Assessment of the Severity of Ischaemia and the Outcomes of Revascularisation in Peripheral Arterial Disease Patients Based on the Skin Microcirculatory Response to a Thermal Load Test.

OBJECTIVE: This study investigated the skin microcirculatory response to a thermal load test using a laser Doppler flowmetry device to evaluate the severity of limb ischaemia and the outcomes of revascularisation in patients with peripheral arterial disease (PAD). METHODS: A total of 34 PAD patients (39 limbs) including 17 critical limb ischaemia (CLI) patients (21 limbs) who underwent revascularisation were enrolled. The skin microcirculation of the dorsal side of the affected foot was investigated for 15 minutes after local heating. The tests were performed both before and after revascularisation, and several parameters gleaned from the microcirculatory fluctuations were analysed and compared with the ankle brachial pressure index and the transcutaneous oxygen tension (tcPO2) values. RESULTS: Among the parameters, significant differences were observed between the CLI patients and patients with claudication with regard to the increasing phase time (Tinc), the difference in the perfusion values at the onset and the peak of the transient increase in blood perfusion (PΔ), the slope of the transient increase in blood perfusion (Sin), and the slope of the decrease in blood perfusion after the peak (Sde). In CLI patients, the PΔ, Sin, and Sde values increased significantly after revascularisation. In the patients with claudication, the changes in the parameters after revascularisation were not statistically significant. The Sde showed the most statistically significant correlation with the tcPO2 value (ρ .759, p < .001). CONCLUSIONS: Thermal load testing can be used to evaluate the severity of limb ischaemia in patients with PAD.

Bilateral External Iliac Venous Aneurysms in a Long-Distance Runner.

Aneurysms of the iliac veins are very rare but are potentially fatal due to their potential to cause thromboembolic complications or even rupture. We herein report an unusual case of bilateral external iliac venous aneurysms in a 50-year-old male long-distance runner who presented with bilateral groin pain. The aneurysms were successfully treated with tangential aneurysmectomy with lateral venorrhaphy. Possible causes and management of iliac venous aneurysms are also discussed in this article.

Multiple Recurrent Pseudoaneurysms after Endovascular Repair of Abdominal Aortic Aneurysm in a Patient with Behçet's Disease.

In Behçet's disease (BD) patients, endovascular repair is a reasonable alternative treatment for aortic aneurysms to avoid postoperative anastomotic pseudoaneurysms. However, there are some complications that may occur after endovascular repair. We herein report the case of a 40-year-old man with active BD developed recurrent aortic pseudoaneurysms at the proximal and distal margins of the stent graft and a femoral puncture site pseudoaneurysm 3 months after endovascular abdominal aortic aneurysm (AAA) repair. The aortic pseudoaneurysms were treated endovascularly, including the use of the chimney technique for the proximal pseudoaneurysm close to the renal arteries and the femoral pseudoaneurysm with surgical excision and reconstruction. Intensive immunosuppressive therapy was initiated immediately after the operation. The patient is in good condition without any complications at 8-month follow-up. This case suggests the utility of the chimney technique and postoperative immediate intensive immunosuppressive therapy in treating recurrent aortic pseudoaneurysms in emergency, active BD patients.

The evaluation of contralateral foot circulation after unilateral revascularization procedures using indocyanine green angiography.

The aim of the present study is to assess the effects of unilateral revascularization on the contralateral foot circulation using indocyanine green (ICG). From January 2016 to April 2016, a total of twenty-one patients were included in this study. The patients underwent elective unilateral revascularization at our institution and we evaluated the feet circulation by indocyanine green angiography (ICGA) tests preoperatively and postoperatively. The ICGA parameters included the magnitude of intensity from the onset of ICG to the maximum intensity (Imax), the time from the onset of ICG to the maximum intensity (Tmax), and the time required to reach the half maximum intensity from the onset of ICG (T1/2). There were significant differences in the treated limb Tmax (P = 0.016) and T1/2 (P = 0.013) values and in the contralateral limb Tmax (P = 0.013), and T1/2 (P < 0.001) values on the perioperative ICGA tests. These results reflect the increase in skin perfusion in the treated limb and the decrease in skin perfusion in the contralateral limb. Unilateral revascularization decreases contralateral foot circulation. The preoperative contralateral lesion should be evaluated when revascularization is performed.

Successful Complete Surgical Resection of a Large Venous Malformation of the Lower Extremity: A Case Report.

Venous malformations (VMs) are the most common type of vascular malformations, resulting from errors in vascular morphogenesis. Because of the wide variety in their presentations, selecting the appropriate treatment, especially for large VMs, may be challenging. Herein, we report a case of a 59-year-old man with a large VM in the lower extremity who achieved favorable outcomes by complete surgical resection. Even large VMs can be successfully treated with surgery when patients are properly selected. An accurate and careful evaluation is essential for achieving optimal outcome in patients with VMs.

Endothelial dysfunction in patients with Buerger disease.

We evaluated the endothelial function of patients with Buerger disease using peripheral arterial tonometry test, and examined the factors that are significantly correlated with the endothelial dysfunction in these patients. We performed the peripheral arterial tonometry test in 22 patients with Buerger disease. We recorded the patients' characteristics, including ankle brachial pressure index and reactive hyperemia index, which reflect the endothelial dysfunction. We divided the patients with Buerger disease into the conservative treatment and lumbar sympathectomy group. While the reactive hyperemia index was not significantly different between these two groups, the ankle brachial pressure index was significantly different (1.12 versus 0.83, P=0.003). Furthermore, the reactive hyperemia index was significantly correlated with the ankle brachial pressure index value in the patients in the lumbar sympathectomy group (ρ=0.848, P=0.005). Given that patients with Buerger disease show impairment of the sympathetic nervous system, we should consider the after-effects of such an impaired system on the condition of these patients. The patients treated with lumbar sympathectomy might be more appropriate to evaluate their endothelial function by a peripheral arterial tonometry test.

The use of dielectric blood coagulometry in the evaluation of coagulability in patients with peripheral arterial disease.

BACKGROUND: Platelets and coagulation proteins contribute to the development of peripheral arterial disease, especially atherosclerotic disease. Several experimental studies have proven a significant correlation between hypercoagulability and atherosclerosis. We used dielectric blood coagulometry, which was initially designed to evaluate the coagulable status, to examine the coagulability of peripheral arterial disease patients, and investigated the factors that were significantly correlated with the results. METHODS: We performed dielectric blood coagulometry in 49 peripheral arterial disease patients. In addition, we recorded the patients' demographic information, including the presence of comorbidities, hemodynamic status, and laboratory findings. To investigate coagulability, we calculated the Tmax value, which indicates the time from recalcification to maximum normalized permittivity. RESULTS: The Tmax values of diabetes mellitus patients were significantly lower than those of non-diabetic patients (1 MHz, P = 0.010; 10 MHz, 0.011). Furthermore, the Tmax value was statistically correlated with the activated partial thromboplastin time (1 MHz, ρ = 0.286, P = 0.048; 10 MHz, ρ = 0.301, P = 0.037). CONCLUSIONS: Dielectric blood coagulometry detected the hypercoagulable status in diabetes mellitus patients, and reflected their level of coagulability, which was also evaluated by the activated partial thromboplastin time.

The possibility of free tissue transfer as a nutrient flap for critical ischemic foot: A case report.

Microsurgical procedure of free tissue transfer in critical limb ischemia patients with large ulceration has already been established. The nutrient flap concept was that transferred tissue functioned not only to cover the skin defect but also as a supplementary blood supply to the ischemic lower leg. This report showed the justification for this concept, which was rarely discussed. A 58-year-old male patient with progressive forefoot gangrene caused by arteriosclerosis obliterans was presented. The distal bypass procedure was performed as revascularization surgery, and a latissimus dorsi (LD) myocutaneous flap was transplanted to cover ulceration. The arterial pedicle of the flap was anastomosed to the vein graft in an end-to-end manner, and the venous pedicle was anastomosed to the posterior tibialis vein in an end-to-end manner. Bypass graft blood flow went straight to the LD flap only. The postoperative course was uneventful. The free flap and right foot survived successfully and the patient was ambulatory with no recurrence of ulceration wearing order-made shoes more than three years after transplantation. Vessel-selective angiography was performed two months after surgery. An angiographic catheter was inserted into the bypass graft, which ran straight through the flap nutrient artery. The results obtained showed that not only the transferred flap area, but also the remaining original foot soft tissue (including the sole and heel) was clearly visualized radiologically only through the flap nutrient vessel. This findings of the angiography appear to provide direct evidence for the nutrient flap concept.

Simultaneous assessment of blood coagulation and hematocrit levels in dielectric blood coagulometry.

BACKGROUND: In a whole blood coagulation test, the concentration of any in vitro diagnostic agent in plasma is dependent on the hematocrit level but its impact on the test result is unknown. OBJECTIVE: The aim of this work was to clarify the effects of reagent concentration, particularly Ca2+, and to find a method for hematocrit estimation compatible with the coagulation test. METHODS: Whole blood coagulation tests by dielectric blood coagulometry (DBCM) and rotational thromboelastometry were performed with various concentrations of Ca2+ or on samples with different hematocrit levels. DBCM data from a previous clinical study of patients who underwent total knee arthroplasty were re-analyzed. RESULTS: Clear Ca2+ concentration and hematocrit level dependences of the characteristic times of blood coagulation were observed. Rouleau formation made hematocrit estimation difficult in DBCM, but use of permittivity at around 3 MHz made it possible. The re-analyzed clinical data showed a good correlation between permittivity at 3 MHz and hematocrit level (R2=0.83). CONCLUSIONS: Changes in the hematocrit level may affect whole blood coagulation tests. DBCM has the potential to overcome this effect with some automated correction using results from simultaneous evaluations of the hematocrit level and blood coagulability.

Novel assessment tool based on laser speckle contrast imaging to diagnose severe ischemia in the lower limb for patients with peripheral arterial disease.

OBJECTIVE: We propose a new assessment tool to diagnose severe ischemia of the lower limb in peripheral arterial disease, using laser speckle contrast imaging to evaluate heating-induced microcirculatory fluctuations in the proximal and distal sites of the dorsal foot. STUDY DESIGN: A cross-sectional study. METHODS: We recorded the slope describing the behavior of perfusion values (decrease or plateau) following the initial, heating-induced increase in perfusion in 63 feet of patients with clinical signs of peripheral arterial disease. RESULTS: The plateau and decrease groups were defined as having perfusion slopes of <0.20 and ≥0.20 PU/min, respectively. Transcutaneous oxygen tension was significantly lower (P < 0.001) in the plateau than in the decrease group (8 vs. 45 mmHg), indicating more severe ischemia. The laser speckle contrast imaging thermal load test discriminated transcutaneous oxygen tension <30 mmHg with good sensitivity (78.7%) and specificity (96.2%), and an area under the curve of 0.908. CONCLUSIONS: Both transcutaneous oxygen tension and the laser speckle contrast imaging thermal load test are useful in diagnosing severe ischemia in the foot. Lasers Surg. Med. 49:645-651, 2017. © 2017. The Authors. Lasers in Surgery and Medicine Published by Wiley Periodicals, Inc.

Endovascular Reintervention for Failing Infrainguinal Bypass Grafts.

OBJECTIVE: Patients with lower extremity bypass grafts that develop stenosis commonly undergo endovascular treatment (EVT) procedures. This study was performed to evaluate the outcomes of EVT procedures for infrainguinal grafts with bypass at risk (BAR). METHODS: We performed a retrospective review of 24 grafts in 22 patients from July 2010 to June 2016. The demographic information of the patients and the characteristics of lesions were examined, and the outcomes with regard to the patency and survival rates were calculated. RESULTS: Twenty-four grafts were evaluated; the initial technical success rate of EVT procedure was 91.7%. Sixteen of 24 bypass grafts (66.7%) required multiple EVT procedures due to graft restenosis. Inflow vessels from the superficial femoral artery were associated with significantly higher rates of single EVT procedures (P = 0.0206). At 2 years, the primary, assisted primary, and secondary patency rates were 30.3%, 69.5%, and 78.0%, respectively. CONCLUSIONS: The EVT procedure is one of the treatment options for the treatment of grafts with BAR and might be associated with an acceptable medium-term patency rate.

Late Stent Graft Infection after the Emergency Endovascular Repair of a Secondary Iliac Artery-Enteric Fistula Treated with Graft Removal and In Situ Aortic Reconstruction Using Femoral Veins.

An arterioenteric fistula is a devastating and life-threatening condition that requires urgent treatment. Less-invasive endovascular treatment has emerged as an alternative to conventional open repair, but postoperative graft infection remains a major concern. We herein report a case of late stent graft infection after emergency endovascular repair of a secondary iliac artery-enteric fistula. The patient was a 63-year-old male who presented with a fever, who had undergone successful endovascular stent grafting for a secondary common iliac artery-enteric fistula 29 months prior. The diagnosis of a stent graft infection was confirmed via computed tomography. He underwent graft removal and in situ reconstruction with femoral vein grafts. At 6-month follow-up, the patient is in a good general condition without any symptoms.

Open Surgical Repair for Inflammatory Abdominal Aortic and Iliac Artery Aneurysms.

BACKGROUND: This study was performed to investigate the outcomes of surgical treatment for inflammatory abdominal aortic aneurysms (IAAAs) and inflammatory iliac artery aneurysms (IIAAs). METHODS: We retrospectively reviewed the charts of patients who underwent open surgical repair (OSR) between January 2000 and June 2013. RESULTS: Nine male and 2 female patients (median age, 67 years) were treated. Five of the 11 patients who underwent OSR developed hydronephrosis, and ureteral stents were placed preoperatively. There were no intraoperative complications during OSR. After OSR, the conditions of 4 of 5 patients with preoperative hydronephrosis improved. During the follow-up period with a mean of 51 months (range, 6-120 months), 2 patients with OSR developed aneurysmal changes at the anastomosis site (84 and 21 postoperative months, respectively), and reintervention for both patients was needed. One patient died because of malignant disease at 96 months postoperatively. CONCLUSIONS: OSR can be safely performed for IAAAs and IIAAs. When an inflammatory aneurysm, especially an IIAA, is complicated by hydronephrosis, OSR might be an effective treatment procedure.

Endothelial Dysfunction of Patients with Peripheral Arterial Disease Measured by Peripheral Arterial Tonometry.

Objective. Endothelial dysfunction plays a key role in atherosclerotic disease. Several methods have been reported to be useful for evaluating the endothelial dysfunction, and we investigated the endothelial dysfunction in patients with peripheral arterial disease (PAD) using peripheral arterial tonometry (PAT) test in this study. Furthermore, we examined the factors significantly correlated with PAT test. Methods. We performed PAT tests in 67 patients with PAD. In addition, we recorded the patients' demographics, including comorbidities, and hemodynamical status, such as ankle brachial pressure index (ABI). Results. In a univariate analysis, the ABI value (r = 0.271, P = 0.029) and a history of cerebrovascular disease (r = 0.208, P = 0.143) were found to significantly correlate with PAT test, which calculated the reactive hyperemia index (RHI). In a multivariate analysis, only the ABI value significantly and independently correlated with RHI (ß = 0.254, P = 0.041). Conclusion. This study showed a significant correlation between RHI and ABI. The PAT test is a useful tool for evaluating not only endothelial dysfunction but also the hemodynamical state in patients with PAD.

The Relationship between Endothelial Dysfunction and Endothelial Cell Markers in Peripheral Arterial Disease.

INTRODUCTION: The endothelial function plays key roles in both promoting and protecting against atherosclerotic disease. Several methods, including peripheral arterial tonometry (PAT), have been reported to be useful for investigating endothelial dysfunction. Furthermore, the level of thrombomodulin (TM) is assumed to reflect the endothelial dysfunction. In the present study, we investigated endothelial dysfunction in patients with peripheral arterial disease (PAD) by measuring their TM levels, and evaluated the correlation between TM and various parameters. MATERIALS AND METHODS: We measured the TM levels and performed PAT in 17 patients with PAD. We also recorded the patients' demographic information, including comorbidities, and investigated their hemodynamic status by measuring the ankle brachial pressure index (ABI). The PAT results were used to calculate the reactive hyperemia index (RHI), which reflected the patients' level of endothelial dysfunction. RESULTS: The RHI and ABI values and the serum level of creatinine were found to be significantly correlated with the TM level (P = 0.040, 0.041 and 0.005, respectively). After setting an RHI value of 1.67 as the cut-off, the patients with RHI values of <1.67 were found to have significantly higher TM levels (median, 20.3 U/mL) than the patients with RHI values of ≥1.67 (median, 13.7 U/mL) (P = 0.023). CONCLUSIONS: The degree of endothelial dysfunction, as calculated by the TM level, might influence the prognostic value of the RHI, which is determined by PAT. The measurement of the TM level and PAT might both be useful methods of measuring endothelial dysfunction in patients with PAD.

A Case of Successful Coil Embolization for a Late-Onset Type Ia Endoleak after Endovascular Aneurysm Repair with the Chimney Technique.

Juxtarenal aortic aneurysms (JRAAs) are challenging to treat by endovascular aneurysm repair (EVAR) procedures. The chimney technique with EVAR (Ch-EVAR) is one of the feasible and less invasive treatments for JRAAs. However, the main concern of Ch-EVAR is the potential risk of "gutters," which can lead to type Ia endoleak (EL). Most type Ia ELs after Ch-EVAR procedures occurred intraoperatively, and these ELs could be treated using an endovascular technique. However, late-onset type Ia ELs could be extremely rare, which might have a fear of conservative treatment. Type Ia ELs are associated with an increased risk of aneurysm rupture; therefore reintervention is recommended as soon as possible, and we should be aware of the occurrence of type Ia ELs after the Ch-EVAR procedure.

Relationship of Inflammatory Biomarkers with Severity of Peripheral Arterial Disease.

Objective. The pentraxin family, including high-sensitivity C-reactive protein (hs-CRP), serum amyloid P (SAP), and pentraxin 3 (PTX3), has been identified as playing a key role in inflammatory reactions such as in atherosclerosis and cardiovascular disease. In this study, we examined the relationship between peripheral arterial disease (PAD) and serum levels of pentraxins. Methods. This study was undertaken via a retrospective review of PAD patients with surgical intervention for lesions of the common femoral artery. We evaluated the preoperative patient conditions, hemodynamic status, such as ankle brachial index (ABI), and clinical ischemic conditions according to Rutherford classification. Preoperatively, we collected blood samples for determining the serum levels of hs-CRP, SAP, and PTX3. Results. Twelve PAD patients with common femoral arterial lesions were treated and examined. The hemodynamic severity of PAD was not negatively correlated with hs-CRP, SAP, or PTX3. The clinical severity evaluated by Rutherford classification was significantly positively correlated with the serum level of PTX3 (p = 0.019). Conclusion. We demonstrated that PTX3 might be a better marker of PAD than hs-CRP and SAP. Furthermore, PTX3 might be a prognostic marker to evaluate the severity of PAD.

Radial artery aneurysm in the anatomical snuff box: A case report and literature review.

INTRODUCTION: Distal radial artery aneurysms of the hand are rare. We herein report a rare case of radial artery aneurysm in the anatomical snuff box. PRESENTATION OF CASE: A 61-year-old woman presented with a chief complaint of a mass on the back of her left hand. A radiological examination showed a distal radial artery aneurysm. The patient underwent successful surgical excision of the aneurysm with radial artery ligation. DISCUSSION: We discuss the etiologies and surgical management of radial artery aneurysms in the anatomical snuff box according to the published literature. CONCLUSION: An accurate diagnosis and a preoperative blood flow evaluation are necessary for appropriate surgical management of radial artery aneurysms.

Usefulness of the transfer function index for diagnosing peripheral arterial disease in patients with arterial calcification.

UNLABELLED: The aim of this study was to investigate which parameters among the ankle brachial index (ABI), toe brachial pressure index (TBI) and transfer function index (TFI) are useful to accurately diagnose PAD in patients with / without arterial calcification, who have undergone some type of diagnostic imaging. PATIENTS AND METHODS: A total of 102 patients with 192 limbs (mean age: 72.0 ± 8.4 years) underwent plain radiography, ABI, TBI and TFI. A receiver operating characteristics (ROC) analysis was performed to assess possible threshold values that predict PAD in these patients. RESULTS: T he a rea u nder t he c urve ( AUC) o f t he ABI, TBI and TFI were 83.0%, 87.9%, 93.1% in the all limbs group, respectively. In the non-calcified lesion group, the AUC of the ABI, TBI and TFI were 94.4%, 87.9%, 93.1%, respectively. In the calcified lesion group, the AUC of the ABI, TBI and TFI were 71.4%, 87.9% and 92.9%, respectively. CONCLUSIONS: A cut-off value of TFI ≦ 1.025 exhibits a higher AUC for detecting the presence of PAD than the ABI and TBI. Therefore, the TFI is considered to be useful to estimate the presence of PAD in all types of patients, especially those with arterial calcification.

The Outcomes of Endovascular Aneurysm Repair with the Chimney Technique for Juxtarenal Aortic Aneurysms.

PURPOSE: We collected our experience in the use of chimney technique with endovascular aneurysm repair (Ch-EVAR) for juxtarenal aortic aneurysms (JAAs), and reviewed the outcomes. METHODS: The patients who were treated with Ch-EVAR between January 2012 and December 2015 were retrospectively reviewed. All of the patients underwent endovascular aneurysm repair (EVAR) under general anesthesia. Femoral arterial access was obtained to place the main body of the endograft; brachial or axillary access was obtained to perform the placement of the chimney stent. RESULTS: We treated 12 patients with 15 renal arteries using the Ch-EVAR procedure. Technical success was achieved in 11 of the 12 (91.6%) cases. Within the first 30 days of postoperative period, the target vessel patency rate was 93.3% (14 of 15 renal arteries). After a median follow-up period of 28 months, one patient required Ch-EVAR-related re-intervention due to a type Ia endoleak, and 13 of the 15 renal arteries were patent at the end of the follow-up period. CONCLUSION: Our findings demonstrate that Ch-EVAR can be completed with a high rate of success. Although early target vessel occlusion or early postoperative mortality might occur, Ch-EVAR could be an alternative treatment for JAA, especially in high risk patients.