The real-world data of lipid-lowering treatment in patients with peripheral artery disease and its association with severity of disease.

BACKGROUND: The risk of coronary artery disease in peripheral arterial disease (PAD) is high, life prognosis is poor, and lipid-lowering treatment with statins has been reported to improve prognosis. In clinical practice, however, hypolipidemia is more common in patients with severe PAD and statin prescription rates appear to be low, but specific data are scarce in Japan. Therefore, we conducted this cross-sectional study in collaboration with other centers of vascular surgery to determine the rate of statin prescriptions for PAD patients in real-world practice, the rate of achievement of low-density lipoprotein (LDL) cholesterol control targets, and whether statin non-use is a determinant factor of critical limb ischemia (CLI). METHODS: A total of 246 PAD patients (97 with CLI) from 5 sites were included in this study. Medical history and blood test data were obtained from medical records and interviews with patients, and were compared between CLI and non-CLI patients. RESULTS: Statin prescription rate was only 34 %. The overall LDL cholesterol control target rate was 46 % of CLI cases and 51 % of non-CLI cases, according to the lipid management criteria of the Japanese Society for Atherosclerosis 2022 guidelines. Patients in the CLI group had a lower mean body mass index and lower LDL cholesterol levels than those in the non-CLI group, suggesting that these factors were responsible for the lower statin prescription rate. However, multivariate analysis revealed that statin non-use was one of the determinants of CLI. CONCLUSIONS: Statin prescription rates for PAD patients were low in real-world practice settings in the field of vascular surgery. Since statin non-use is a determinant of CLI, there is a need to educate physicians engaged in treatment regarding lipid-lowering treatment with statins.

One Year Outcomes of Zilver PTX Versus Eluvia for Femoropopliteal Disease in Real-World Practice: REALDES Study.

PURPOSE: This multicenter, prospective, observational study aimed to compare Zilver PTX and Eluvia stents in real-world settings for treating femoropopliteal lesions as the differences in the 1-year outcomes of these stents have not been elucidated. MATERIALS AND METHODS: Overall, 200 limbs with native femoropopliteal artery disease were treated with Zilver PTX (96 limbs) or Eluvia (104 limbs) at 8 Japanese hospitals between February 2019 and September 2020. The primary outcome measure of this study was primary patency at 12 months, defined as a peak systolic velocity ratio of ≤2.4, without clinically-driven target lesion revascularization (TLR) or stenosis ≤50% based on angiographic findings. RESULTS: The baseline clinical and lesion characteristics of Zilver PTX and Eluvia groups were roughly comparable (of all limbs analyzed, approximately 30% presented with critical limb-threatening ischemia, approximately 60% presented with Trans-Atlantic Inter-Society Consensus II C-D, and approximately half had total occlusion), except for the longer lesion lengths in the Zilver PTX group (185.7±92.0 mm vs 160.0±98.5 mm, p=0.030). The Kaplan-Meier estimates of primary patency at 12 months were 84.9% and 88.1% for Zilver PTX and Eluvia, respectively (log-rank p=0.417). Freedom from clinically-driven TLR rates were 88.8% and 90.9% for Zilver PTX and Eluvia, respectively (log-rank p=0.812). CONCLUSIONS: The results of the Zilver PTX and Eluvia stents were not different regarding primary patency and freedom from clinically-driven TLR at 12 months after treating patients with femoropopliteal peripheral artery disease in real-world settings. CLINICAL IMPACT: This is the first study to reveal that the Zilver PTX and Eluvia have similar results in real-world practice when the proper vessel preparation is performed. However, the type of restenosis in the Eluvia stent may differ from that in the Zilver PTX stent. Therefore, the results of this study may influence the selection of DES for femoropopliteal lesions in routine clinical practice.

[Usage of New Device to Prevent Sternum Separation after Median Sternotomy in 140 Cases].

While minimally invasive cardiac surgery (MICS) has become increasingly popular recently even in the field of cardiovascular surgery, the conventional full median sternotomy is still the main approach to the mediastinum, especially for cases which cannot be applied for MICS or in the facilities where MICS is not performed. It has been known that sternal instability is one of the leading causes of sternal infection after median sternotomy. Therefore, we have sought for an additional product to secure strong sternal stability. Since August in 2018, we used a new type of corrugated plate( Super Fixsorb Wave) which is placed inside the sternum in addition to regular sternal wires for 140 patients who had full median sternotomy. Up to now, we have no complications regarding sternotomy including mediastinitis. We believe that additional use of Super Fixsorb Wave enables firm sternal stability and prevents mediastinitis following full median sternotomy.

Differences in Physical Activity between Patients with Peripheral Artery Disease and Healthy Subjects.

OBJECTIVES: Peripheral artery disease (PAD) is a significant prognostic marker of poor long-term survival due to limited physical activity associated with various functional problems, such as intermittent claudication. A physically active lifestyle has the potential to modify peripheral artery risk factors and promote general health. While low daily physical activity levels have been recognized in the population of PAD, the exact level has yet to be quantified due to lack of research. The aim of the present study was to compare physical activity level (PAL) and time spent at activities of different intensity levels between patients with PAD and healthy individuals. The study subjects were 10 patients with PAD and 10 age-matched healthy control subjects. We measured the time spent at light, moderate, or vigorous physical activity using triaxial accelerometer and calculated PAL. Intermittent claudication onset distance and maximum walking distance were defined as the distance walked at which the subject first reported leg pain and the distance at which the subject was unable to continue walking because of leg pain, respectively. RESULTS: Our results showed (i) lower PAL in patients with PAD compared with the controls; (ii) while there was no significant difference in the high-intensity activity between the two groups, the light- and moderate-intensity activities of the PAD group were significantly lower than the controls, the time spent at moderate-intensity activity was approximately 50% less; and (iii) among patients with PAD, low PAL did not correlate directly with intermittent claudication. CONCLUSIONS: PAD patients limit the amount of their physical activity, especially light and moderate intensities. Our study highlights the importance of spending more time walking in daily life.

Long-Term Results of Crossover Bypass for Iliac Atherosclerotic Lesions in the Era of Endovascular Treatment: The Re-ACTION Study (Retrospective Assessment of Crossover Bypass as a Treatment for Iliac LesiONs).

Objective: The aim of this study was to elucidate the long-term results of crossover bypass (CB) for iliac atherosclerotic lesions in the era of endovascular treatment (EVT). Methods: A retrospective multicenter cohort study was performed. CB was performed in 242 patients between 2003 and 2014 by vascular surgeons at multiple medical centers in Japan. Results: Perioperative mortality was 1.7%. Primary patency rates were 86% at 5 years and 82% at 8 years. Univariate analysis showed that critical limb ischemia (Rutherford class 4-6), vein graft, and superficial femoral artery occlusion were significantly associated with low primary patency. In multivariate analysis, only critical limb ischemia influenced primary patency. The secondary patency rate was 87% at both 5 and 8 years. The limb salvage rate was 98% at both 5 and 8 years. The overall survival rates were 71% at 5 years and 49% at 8 years. Conclusion: The long-term results of CB were good in our study, compared with previous reports. Our results suggest that CB remains an option for the arterial reconstruction in unilateral iliac occlusive disease after EVT failed.

Chylothorax Associated with Chronic Lymphocytic Leukemia.

An 80-year-old man who had suffered from chronic lymphocytic leukemia (CLL) and achieved complete remission was admitted to our hospital due to right pleural effusion. Thoracentesis revealed that the effusion was chyle. Lymphoscintigraphy showed an obstruction of the thoracic duct below the sternum. CD45-gated flow cytometry of the pleural effusion showed elevated numbers of CD5- and CD23-positive lymphocytes and a high serum level of soluble interleukin-2 receptor. These results suggested that the chylothorax was caused by the obstruction of the thoracic duct by the sludging of either abnormal lymphocytes of CLL or transformed malignant lymphoma cells.

Closure of esophagotracheal fistula after esophagectomy for esophageal cancer.

Fistula between the trachea and esophagogastric anastomosis after esophagectomy is rare. We successfully treated a 75-year-old woman with such a lesion by single-stage repair. The patient had undergone radical esophagectomy 20 years ago, and repeatedly developed aspiration pneumonia for recent 5 years. Radiological and endoscopic examinations demonstrated the fistula between the trachea at the level of sternal notch and esophagogastric anastomosis. The fistula was separated and the defects on both sides were closed. A sternocleidomastoid muscle flap was inserted between the two structures. The postoperative course was uneventful.

Left ventricular ball-like thrombus after acute myocardial infarction with essential thrombocythemia.

Left ventricular (LV) thrombus after acute myocardial infarction (AMI) is a frequent complication that is associated with a risk of systemic embolism. Essential thrombocythemia (ET) has opposing tendencies towards hemorrhage and thrombogenesis and it can cause AMI via thrombogenesis. Ball-like LV thrombus is associated with a high risk of systemic embolism. We describe surgical resection of LV ball-like thrombus from a patient with ET. A 60-year-old woman presented at our hospital with transient ischemic attack accompanied by transient hemiplegia. Ultrasonic cardiography revealed a mobile ball-like thrombus in the LV after transmural AMI of the anterior wall. We performed emergency LV thrombectomy because of the mobile LV thrombus with embolism. Platelet aberrations and pathological bone marrow findings were consistent with a diagnosis of ET. We administered the patient with anti-coagulation drugs and the DNA replication inhibitor hydroxycarbamide to decrease the platelet count. She continues to survive and is doing well without major postoperative complications. .

Acute reductions in blood flow restricted to the dorsomedial medulla induce a pressor response in rats.

OBJECTIVES: The brainstem nucleus of the solitary tract (nucleus tractus solitarii, NTS) is a pivotal region for regulating the set-point of arterial pressure, the mechanisms of which are not fully understood. Based on evidence that the NTS exhibits O2-sensing mechanisms, we examined whether a localized disturbance of blood supply, resulting in hypoxia in the NTS, would lead to an acute increase in arterial pressure. METHODS: Male Wistar rats were used. Cardiovascular parameters were measured before and after specific branches of superficial dorsal medullary veins were occluded; we assumed these were drainage vessels from the NTS and would produce stagnant hypoxia. Hypoxyprobe-1, a marker for detecting cellular hypoxia in the post-mortem tissue, was used to reveal whether vessel occlusion induced hypoxia within the NTS. RESULTS: Following vessel occlusion, blood flow in the dorsal surface of the medulla oblongata including the NTS region showed an approximately 60% decrease and was associated with hypoxia in neurons located predominantly in the caudal part of the NTS as revealed using hypoxyprobe-1. Arterial pressure increased and this response was pronounced significantly in both magnitude and duration when baroreceptor reflex afferents were sectioned. CONCLUSION: These results suggest that localized hypoxia in the NTS increases arterial pressure. We suggest this represents a protective mechanism whereby the elevated systemic pressure is a compensatory mechanism to enhance cerebral perfusion. Whether this physiological mechanism has any relevance to neurogenic hypertension is discussed.

Comparison of the waveforms of transit-time flowmetry and intraoperative fluorescence imaging for assessing coronary artery bypass graft patency.

PURPOSE: An intraoperative fluorescence imaging (IFI) system, which can provide visual images, could be the common method for assessing graft patency intraoperatively. We conducted a prospective comparison of the diagnostic accuracy of both the fast Fourier transformation (FFT) analysis of transit-time flowmetry (TTFM) waveform and the IFI system to determine graft failure. METHODS: The study included 10 saphenous vein grafts (SVGs), all of which were aortocoronary grafts. Each patient underwent isolated coronary artery bypass grafting (CABG), including conventional CABG or off-pump CABG, and then underwent X-ray angiography after CABG. When intraoperative hemodynamics had stabilized, the grafts were evaluated with both the IFI system and TTFM. Based on the obtained flow profile of TTFM, certain variables were calculated. The waveforms of TTFM were analyzed with the FFT series. Harmonic distortion (HD) was calculated from the amplitudes, and the fundamental frequency was thus determined using the FFT series. RESULTS: The IFI system demonstrated a satisfactory flow of all grafts. X-ray angiography demonstrated that one SVG was 75% stenosed, and the others were patent. The mean graft flow (MGF) and the pulsatility index (PI) of the patent SVGs were not significantly different from those of the stenosed SVG. The HD of the patent SVGs was significantly different from that of the stenosed SVG. CONCLUSION: The HD of the TTFM waveform can provide better diagnostic accuracy for detecting clinically significant grafts than MGF and PI of TTFM and the IFI system.

Adrenomedullin 2 microinjection into the nucleus tractus solitarius elevates arterial pressure and heart rate in rats.

Adrenomedullin 2 (AM2), a novel member of the calcitonin gene-related peptide family, has emerged as a multifunctional peptide controlling endocrine and cardiovascular functions and physiological behaviors. Both central and peripheral administration of AM2 can have profound effects on systemic and/or pulmonary circulation in mammals. However, the target nuclei of AM2 and the role of central AM2 in cardiovascular regulation remain unknown. In the present study, we microinjected AM2 into the rat nucleus tractus solitarius (NTS), the central termination site of baroreceptor afferents. Consistent with previous reports showing the hypertensive effect of intracerebroventricular administration of AM2, the direct microinjection of the peptide into the NTS increased arterial pressure as well as heart rate in rats. Importantly, this effect of AM2 on cardiovascular regulation was significantly attenuated by an antagonist of receptor components for AM2 that were abundant in the rat NTS. Our results indicate that AM2 may play an important role in the regulation of the cardiovascular system at the NTS level.

Ultrasonographic measurement of intima-media thickness of the carotid artery before coronary artery bypass grafting.

PURPOSE: We evaluated the usefulness of measuring intima-media thickness (IMT) of the carotid artery by ultrasonography before coronary artery bypass grafting (CABG). METHODS: Seventy-three patients who underwent carotid ultrasonography before CABG were selected for this study. The maximum IMT (max IMT) in the bilateral common carotid artery was used as the index of carotid ultrasonography. As a quantitative measure of coronary atherosclerosis, we calculated Gensini's coronary score (GCS) from the preoperative coronary angiography. RESULTS: There was a positive correlation between the max IMT and the GCS. Furthermore, the max IMT of the patients with myocardial infarction was significantly greater than that of the patients with angina pectoris. CONCLUSIONS: Carotid ultrasonography before CABG is useful, not only for the morphological evaluation of the stenotic lesions of the neck vessels, but also for the quantitative prediction of atherosclerosis in the native coronary artery. The max IMT may predict the progression of atherosclerotic change of the native coronary artery from angina pectoris to myocardial infarction.

Aortic root replacement with a freestyle stentless valve for aortitis syndrome with ascending aortic aneurysm and aortic regurgitation.

A 47-year-old woman who had been diagnosed as having aortitis syndrome underwent aortic root replacement for an ascending aortic aneurysm and aortic regurgitation. Because the patient has been treated with steroids for more than 20 years, a Freestyle stentless valve was used to avoid the risk of valve detachment. There were no complications observed during the postoperative course. Although long-term follow-up will be necessary to observe the valve durability, the Freestyle stentless valve seems to be useful for aortic root replacement in patients at high risk of valve detachment due to aortitis syndrome.

Successful repair of a large pseudoaneurysm of the left ventricle late after mitral valve replacement due to rupture of the papillary muscle following acute myocardial infarction.

We present a rare case demonstrating a large pseudoaneurysm of the left ventricle late after mitral valve replacement due to rupture of the papillary muscle following acute myocardial infarction. A 52-year-old man, who had undergone mitral valve replacement 7 months previously, presented with severe congestive heart failure. Echocardiography and computed tomography of the chest demonstrated a large pseudoaneurysm of the left ventricle. The patch repair of the orifice of the pseudoaneurysm was successfully performed.

Carotid stenosis and peripheral artery disease in Japanese patients with coronary artery disease undergoing coronary artery bypass grafting.

The combination of a change in lifestyle toward Western habits and an aging society, has led to a steady increase in the incidence of atherosclerotic diseases in the Japanese population. Coronary artery disease (CAD), carotid stenosis (CS), and peripheral artery disease (PAD) are major manifestations of generalized atherosclerosis and increase the risk of cardiovascular events. However, the incidence of CS and PAD in Japanese patients with CAD is not well known, so the present study investigated this in 380 consecutive patients with CAD undergoing elective coronary aorta bypass grafting (CABG) at Kishiwada Tokushukai Hospital between October 1999 and October 2001. The coexistence of CS and PAD in all patients was preoperatively evaluated by duplex ultrasonography and the ankle - brachial index (ABI). The average age of the study population was 66.09.1 years (range, 42-87). The number of male patients was 293 (77.1%). The incidence of CS was 13.7% and 15.3% for PAD. Multivariate logistic regression analysis demonstrated that no particular traditional atherosclerotic risk factor, such as hypertension, hyperlipidemia, diabetes mellitus, and smoking, was able to predict either CS or PAD, but CS and PAD were independent predictors of each other. The results of the study suggest that CS and PAD were not only highly prevalent but also strongly associated with each other in this cohort of CAD patients. Accordingly, extracoronary atherosclerotic disease should be assessed in Japanese CAD patients.