Serious Adverse Events with Cyanoacrylate Closure of Varicose Veins: An Initial Report from a Large-Scale National Survey in Japan.

Objective: Cyanoacrylate closure (CAC) is a minimally invasive technique for the treatment of varicose veins. A recent paper reported serious adverse events (AEs) associated with this use. This triggered an urgent survey to determine the incidence of AEs in Japan. Methods: The CAC-AE survey was sent to all 1,030 institutions authorized for CAC treatments. Cases performed between January 2020 and October 2023 were surveyed. Data on serious AEs and mortality were collected. Results: There were 623 surveys returned. There were 16 cases of proximal deep vein thrombosis, 3 cases of pulmonary embolism (PE), and 0 cases of stroke. Deep vein occlusion due to cyanoacrylate extension was observed in 1 case. Vein resection due to infection was observed in 4 cases. There were 299 cases of localized phlebitis and/or allergic reactions requiring steroid administration. Systemic allergic reactions requiring steroid administration were observed in 66 cases. There was no anaphylaxis associated with cyanoacrylate. There was one postoperative death from PE. Conclusion: This report's intent is to provide real world data on serious AEs following CAC from Japan given current concern over these events. An extensive report investigation of individual complications with analysis including causality will be provided following a full investigation separately.

Store-operated calcium entry via ORAI1 regulates doxorubicin-induced apoptosis and prevents cardiotoxicity in cardiac fibroblasts.

Despite exhibiting cardiotoxicity, doxorubicin (DOX) is widely used for cancer treatments. Cardiac fibroblasts (CFs) are important in the pathogenesis of heart failure. This necessitates the study of the effect of DOX on CFs. The impairment of calcium (Ca2+) homeostasis is a common mechanism of heart failure. Store-operated Ca2+ entry (SOCE) is a receptor-regulated Ca2⁺ entry pathway that maintains calcium balance by sensing reduced calcium stores in the endoplasmic reticulum. ORAI1, a calcium channel protein and the most important component of SOCE, is highly expressed in human cardiac fibroblasts (HCFs). It is upregulated in CFs from failing ventricles. However, whether ORAI1 in HCFs is increased and/or plays a role in DOX-induced cardiotoxicity remains unknown. In this study, we aimed to elucidate the relationship between ORAI1/SOCE and DOX-induced heart failure. Induction of apoptosis by DOX was characterized in HCFs. Apoptosis and cell cycle analyses were performed by fluorescence-activated cell sorting (FACS). Reactive oxygen species (ROS) production was measured using fluorescence. YM-58483 was used as an ORAI1/SOCE inhibitor. ORAI1-knockdown cells were established by RNA interference. In vivo experiments were performed by intraperitoneally injecting YM-58483 and DOX into mice. We first demonstrated that DOX significantly increased the protein expression level of p53 in HCFs by western blotting. FACS analysis revealed that DOX increased early apoptosis and induced cell cycle arrest in the G2 phase in fibroblasts. DOX also increased ROS production. DOX significantly increased the expression level of ORAI1 in CFs. Both YM-58483 and ORAI1 gene knockdown attenuated DOX-induced apoptosis. Similarly, YM-58483 attenuated cell cycle arrest in the G2 phase, and ORAI1 knockdown attenuated DOX-induced ROS production in HCFs. In the animal experiment, YM-58483 attenuated DOX-induced apoptosis. In HCFs, ORAI1/SOCE regulates p53 expression and plays an important role in DOX-induced cardiotoxicity. ORAI1 may serve as a new target for preventing DOX-induced heart failure.

Remote simulator training of coronary artery bypass grafting during the coronavirus disease 2019 pandemic.

OBJECTIVES: The coronavirus disease 2019 pandemic presents in-person exposure risk during surgical education. We aimed to validate the feasibility of fully remote faculty-supervised surgical training sessions focused on coronary artery bypass grafting using a synthetic simulator and online videochat software. METHODS: This observational study organized 24 sessions of 2-hour remote training. Each session involved 3 trainees, 1 faculty member, and 1 host. A total of 70 trainees and 24 faculty members were enrolled. The participants joined the remote sessions via online videochat and performed focused training in coronary artery anastomosis using a commercially available simulator. A survey was conducted to validate the feasibility of the remote sessions. Performance improvement of the trainees who repeatedly participated (n = 13) were analyzed comparing initial and final scores of various performance indicators. RESULTS: All trainees and faculty members were satisfied with the efficacy of the remote session. Additionally, most trainees (79%) and faculty members (95%) agreed that the remote training sessions were equivalent to conventional onsite training seminars. A significant improvement between initial and last sessions was observed in the scoring components of near side (3.4 ± 1.0 vs 4.1 ± 0.9; P = .02), far side (3.3 ± 0.8 vs 3.9 ± 0.8; P = .03), external appearance (3.5 ± 0.8 vs 4.2 ± 0.7; P = .01), and internal appearance (2.8 ± 0.9 vs 4.0 ± 0.9; P = .004). CONCLUSIONS: Faculty-supervised remote surgical training sessions were executed with satisfactory results. This methodology may have important implications for surgical education during the coronavirus disease 2019 pandemic.

A massive postoperative stroke caused by a carotid thrombus that occurred during the surgical repair of an aortic dissection.

A 59-year-old man with no prior neurological deficits developed a massive stroke during the repair of a double-barreled acute type A aortic dissection with major entry in the ascending aorta and an occluded brachiocephalic artery. As right cerebral ischemia was alleviated by the circle of Willis, the patient was alert and conscious preoperatively. Nevertheless, the thrombus in the right carotid artery induced a severe postoperative right cerebral embolism. In conclusion, occlusion of the carotid artery is a risk factor of postoperative severe stroke, even in patients without neurological symptoms preoperatively.

[Doxorubicin directly induced fibrotic change of cardiac fibroblasts].

Doxorubicin (DOX)-induced cardiomyopathy has a poor prognosis. No early detection or effective treatment methods are available in clinical. The mechanisms of cardiotoxicity were considered as oxidative stress and apoptosis in cardiomyocytes. However, the effect of DOX on cardiac fibroblasts remains to be developed. We investigated the direct effect of DOX on the function of human cardiac fibroblasts (HCFs) independently of cell death pathway. Animal study showed that lower dose of DOX (4 mg/kg/week for 3 weeks, i.p.) than a toxic cumulate dose, induced perivascular fibrosis without cell death in hear of mice. DOX increased the protein expression of α-SMA (a marker of trans-differentiation) in HCFs culture cells, indicating that DOX promoted the trans-differentiation of HCFs into myofibroblast. DOX also increased the mRNA and protein expression of matrix metalloproteinase (MMP)-1 in less than 0.1 µM which did not induce cell apoptosis of HCFs cells via PI3K/Akt pathway in HCFs. DOX increased Interleukin-6 (IL-6) via transforming growth factor (TGF)-ß/Smad pathway. In addition, DOX induced the mitochondrial damage and increased the expression of Interleukin-1 (IL-1) via stress-activated protein kinases (SAPK)/ c-Jun NH-2termial kinase (JNK). A peroxisome proliferator-activated receptor gamma (PPARγ) agonist, pioglitazone hydrochloride attenuated the expression of fibrotic marker such as α-SMA and galectin-3 and collagen1 via SAPK/JNK signaling. Pioglitazone also suppressed DOX-induced early fibrotic response in vivo. In conclusion, these findings suggested that low dose DOX induced reactive fibrotic change of cardiac fibroblasts via cell death-independent pathway. There may be potentially new mechanisms of DOX induced cardiotoxicity in clinical usage.

Veno-arterio-pulmonary-arterial extracorporeal membrane oxygenation in descending aortic surgery.

Hypoxia during one-lung ventilation is a significant problem in descending aortic surgery via left thoracotomy. Veno-arterio-pulmonary-arterial extracorporeal membrane oxygenation (VAPa-ECMO), which consists of veno-arterial extracorporeal membrane oxygenation (VA-ECMO) and an additional arterial branch to perfuse a pulmonary artery (Pa), is useful.

A two-stage reconstruction for aortoesophageal fistula after replacement of thoracic aorta for Stanford Type B dissecting aortic aneurysm: esophagectomy and a double-tract reconstruction using the pedicled jejunum: a case report and literature review.

An aortoesophageal fistula (AEF) is a rare, potentially fatal condition, and esophagectomy is usually performed simultaneously with aortic surgery. However, esophageal reconstruction method has not been established. This case report describes a two-stage operation for AEF after replacement of thoracic aorta for Stanford Type B dissecting aortic aneurysm. A 61-year-old man who had underwent total arch replacement with frozen elephant trunk for Stanford Type B dissecting aortic aneurysm 3 years ago admitted to the hospital with high fever. Based on the computed tomography and endoscopic findings, he was diagnosed with having aortoesophageal fistula (AEF). After administration of antibiotics with fasting foods and drinks for a month, he underwent the second aortic replacement, thoracic esophagectomy, cervical esophagostomy, gastrostomy and omental wrapping. After 3 months, he underwent double-tract reconstruction using the pedicled jejunal transfer with supercharge and superdrainage via the subcutaneous route. After reconstruction surgery, the patient was doing well. Two-stage reconstruction was a safe procedure for AEF case who underwent aortic replacement, esophagectomy and omental wrapping. The pedicled jejunum reconstruction via subcutaneous route is an optional procedure for second reconstruction surgery.

Venous thromboembolism complications after endovenous laser ablation for varicose veins and role of duplex ultrasound scan.

OBJECTIVE: A nationwide survey was conducted in Japan to determine the incidence of venous thromboembolism (VTE) after endovenous thermal ablation for varicose veins and to investigate its pathogenic background. METHODS: The survey targeted all cases of endovenous thermal ablation between January 2011 and December 2013. Based on this survey, a retrospective study of patients who developed endovenous heat-induced thrombosis (EHIT) of classes 2 to 4, no EHIT-related deep venous thrombosis (DVT), and pulmonary embolism (PE) was conducted. Lower extremity venous ultrasound was performed within 72 hours and at 1 to 3 months postoperatively in all institutions. We investigated factors associated with the occurrence of complications and the usefulness of postoperative ultrasound. RESULTS: Survey responses were collected from 213 institutions. Endovenous laser ablation was performed for 43,203 patients (EHIT 2 in 318 patients, EHIT 3 in 50 patients, EHIT 4 in 7 patients, other DVTs in 24 patients, and PE in 3 patients). The incidence of VTE complications was 1.0% for EHIT 2, 0.11% for EHIT 3, 0.013% for EHIT 4, 0.063% for other DVTs, and 0.0067% for PE based on the adjusted population. Sex, age, obesity, origin of the varicose vein, vein diameter, and preoperative Caprini score were not strong indicators of VTE complications. Of 50 patients with EHIT 3, there were 35 patients who had EHIT 3 during the first postoperative ultrasound session. In one patient, EHIT 3 progressed to EHIT 4 despite initiation of anticoagulant therapy. Of seven patients with EHIT 4, only one patient had EHIT 4 at the first postoperative ultrasound examination. Because ultrasound performed before the occurrence of EHIT 4 revealed that three patients had EHIT 2 or EHIT 3, EHIT 4 could have possibly been predicted by ultrasound. Of three patients with PE, two developed PE before ultrasound, and EHIT was not detected by ultrasound in one of those patients before PE developed. Anticoagulant therapy was administered in most patients with EHIT 3 and all patients with EHIT 4 and PE, with favorable outcomes. CONCLUSIONS: The incidence of VTE complications after endovenous laser ablation was low. Furthermore, the value of performing postoperative ultrasound for VTE management seems to be low because the occurrence of severe VTE complications could not be predicted by lower extremity venous ultrasound. Although the perioperative detection of VTE complications by this modality resulted in the early administration of anticoagulant therapy and may have contributed to improved prognosis, the number of those patients was limited.

Clinical Course of Asymptomatic Isolated Distal Deep Vein Thrombosis of the Leg: A Single-Institution Study.

Background: The natural history of asymptomatic isolated distal deep vein thrombosis (DVT) of the leg is unclear. This study aimed to describe a 3-month and 1-year clinical course after diagnosis of asymptomatic isolated distal DVT of the leg. Methods: This study included 127 patients with asymptomatic, sonographically proven isolated distal DVT who did not receive anticoagulant therapy and were retrospectively evaluated at our hospital between May 2014 and September 2016. After 3 months and 1 year, the presence or absence of venous thromboembolism recurrence and extension of DVT toward proximal veins was sonographically confirmed. Results: At 3-month and 1-year follow-ups, 125 and 109 patients were observed, respectively. All patients showed no symptoms or findings suspecting venous thromboembolism recurrence during the observation period. However, 43 patients underwent repeat ultrasonic examination, and thrombus extension was confirmed in 2 patients. Conclusions: Asymptomatic isolated distal DVT of the leg showed good prognosis, and thus uniform anticoagulation therapy was considered unnecessary. (This is a translation of Jpn J Phlebol 2018; 29(3): 309-314.).

Treatment of coronary malperfusion in type A acute aortic dissection.

Coronary malperfusion is one of the most dreadful complications of acute aortic dissection because it causes catastrophic acute myocardial infarction in patients who are already severely ill. Our strategy was as follows. After the administration of heparin, emergency percutaneous coronary intervention (PCI) was urgently performed at the same time as starting to prepare the operating room. A stent was then placed to cover the full length of dissected coronary artery. Patients whose cardiac function improved after successful coronary artery reperfusion were transferred to the operating room to undergo central repair surgery. If the cardiac function did not recover even after coronary reperfusion, and the patient required extracorporeal membrane oxygenation, we considered the best supportive care without performing central repair surgery. In patients with left coronary malperfusion, we believe that preoperative PCI must be performed immediately. Preoperative PCI might delay central repair surgery and potentially increase the risk of catastrophic cardiac tamponade. However, the benefit of PCI in preserving cardiac function exceeds the risk of cardiac tamponade. The indications of PCI before central repair in patients with right coronary malperfusion should be considered after assessing each patient's condition, including the presence or absence of cardiac tamponade and right ventricular infarction, left ventricular function, the immediate availability of cardiologists or cardiac surgeons, and the speed of preparing the operating room.

[Effectiveness of the Waffle Procedure for Constrictive Pericarditis].

A 66-year-old woman was referred to our hospital with dyspnea. Right-sided congestive pleural effusion of an unknown etiology was detected and she was diagnosed with constrictive pericarditis. Pericardiectomy was performed via median sternotomy under extracorporeal circulation because severe adhesion was observed. However, hemodynamics did not improve after pericardial resection because of thickend epicardium in front of the right ventricle. Hence, the waffle procedure was additionally performed on the anterior surface of the right ventricle after coming-off the extracorporeal circulation. Although significant cardiac dilatation was achieved, hemodynamics did not change markedly. The symptoms gradually alleviated postoperatively and cardiac catheterization performed 3 weeks later revealed marked improvement in hemodynamics. Although improvement in hemodynamics takes time, the waffle procedure appears to be effective.

Therapeutic outcome after resection of pulmonary metastases from oral and/or head and neck cancers: complete republication of the article published in Jpn J Chest Surg.

OBJECTIVE: Thus far, very few studies have assessed the efficacy and outcome of resection of pulmonary metastases originating from primary oral cancer and/or head and neck cancer. METHODS: We retrospectively reviewed 13 cases that had metastases from primary oral cancers and/or head and neck cancers, and had undergone metastasectomy in our hospital from January 2000 through March 2011. RESULTS: Twelve patients were male and one was female. The median disease-free interval from the time of treatment of their primary cancer was 12 (range 1-73) months. Eleven cases underwent partial resection, one underwent segmentectomy, and one underwent lobectomy. The overall 5-year survival rate after last pulmonary metastasectomy was 45.7 %, and the median survival time was 23 months. Factors predicting a poor prognosis according to univariate analysis were a disease-free interval of <12 months and a diagnosis of stage IV primary cancer, but multivariate analysis revealed no significant prognostic factors. CONCLUSIONS: Pulmonary metastasectomy would give a chance for long-term survival in patients with oral and/or head and neck cancers.

[Curative resection of a case of advanced gastric cancer with peritoneal dissemination responding well to combination chemotherapy of docetaxel,cisplatin and S-1].

We report a curative resection of a case with advanced gastric cancer responding remarkably well to combination chemotherapy of docetaxel, cisplatin and S-1. The patient was a 71-year-old man with gastric cancer of Borrmann type 3 accompanied with N3. Staging laparoscopy revealed peritoneal dissemination. He was administered docetaxel intravenously at 40mg/ m2 on day 1, cisplatin intravenously at 60 mg/m2 on day 1, and S-1 orally at 80 mg/m2 on days 1 to 14. This treatment was repeated every 28 days as one course. According to gastroscope and CT findings, a significant tumor reduction was obtained after 4 courses. After 6 courses, a CT scan revealed partial response of the lymph node metastasis, and the serum CEA value was normalized. Curative total gastrectomy was performed. The histological effect of the primary lesion was judged to be grade 2. Combination chemotherapy of S-1, cisplatin and docetaxel can be effective and feasible for advanced gastric cancer.