The mean patient age was 36 ± 19 years, 78% were male, and the incidence of PAES was 0.24 limbs/centre/year, reflecting a clinical setting where PAES cases are not centralised. The most frequent arterial symptom was intermittent claudication (90%). Computed tomography was performed in 57 limbs (98%) for the diagnosis, however active manoeuvres such as dorsiflexion and plantarflexion during the examination was performed in only 13 limbs (22%), and occlusion of the popliteal artery was present in 38 limbs (66%) at diagnosis. Regarding surgical treatment, myotomy alone was performed in only seven limbs (12%), and other limbs were revascularised. Mean follow up was 26 ± 20 months, and surgical treatment was effective as it relieved symptoms in > 96% of limbs, with five year primary and secondary patency of the surgical treatment for PAES of 72% and 93%, respectively. CONCLUSION: Results of surgical treatment were acceptable even in a clinical setting where PAES cases were not centralised. However, a low incidence of active manoeuvres performed during the examination and a high incidence of occlusion at diagnosis suggests there may be delayed or underdiagnosis of PAES in Japan, and increased awareness for PAES is warranted.

Midterm Performance of the Autologous Adventitial Overlay Method in Aortic Surgery.

BACKGROUND: We developed an adventitial overlay method for reinforcing aortic anastomoses. This study evaluated the midterm morphological and clinical outcomes of this method. METHODS: We harvested and prepared adventitia from a resected aneurysm or dissected aortic wall and performed aortic repair using the adventitial overlay method. At the midterm follow-up, we examined the differences among overlay, inversion, and felt-sandwich (FS) methods by evaluating the morphology of the anastomosis using computed tomography (CT) scans. Moreover, we performed macroscopic evaluation of one patient who required a second operation. RESULTS: Between May 2009 and April 2020, 160 consecutive patients (104 males, 56 females; mean age, 68.6 ± 11; range, 39-88 years) underwent thoracic aortic surgery. The overlay technique was successfully performed in 84 cases. The anastomosis sites of the overlay method maintained their morphology without any clinical complications. The inner diameter ratio of anastomosis/graft was measured using CT, which revealed that the overlay method was not significantly different from inversion and was significantly larger than the FS method. There was no anastomotic stenosis in the proximal or distal overlay anastomosis. Only one patient required a second operation for an enlarged aneurysm of the distal false lumen. We observed that the proximal overlaid adventitia was smoothly attached to the native lumen and was macroscopically indistinguishable from the original intima. CONCLUSIONS: This study showed the midterm stability of the overlay technique. The midterm outcome was clinically acceptable. No anastomotic stenosis or pseudoaneurysm formation in either the true aortic aneurysm or dissection cases was observed.

Anomalous systemic arterial supply to the basal segment of the lung with giant aberrant artery: a case report.

BACKGROUND: Anomalous systemic arterial supply to the basal segment of the lung (ABLL) is a relatively rare congenital anomaly characterized by aberrant systemic arterial blood flow to the basal segment of the lung. We experienced a rare presentation of ABLL, in which a giant aberrant artery with the same dimensions as that of the descending aorta flowed from the celiac artery to left lower lobe. CASE PRESENTATION: An otherwise healthy 42-year-old man was referred to our department due to an abnormal chest X-ray. Enhanced computed tomography revealed a huge and winding aberrant artery with mural thrombus originating from the celiac artery and perfusing into the left lower lobe. We diagnosed giant ABLL and considered possible concomitant pulmonary arteriovenous fistula. The diameter of the aberrant artery was > 30 mm and high-pressure flow was assumed; therefore, we performed staged resection of the left lower lobectomy including division of the aberrant artery at the pulmonary ligament and subsequent embolization of the remnant arterial flow uneventfully. Pathologically, the aberrant artery was abundant with elastic fibers, and dissections of the tunica media and mural thrombus were observed; however, arteriovenous fistula was not confirmed. At 6 postoperative months, enhanced computed tomography showed the aberrant artery to be completely occluded without any symptoms. CONCLUSIONS: We present a case of ABLL that was successfully managed by surgical resection of the left lower lobe with most of the giant aberrant artery and subsequent embolization of the remnant portion. Our study demonstrates that a staged surgical therapy is an acceptable approach for ABLL in case of complication with a giant aberrant artery.

Intimal regeneration after coronary endarterectomy and onlay grafting in coronary artery bypass grafting.

OBJECTIVES: Coronary onlay grafting, with or without endarterectomy, has been widely used for the treatment of diffuse lesions. Recent studies have demonstrated excellent long-term patency and favorable remodeling of onlay anastomosis; however, the underlying mechanisms remain unknown. Here, we describe the mechanism of intimal regeneration based on postmortem pathological evaluation of a patient who had undergone onlay grafting with coronary endarterectomy. METHODS: The onlay anastomosis was analyzed using a combination of immunohistological stainings, namely, H&E, vimentin, α-SMA, factor VIII, and Ki-67, to identify the source and mechanism of intimal regeneration after onlay grafting with endarterectomy. RESULTS: Our results suggest that the regenerated endothelium derives from the smooth muscle cells of the endarterectomized media of the coronary artery and that it circumferentially covers the internal lumen of the arterial graft. CONCLUSIONS: Intimal regeneration, derived from the smooth muscle cells of the endarterectomized coronary artery that proliferate toward the graft lumen, may be a key mechanism that underlies the observed favorable remodeling after onlay grafting during coronary endarterectomy.

Segmental clamp and distal perfusion technique for reducing myocardial ischemia during coronary onlay grafting on a beating heart.

We present a segmental clamp with distal perfusion technique to reduce myocardial ischemia during onlay grafting, on a beating heart. After a proximal coronary arteriotomy for 2-3 cm, the distal artery is perfused through a cannula, with femoral arterial blood (distal perfusion with external shunt). During proximal and distal coronary snare clamping with distal perfusion, onlay anastomosis is performed, from the heel toward the point of cannula insertion. We then move the proximal clamp to the onlay area and open the graft, to get early proximal coronary reperfusion. The arteriotomy is extended, and this procedure is repeated to achieve complete beating heart onlay anastomosis. We safely performed this procedure on the beating heart off-pump or on-pump in 95 patients with no perioperative myocardial infarction, no intraoperative hemodynamic deterioration, no 30-day mortality. This technique reduces regional myocardial ischemic and secures the safety for onlay grafting on the beating heart.

Early and Mid-Term Outcomes Following TEVAR for Chronic Type B Aortic Dissection.

We examined the outcomes of aortic remodeling for chronic type B aortic dissection (cTBD) after thoracic endovascular aneurysm repair (TEVAR). Objective & Methods: Thirty-eight patients underwent TEVAR for cTBD at our institution. We classified cTBD patients into the early cTBD group (16 cases, 2 weeks-4 months from onset) and late cTBD group (22 cases, >4 months from onset). Results: There were no cases of paraplegia, stroke, and hospital death in both groups. There was no worsening of complicated cases. We achieved false lumen thrombosis in cases with a double-barreled thoracic aorta. The early cTBD group had more complete shrinkage cases (60%) than the late cTBD group (11%). Conclusion: We obtained favorable mid-term outcomes after TEVAR for cTBD patients. Early cTBD patients obtained good aortic remodeling with TEVAR. (This is a translation of Jpn J Vasc Surg 2016; 25: 233-239.).

Aortic arch surgery in octogenarians: is it justified?

OBJECTIVES: Elderly patients are sometimes denied aortic arch surgery because of the perception of poor outcomes and an unacceptable quality of life (QOL). In this study, we evaluated the early clinical outcomes, long-term survival and QOL following surgical treatment for aortic arch disease in octogenarian patients. METHODS: A total of 47 consecutive patients over the age of 80 years were referred to our institutions. Of these patients, 20 underwent surgical intervention (surgical group) and 27 were treated medically (medical group). Kaplan-Meier survival analysis was performed between the two groups, and the results were compared with age-matched population data. The risk factors for mortality were determined using a Cox regression analysis. A QOL assessment was performed using the 36-item Short Form Health Survey. RESULTS: The patient characteristics at baseline were not significantly different between the two groups. In the surgical cases, conventional total aortic arch replacement was performed in 15 patients, debranched thoracic endovascular aortic repair (TEVAR) in 2 and chimney TEVAR in 3. Emergency procedures were performed in 3 patients. No hospital deaths occurred in the surgical groups. Reoperation for bleeding was required in 2 patients, and prolonged mechanical ventilation was required in 4 patients. The 5-year survival was 61.5% in the surgical group and 14.2% in the medical group (P = 0.02). Freedom from aorta-related death at 5 years was 92.3% in the surgical group and 32.3% in the medical group (P = 0.01). There were no differences in the 5-year survival between patients undergoing surgical intervention and the sex- and age-matched population (P = 0.80), whereas the 5-year survival was significantly lower in patients who received medical therapy relative to the sex- and age-matched population (P < 0.001). Medical therapy was the sole risk factor for mortality (hazard ratio: 3.16, P = 0.04). Among the survivors at mid-term, the quality-of-life measures were similar between those in the surgical group and those in the medical group. CONCLUSIONS: Surgical intervention for aortic arch disease in octogenarians can yield satisfactory early clinical outcomes and acceptable mid-term survival with adequate daily activity. This study indicates that among octogenarians, age alone should not disqualify a patient from receiving an aortic arch intervention.

Chimney technique for aortic dissection involving an aberrant right subclavian artery.

We report a case involving a ruptured acute type B aortic dissection originating from an aberrant right subclavian artery (ARSA). A thoracic stent-graft was deployed in the distal arch close to the origin of the ARSA; the entry site at the origin of the ARSA was embolized with metallic coils. Perfusion of the left subclavian artery was preserved without a surgical bypass by using a chimney graft. This procedure is a feasible and less invasive treatment for high-risk sternotomy patients and is an effective strategy for acute aortic dissections involving an ARSA.

Single-stage thoracic and abdominal endovascular aneurysm repair for multilevel aortic disease.

This investigation evaluated the results of single-stage thoracic endovascular aneurysm repair (TEVAR) and endovascular aneurysm repair (EVAR) for multilevel aortic disease in a series of nine patients. The lesions repaired included thoracic and abdominal aortic aneurysms (n= 7) and subacute type B dissections with abdominal aortic aneurysms (n=2). All procedures were successfully performed, and none of the patients experienced postoperative stroke or spinal cord ischemia. The median follow-up period for these patients was 18.9 months (range 1.7-31.4 months) and none of the patients exhibited any signs of type I endoleaks or aneurysmal diameter enlargements more than 5 mm. In conclusion, single-stage TEVAR and EVAR procedures for multilevel aortic disease were found to be safe and feasible modalities for high-risk patients.

Perioperative synbiotic therapy in elderly patients undergoing gastroenterological surgery: a prospective, randomized control trial.

OBJECTIVE: Enteral administration of synbiotics has been reported to be beneficial during various types of surgery, but its clinical value in elderly surgical patients remains unclear. The aim of this study was to quantitatively evaluate the changes in gut microbiota and environment induced by perioperative synbiotic therapy, and to investigate whether it is possible to reduce infectious complications in elderly patients undergoing gastroenterological surgery. METHODS: Forty-eight patients over the age of 70 y were randomized into a group receiving 7 d of preoperative and 10 d of postoperative synbiotic therapy (S group) and a control group without synbiotic therapy (C group). A fecal sample collected before and after surgery in each group was used for a quantitative evaluation of the microbiota. RESULTS: Forty-eight patients completed the trial (25 in the S group and 23 in the C group). Synbiotic therapy significantly maintained the status of Bifidobacterium and Lactobacillus, whereas the number of Enterobacteriaceae, Staphylococcus, and Pseudomonas was significantly decreased. The total organic acid and short-chain fatty acid concentrations were increased, and the pH was markedly decreased, in the S group compared with the C group. The incidence of postoperative infectious complications was 12% in the S group and 36% in the C group, however, the difference did not reach statistical significance (P = 0.06). A multivariate analysis revealed that only the use of perioperative blood transfusion was an independent risk factor for infectious complications. CONCLUSIONS: Synbiotic therapy improved the intestinal microbial environment, and might decrease the incidence of infectious complications in elderly surgical patients.

Endovascular repair of distal arch aneurysm with double-chimney technique.

We report 2 cases of distal arch aneurysm treated by thoracic endovascular aneurysm repair (TEVAR) with the "double-chimney technique." This technique permitted the implantation of a thoracic stent graft in the ascending aorta over the arch branches while preserving perfusion of innominate and left common carotid arteries without debranching bypasses. The procedure is a feasible and less invasive treatment for distal arch aneurysm with a short proximal neck (<2 cm to the origin of the innominate artery) in patients at high risk when undergoing sternotomy and in emergent cases.

Experimental and clinical studies investigating the efficacy of distal anastomosis with patch plasty in bypass operations with expanded polytetrafluoroethylene grafts.

PURPOSE: We investigated the efficiency of distal anastomosis with patch plasty (DAPP), both experimentally and clinically. METHODS: In our experimental study, dogs were divided into two groups: a control group in which anastomosis was performed without DAPP ( n = 7), and a DAPP group in which DAPP was performed at the distal anastomosis ( n = 7). In our clinical study, 169 femoropopliteal bypasses were divided into three groups and analyzed. In one group, the saphenous vein was used (SVG group, n = 65); in one group, an expanded polytetrafluoroethylene (ePTFE) graft was used without DAPP (ePTFE group, n = 64); and in one group, an ePTFE graft was used with DAPP (DAPP group, n = 40). RESULTS: In the experimental study, the ratio between the area of thrombus adherence and the entire area of the intraluminal surface of the graft, defined as the thrombus covering ratio, was 48.9% in the control group and 30.2% in the DAPP group. The ratio in the DAPP group was significantly lower than that in the control group. In the clinical study, although there were no significant differences among the three groups in cumulative patency rates of the femoral above-knee popliteal arterial bypasses, the patency in the DAPP group was excellent. The cumulative patency rates of the femoral below-knee popliteal arterial bypasses in the ePTFE group were significantly lower than those in the other two groups. CONCLUSION: There results suggest that the addition of DAPP may achieve excellent graft patency.

Enhanced tumor necrosis factor- alpha expression in small sized abdominal aortic aneurysms.

Circulating levels of tumor necrosis factor alpha (TNF- alpha) are elevated in the patients with abdominal aortic aneurysm (AAA). We investigated TNF- alpha expression and cellular infiltration in the walls of AAAs of different sizes. Twenty-seven surgical specimens of AAAs were categorized according to the maximum aneurysm diameter into a small size group (less than 50 mm in diameter, n = 8; S group), a medium-sized group (50 to 59 mm in diameter, n = 11; M group), and a large size group (larger than 59 mm in diameter, n = 8; L group). The level of TNF- alpha and interleukin-1 beta(IL-1 beta) in the aneurysm wall was measured by ELISA. Immunohistochemical staining was performed to observe the TNF- alpha expression and the infiltration of macrophages and lymphocytes in aneurysm walls. Enzyme-linked immunosorbent assay showed that the level of TNF- alpha in the S group (5.47 +/- 3.48 pg/mg protein) was significantly higher ( p < 0.05) than that in the M group (2.70 +/- 1.33 pg/mg protein) or the L group (1.82 +/- 1.21 pg/mg protein). No significant difference in IL-1 beta was observed between the S, M, and L groups. Immunohistochemical analysis also showed that TNF- alpha was expressed strongly in the S group but was negative or weakly positive in the M and L groups. Furthermore, the expression of TNF- alpha was seen mainly where the aneurysm wall showed atheromatous change and macrophage infiltration. These results indicated that the expression of TNF- alpha in the aneurysm wall was enhanced in small AAAs, and this enhancement might be related to the infiltration of macrophages.

[Two cases of non-curatively resected scirrhous gastric cancer that responded well to weekly paclitaxel therapy].

We report 2 cases in which the weekly administration of paclitaxel proved to be effective for patients with scirrhous gastric cancer who underwent a curability C operation. Weekly paclitaxel therapy was observed to effectively treat peritoneal and retroperitoneal dissemination. After this treatment the tumor markers decreased markedly. This weekly paclitaxel therapy was observed to cause no adverse effects, and thanks to the treatment the patients were able to consume normal meals. These patients could also be sufficiently treated as outpatients. Weekly paclitaxel therapy is thus considered to be effective for the treatment of advanced scirrhous gastric cancer with peritoneal and retroperitoneal dissemination.

Improved angiogenic potency by implantation of ex vivo hypoxia prestimulated bone marrow cells in rats.

Therapeutic angiogenesis can be induced by local implantation of bone marrow cells. We tried to enhance the angiogenic potential of this treatment by ex vivo hypoxia stimulation of bone marrow cells before implantation. Bone marrow cells were collected and cultured at 33 degrees C under 2% O(2)-5% CO(2)-90% N(2) (hypoxia) or 95% air-5% CO(2) (normoxia). Cells were also injected into the ischemic hindlimb of rats after 24 h of culture. Hypoxia culture increased the mRNA expression of vascular endothelial growth factor (VEGF), vascular endothelial (VE)-cadherin, and fetal liver kinase-1 (Flk-1) from 2.5- to fivefold in bone marrow cells. The levels of VEGF protein in the ischemic hindlimb were significantly higher 1 and 3 days after implantation with hypoxia-cultured cells than with normoxia-cultured or noncultured cells. The microvessel density and blood flow rate in the ischemic hindlimbs were also significantly (P < 0.001) higher 2 wk after implantation with hypoxia-cultured cells (89.7 +/- 5.5%) than with normoxia-cultured cells (67.0 +/- 9.6%) or noncultured cells (70.4 +/- 7.7%). Ex vivo hypoxia stimulation increased the VEGF mRNA expression and endothelial differentiation of bone marrow cells, which together contributed to improved therapeutic angiogenesis in the ischemic hindlimb after implantation.

Can nonpenetrating vascular closure staples and hepatocyte growth factor prevent intimal hyperplasia following ePTFE grafting of the carotid artery in rabbits?

PURPOSE: To evaluate whether nonpenetrating vascular closure staples (VCS) and hepatocyte growth factor (HGF) can effectively prevent anastomotic intimal hyperplasia. METHODS: An expanded polytetrafluoroethylene graft, 2 mm in diameter, was implanted in the common carotid artery of rabbits divided into three experimental groups. In the control group, distal anastomosis was performed with interrupted suturing; in the VCS group, clips were applied along the lateral suture line after the placement of stay sutures; and in the VCS + HGF group, the same anastomotic technique was performed as in the VCS group, followed by the administration of the HGF for 4 days. RESULTS: The time taken to complete the anastomosis was significantly less in both the VCS groups than in the control group ( P < 0.0001). On postoperative day (POD) 28, the patency rate was significantly lower ( P < 0.05) in the VCS group (42.9%) than in the control group (100%), but the rate in the VCS + HGF group (100%) was the same as that in the control group. Intimal thickness was significantly less in the control group than in either the VCS or VCS + HGF groups ( P< 0.05). The percentage of area stenosis was significantly less ( P< 0.01) in the control group than in the VCS group. CONCLUSION: The VCS clip failed to suppress intimal thickness or reduce the percentage of stenosis at the anastomotic site.

Hilar lymph nodes in N2 disease: survival analysis of patients with non-small cell lung cancers and regional lymph node metastasis.

PURPOSE: This study was conducted to accurately define the N status of non-small cell lung carcinoma (NSCLC). METHODS: We retrospectively reviewed 147 patients with NSCLC and pathologically positive regional lymph nodes who underwent major pulmonary resections with complete mediastinal lymph node dissections. RESULTS: The overall 5-year survival rate was 41% after a median follow-up period of 33 months. The survival rate of patients with hilar N1 disease (26%) was significantly lower (P = 0.002) than that of those with interlobar and intrapulmonary N1 disease (60%). The survival rate of patients with hilar N1 disease (26%) was similar to that of those with N2 disease (33%; P = 0.56). Cox proportional hazards analysis with the covariates of age, sex, cell type, site of resection, pathological T factor, and pathological N factor revealed that pathological N factor indicated a relative risk for N2 disease of 1.76 (P = 0.028). Grouping hilar N1 disease with N2 disease showed that the relative risk of this "new N2 disease" with the same covariates was 2.65 (P = 0.002). CONCLUSION: According to our data, hilar N1 disease should be grouped with N2 disease because this combined category accurately reflects surgical outcome.