Appropriate Surgical Treatment of Symptomatic Primary Varicose Veins Decreases Systemic Inflammatory Biomarkers.

Objective: To evaluate the relationship between systemic inflammatory biomarkers and efficacy of surgical treatment of primary varicose veins of the lower extremities. Methods: Total 12 patients who underwent endovenous laser ablation or stripping of varicose veins and six healthy subjects were enrolled. Structural and molecular changes of varices were assessed by immunohistochemical staining with anti-monocyte chemotactic protein-1 (MCP-1). MCP-1 and interleukin-6 (IL-6) levels in systemic antecubital blood were measured before and at 12 weeks after treatment. Results: Immunohistochemical staining revealed prominent manifestation of MCP-1-positive endothelial cells in the walls of varices. Preoperative serum MCP-1 and IL-6 levels in the patients were significantly higher than those in the control (166±12 pg/mL vs 99±10 pg/mL, p=0.003; 5.1±0.95 pg/mL vs 0.0±0.0 pg/mL, p=0.001, respectively). The values were significantly correlated with the severity of chronic venous insufficiency (CVI). Postoperative serum MCP-1 level significantly decreased compared with the preoperative level (152±10 pg/mL vs 166±12 pg/mL, p=0.048). The values after endovenous laser ablation did not significantly decrease compared with those after stripping. Conclusion: Varicose veins with CVI increase inflammatory biomarker levels in the local tissue and systemic blood. Appropriate treatment of symptomatic varicose veins decreases inflammatory biomarker levels.

Septic True Aneurysm of the Posterior Tibial Artery Diagnosed after Anterior Arthroscopic Debridement of a Septic Ankle following Infective Endocarditis: A Case Report.

INTRODUCTION: There have been reports of true aneurysm of the posterior tibial artery, but only three reports have described true aneurysm of the posterior tibial artery at the ankle, and there has been only one report of tarsal tunnel syndrome caused by true aneurysm of this artery. In this case report, we describe a rare case of true septic aneurysm of the posterior tibial artery presenting as tarsal tunnel syndrome which was found after anterior arthroscopic debridement of a septic ankle in a 55-year-old man. CASE REPORT: 13 years earlier, this patient had undergone aortic valve replacement for severe aortic regurgitation caused by infective endocarditis with aortic valve vegetations. Since then, the patient had been treated with the oral anticoagulant warfarin. The aneurysm was successfully treated by a saphenous vein graft and administration of antibiotics. The patient likely developed septic ankle and aneurysm as a consequence of infective endocarditis. CONCLUSIONS: Magnetic resonance imaging should be performed before arthroscopic surgery to rule outaneurysm, especially in a patient with a septic ankle and/ora history of infective endocarditis.

Long-term Results After Open Mitral Commissurotomy for a One-Month-Old Infant With Mitral Stenosis.

The strategy for an infant with congenital mitral stenosis should be determined by three important factors: left ventricular volume, the degree of the systemic outflow tract obstruction, and the type of mitral valve dysfunction. A successful staged biventricular repair in early infancy for a patient who had congenital mitral stenosis with short chordae, hypoplastic left ventricle and coarctation of the aorta, and the long-term results are described. There were the following important hemodynamic factors that led to the successful biventricular repair in the patient. Total systemic output was barely supplied through the hypoplastic left ventricle after closure of the ductus arteriosus on admission. The neonate underwent repair of coarctation of the aorta alone as the initial stage at 9 days after birth. Also, spontaneous closure of the foramen ovale following repair of coarctation of the aorta accelerated the progressive left ventricular growth. Open mitral commissurotomy with an interatrial fenestration using the modified Brawley's approach was performed for a 40-day-old infant. Good left ventricular growth and good mitral valve function have been observed for 18 years after open mitral commissurotomy. Appropriate early augmentation of left ventricular inflow through the mitral valve might be effective for growth of a hypoplastic left ventricle. J. Med. Invest. 64: 187-191, February, 2017.

Effects of Transplanted Human Cord Blood-Mononuclear Cells on Pulmonary Hypertension in Immunodeficient Mice and Their Distribution.

OBJECTIVES: To investigate the effects of human umbilical cord blood-derived mononuclear cell (hUCB-MNC) transplantation on pulmonary hypertension (PH) induced by monocrotaline (MCT) in immunodeficient mice and their distribution. METHODS: MCT was administered to BALB/c Slc-nu/nu mice, and PH was induced in mice 4 weeks later. Fresh hUCB-MNCs harvested from a human donor after her delivery were injected intravenously into those PH mice. The medial thickness of pulmonary arterioles, ratio of right ventricular to septum plus left ventricular weight (RV/S+LV), and ratio of acceleration time to ejection time of pulmonary blood flow waveform (AT/ET) were determined 4 weeks after hUCB-MNC transplantation. To reveal the incorporation into the lung, CMTMR-labeled hUCB-MNCs were observed in the lung by fluorescent microscopy. DiR-labeled hUCB-MNCs were detected in the lung and other organs by bioluminescence images. RESULTS: Medial thickness, RV/S+LV and AT/ET were significantly improved 4 weeks after hUCB-MNC transplantation compared with those in mice without hUCB-MNC transplantation. CMTMR-positive hUCB-MNCs were observed in the lung 3 hours after transplantation. Bioluminescence signals were detected more strongly in the lung than in other organs for 24 hours after transplantation. CONCLUSIONS: The results indicate that hUCB-MNCs are incorporated into the lung early after hUCB-MNC transplantation and improve MCT-induced PH. J. Med. Invest. 64: 43-49, February, 2017.

Successful management using airway pressure release ventilation for severe postoperative pulmonary edema.

INTRODUCTION: Postoperative pulmonary edema is a fatal adverse event after a cardiac surgery. We here report successful management using airway pressure release ventilation (APRV) for severe hypoxia with pulmonary edema after a cardiac surgery. PRESENTATION OF CASE: A 58-year-old man underwent an uneventful mitral valve repair. Immediately afterwards, the patient became agitated and made vigorous inspiratory efforts. His oxygen saturation dropped to 90%. Coarse inspiratory rhonchi were heard on auscultation, and copious, pink, frothy sputum was obtained with suctioning. Initial chest radiograph showed right-sided patchy opacities and interstitial infiltrates. A transthoracic echocardiogram demonstrated normal cardiac function. With worsening respiratory failure on mechanical ventilation, APRV was attempted. His condition and blood gas was subsequently improved. Over the following 3days, the patient experienced an uneventful postoperative course and was discharged to home on postoperative day 14. DISCUSSION: Extracorponeal membrane oxygenation (ECMO) is the most effective for severe hypoxia with pulmonary edema; however, ECMO is associated with hemorrhage and infectious complications. Alteratively, APRV was required for the successful management for severe hypoxia with pulmonary edema. CONCLUSION: APRV could be effective for severe hypoxia with pulmonary edema after a cardiac surgery.

Blunt Abdominal Aortic Injury Associated with L2 Vertebral Fracture.

Blunt abdominal aortic injury (BAAI) is very rare. In general, BAAI occurs in high-energy accidents. Here, we present a case of BAAI in a low-energy accident. A 70-year-old female was injured after falling 3 m. Her vital signs were stable. She had lumbar fractures (L1, L2) and BAAI associated with a fragment of the fractured L2 vertebral body. On the fifth posttrauma day, we performed an operation because computed tomography showed a bone fragment of the lumbar fractures (L1, L2) threatening the abdominal aorta. The aortic injury site was transected, and the fragment of the L2 vertebral body was removed. Even in low-energy accidents, BAAI should be considered. BAAI with stable vital signs can be electively treated.

Efficacy and Optimal Timing of Endovascular Treatment for Type B Aortic Dissection.

OBJECTIVES: To determine the efficacy and the optimal timing of thoracic endovascular aortic repair (TEVAR) for closing the primary entry in uncomplicated patients with chronic type B aortic dissection and a patent false lumen (FL). METHODS: Thirteen patients underwent TEVAR for aortic dissection between 2008 and 2012. These patients had chronic dissection with a patent FL and expansion of the aorta. Early TEVAR was performed for five patients within 1-7 months from the index dissection (TEVAR-EC group) and delayed TEVAR was performed for eight patients within 1-16 years (TEVAR-DC group). Changes in the diameters and volumes of the true lumen (TL) and FL and the aortic remodeling were assessed by multidetector computed tomography for 3 years after TEVAR. RESULTS: The reduction rate of FL in the thoracic aorta was notably higher in the TEVAR-EC group than in the TEVAR-DC group regardless of the presence or absence of distal retrograde flow. There was a significant TL expansion despite different timings of TEVAR. CONCLUSIONS: Early TEVAR resulted in good prognosis and preferable aortic remodeling in uncomplicated patients with chronic type B aortic dissection and a patent FL, and we recommend early TEVAR within seven months after the index dissection.

Successful management of threatened aortic rupture late after rib fracture caused by blunt chest trauma.

A 62-year-old man was crushed in a car accident and diagnosed with a fractured left ninth rib, pulmonary and heart contusion, hemopneumothorax, and descending aortic injury based on a computed tomography scan. He underwent chest tube drainage and was intubated for mechanical ventilation because a bone fragment of the ninth rib threatened to penetrate the descending aorta. On the second posttrauma day, computed tomography showed the bone fragment of the ninth rib approaching the descending aorta. He underwent graft replacement of the injured portion of the descending thoracic aorta, and we removed the fractured left ninth rib.