Comparison of Aortobifemoral Bypass and Endovascular Treatment for Chronic Infrarenal Abdominal Aortic Occlusion From the CHAOS (CHronic Abdominal Aortic Occlusion, ASian Multicenter) Registry.

PURPOSE: To directly compare the clinical outcomes of aortobifemoral bypass surgery (ABF) and endovascular treatment (EVT) for chronic total occlusion (CTO) of the infrarenal abdominal aorta (IAA). MATERIALS AND METHODS: In this retrospective, multicenter study, we used an international database of 436 patients who underwent revascularization for CTO of the IAA between 2007 and 2017 at 30 Asian cardiovascular centers. After excluding 52 patients who underwent axillobifemoral bypass surgery, 384 patients (139 ABFs and 245 EVTs) were included in the analysis. Propensity score-matched analysis was performed to compare clinical results in the periprocedural period and the long-term. RESULTS: Propensity score matching extracted 88 pairs. Procedure time (ABF; 288 [240-345] minutes vs EVT; 159 [100-205] minutes, p<0.001) and length of hospital stay (17 [12-23] days vs 5 [4-13] days, p<0.001) were significantly shorter in the EVT group than in the ABF group, while the proportions of procedural success (98.9% versus 96.6%, p=0.620), complications (9.1% versus 12.3%, p=0.550), and mortality (2.3% versus 3.8%, p=1.000) were not different between the groups. At 1 months, ABI significantly increased more in the ABF group for both in a limb with the lower (0.56 versus 0.50, p=0.018) and the higher (0.49 versus 0.34, p=0.001) baseline ABI, while the change of the Rutherford category was not significantly different between the groups (p=0.590). At 5 years, compared with the EVT group, the ABF group had significantly better primary patency (89.4±4.3% versus 74.8±4.3%, p=0.035) and survival rates (86.9±4.5% versus 66.2±7.5%, p=0.007). However, there was no significant difference between the groups for secondary patency (100.0%±0.0% versus 93.5%±3.9%, p=0.160) and freedom from target lesion revascularization (TLR) (89.3±4.3% vs 77.3±7.3%, p=0.096). CONCLUSION: Even with recent advancements in EVT, primary patency was still significantly better for ABF in CTO of the IAA. However, there was no difference between the groups in terms of secondary patency and freedom from TLR at 5 years. Furthermore, there was no difference in procedural success, complications, mortality, and improvement in the Rutherford classification during the periprocedural period, with significantly shorter procedure time and hospital stay in the EVT group.

Drug Eluting Versus Covered Stent for Femoropopliteal Artery Lesions: Results of the ULTIMATE Study.

OBJECTIVE: Stent grafts (SG) and drug eluting stents (DES) have emerged to combat intimal hyperplasia. It remains unclear which type of stent yields superior outcomes in femoropopliteal (FP) arterial lesions. This study compared the clinical data between the VIABAHN SG and the Eluvia DES two years after endovascular treatment. METHODS: In this retrospective multicentre study, 504 cases with a lesion length > 10 cm treated either with SG or DES were analysed. Ankle brachial index (ABI) measurements were conducted before and after the endovascular procedure, and every three months thereafter. When the ABI dropped ≥ 0.15 compared with the baseline value, a duplex ultrasound was conducted to check stent patency. The outcome measures were stent patency rates, freedom from target lesion revascularisation (TLR), stent thrombosis, and acute limb ischaemia (ALI) accompanying loss of patency rates. Propensity score matching (PSM) was performed to adjust for confounding baseline characteristics. RESULTS: PSM extracted 219 limbs in the SG group and 109 limbs in the DES group. Compared with the SG group, the DES group had statistically significantly higher rates of freedom from TLR (86.0 ± 4.2% vs. 73.1 ± 4.8%, p = .040), and ALI accompanying loss of patency (98.9 ± 1.1% vs. 93.5 ± 1.8%, p = .029) at two years. Primary patency (75.9 ± 5.9% vs. 69.5 ± 5.9%, p = .087) and freedom from stent thrombosis (90.4 ± 3.3% vs. 81.2% ± 3.0%, p = .11) were not statistically significantly different. For lesions ≤ 15 cm, primary patency in the DES group was statistically significantly better than the SG group. CONCLUSION: FP lesions treated with Eluvia DES had a higher primary patency rate in lesions ≤ 15 cm, freedom from clinically driven TLR and ALI accompanying loss of patency than the VIABAHN SG.

Cigarette Smoke Extract Activates Tartrate-Resistant Acid Phosphatase-Positive Macrophage.

BACKGROUND: It has been reported that smoking is one of the strongest positive risk factors for abdominal aortic aneurysms (AAAs). Although many studies have been directed to decipher the effect of smoking on AAA, its effect on macrophage activation has not yet been explored. OBJECTIVES: We have reported the importance of osteoclastogenesis (OCG) in aneurysm formation. Therefore, we examined the effect of cigarette smoking on OCG and arterial aneurysmal formation by using cigarette smoke extract (CSE) in this study. METHODS: Macrophage cell lines were stimulated with CSE, and their activation and differentiation were examined in vitro. Since macrophages activated through the OCG pathway are identified by tartrate-resistant acid phosphatase (TRAP) expression, these cells are referred to as TRAP-positive macrophages (TPMs) in this study. We also applied CSE-contained PBS in the calcium chloride-induced mouse carotid aneurysm model in vivo. RESULTS: Macrophages stimulated with CSE expressed significantly higher levels of nuclear factor of activated T-cells cytoplasmic 1 (NFATc1), TRAP, cathepsin K, matrix metalloproteinase-9 and membrane-type metalloproteinase (MT1-MMP). CSE-treated mouse aneurysms showed increased aneurysm size with increased TPM infiltration and protease expression compared to non-CSE-treated mouse aneurysms. CONCLUSIONS: These results suggest that CSE intensifies OCG in macrophages and promotes arterial aneurysmal progression.

Digoxin Attenuates Receptor Activation of NF-κB Ligand-Induced Osteoclastogenesis in Macrophages.

BACKGROUND: Even though hypoxia-inducible factor-1α (HIF-1α) is among the transcriptional factors demonstrated to contribute to the formation of abdominal aortic aneurysms (AAAs), the precise mechanism has been unclear. Digoxin is known as an inhibitor of HIF-1α, and shows a protective effect against the progression of AAAs. OBJECTIVES: We tested the effect of digoxin on osteoclastogenesis (OCG) and examined the pathway through which digoxin exerts inhibition of HIF-1α. MATERIALS AND METHODS: RAW 264.7 macrophage cells were cultured and stimulated by soluble receptor activator of NF-κB ligand (sRANKL) with or without digoxin. First, we tested the effect of digoxin to attenuate macrophage activation, which led to OCG, characterized by tartrate-resistant acid phosphatase (TRAP)-positive macrophages (TPMs). RESULTS: The activation of TPMs stimulated by sRANKL was attenuated by digoxin treatment. Furthermore, the receptor activator of NF-κB (RANK)/receptor activator of NF-κB ligand (RANKL) complex signaling pathway, which is stimulated by HIF-1α, was downregulated by digoxin treatment. CONCLUSIONS: These results show that digoxin attenuates OCG. By inhibition of HIF-1α, digoxin decreases OCG through the downregulation of the RANK/RANKL signaling pathway. Therefore, digoxin is a potential candidate for medical treatment of AAAs.

Osteoclast-Like Cells in Aneurysmal Disease Exhibit an Enhanced Proteolytic Phenotype.

Abdominal aortic aneurysm (AAA) is among the top 20 causes of death in the United States. Surgical repair is the gold standard for AAA treatment, therefore, there is a need for non-invasive therapeutic interventions. Aneurysms are more closely associated with the osteoclast-like catabolic degradation of the artery, rather than the osteoblast-like anabolic processes of arterial calcification. We have reported the presence of osteoclast-like cells (OLCs) in human and mouse aneurysmal tissues. The aim of this study was to examine OLCs from aneurysmal tissues as a source of degenerative proteases. Aneurysmal and control tissues from humans, and from the mouse CaPO4 and angiotensin II (AngII) disease models, were analyzed via flow cytometry and immunofluorescence for the expression of osteoclast markers. We found higher expression of the osteoclast markers tartrate-resistant acid phosphatase (TRAP), matrix metalloproteinase-9 (MMP-9), and cathepsin K, and the signaling molecule, hypoxia-inducible factor-1α (HIF-1α), in aneurysmal tissue compared to controls. Aneurysmal tissues also contained more OLCs than controls. Additionally, more OLCs from aneurysms express HIF-1α, and produce more MMP-9 and cathepsin K, than myeloid cells from the same tissue. These data indicate that OLCs are a significant source of proteases known to be involved in aortic degradation, in which the HIF-1α signaling pathway may play an important role. Our findings suggest that OLCs may be an attractive target for non-surgical suppression of aneurysm formation due to their expression of degradative proteases.

In Patients with Severe Peripheral Arterial Disease, Revascularization-Induced Improvement in Lower Extremity Ischemia Can Be Detected by Laser Speckle Contrast Imaging of the Fluctuation in Blood Perfusion after Local Heating.

BACKGROUND: We previously reported the utility of the perfusion value (PV) fluctuation slope for detecting severe ischemia in the lower limb. Our approach was based on a thermal load test mimicking the well-known physiological reaction termed "cold-induced vasodilation," which is known to occur as a 3-phase phenomenon. The slope parameter quantifies the decrease in PVs accompanying the relative cooling (third phase) following the transient increase in blood flow (second phase) induced by the applied thermal load. This phenomenon of "relative" cold-induced vasodilation (rCIVD) can be monitored using laser speckle contrast imaging (LSCI) after applying the thermal load (LTL test). Here, we aimed to determine whether the slope parameter obtained via the LTL test also reflects the improvement in hemodynamics after revascularization. METHODS: The study enrolled 16 patients (18 limbs), who underwent revascularization for peripheral arterial disease (PAD). The measurements were performed at 2 sites in each limb (in total, 34 sites; 2 sites in one patient were excluded because of significant movement during the measurement). For each site, we recorded the slope describing the behavior of PVs (decrease or plateau) in the third phase of rCIVD, following the initial, heating-induced increase in perfusion (second phase of rCIVD). The plateau group (group P), which included patients with an abnormal rCIVD, and the decrease group (group D), which included patients with a normal rCIVD, were defined based on perfusion slope values of <0.20 and ≥ 0.20 perfusion units/min, respectively. We also quantified the transient increase in perfusion (from baseline to peak) as a descriptor of perfusion behavior during the second phase of rCIVD. RESULTS: In group P, the change in median values (25-75%) of the slope, transcutaneous oxygen tension, and ankle-brachial index (ABI) from before to after operation was (-0.02 [-0.04 to 0.02]; 4 [1-11]; and 0.08 [0-0.27]) to (0.39 [0.32-0.59]; 46 [37-54]; and 0.81 [0.72-0.90]). Conversely, in group D, the change in the median values of the slope, transcutaneous oxygen tension, and ABI between before and after operation was (0.38 [0.32-0.49]; 40.5 [35-45]; and0.58 [0.57-0.65]) to (0.44 [0.30-0.64]; 52 [43-56]; and 0.92 [0.81-0.99]). Sites exhibiting perfusion pattern of group D in the third phase of rCIVD showed no significant change in slope after revascularization (P = 0.21), whereas the slope in group P increased significantly after revascularization, becoming similar to the postoperative slopes in group D (P = 0.81). The amount of transient increase in perfusion, which quantified the behavior in the second phase of rCIVD, showed a similar behavior. Preoperatively, all patients in group P had rest pain and/or ulcer of the foot, whereas only few patients in group D had such symptoms. CONCLUSIONS: Normal rCIVD response in the LTL test indicates less-than-severe ischemia, while abnormal rCIVD response measured via the LTL test indicates severe ischemic symptoms, such as critical limb ischemia. Notably, patients with an abnormal rCIVD response can develop a normal rCIVD response following revascularization, thereby reflecting an improvement in blood flow. The LTL test assessing rCIVD response can be useful for detecting severe limb ischemia, such as critical limb ischemia (CLI), and determining the departure from severe limb ischemia by revascularization.

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.

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.

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.

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.

Significance of the Lateral Thoracic Artery in Pectoralis Major Musculocutaneous Flap Reconstruction: Quantitative Assessment of Blood Circulation Using Indocyanine Green Angiography.

Free tissue transfer is the preferred reconstruction option in most major head and neck reconstructions. The pectoralis major muscle musculocutaneous (PMMC) flap is commonly used in salvage of necrotic free flaps and is the first choice for patients who are not candidates for free flaps. The lateral thoracic artery (LTA), which is thought to contribute to blood perfusion of the inferior and lateral mammary area, is not preserved in a conventionally harvested PMMC flap. With regard to blood supply, it has been suggested that the LTA should be preserved, in addition to the pectoral branch of the thoracoacromial artery, when a skin island is designed in the lower chest to attain a pedicle length sufficient for head and neck reconstruction. However, an effect on hemodynamic improvement using the LTA has not been shown quantitatively. In this study, we examined 8 patients with oral cancer who underwent reconstruction procedures with a bipedicle PMMC flap that included the LTA, in addition to the thoracoacromial artery. Intraoperative indocyanine green angiography was performed to examine circulation to the PMMC flap with or without LTA clamping after harvesting. After image processing, data were analyzed using a new quantitative perfusion assessment system with parameters that we recently established for assessment of peripheral arterial disease of the lower limbs. All patients had good clinical courses with whole-flap survival, no vascular insufficiency of the skin island, and no fistula formation. Intraoperative indocyanine green angiography showed an increased inflow rate into the skin island in an LTA-declamped condition in all cases, implying that the preserved LTA increased the blood supply to skin islands in the pectoralis major muscle. We conclude that preserving the LTA in a PMMC flap can increase blood perfusion and stabilize the vascularity of the flap, making the reconstruction more effective and reliable than with use of a conventionally harvested flap. Therefore, it is worthwhile to preserve the LTA as a major contributor to a lateral and distal PMMC flap.

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.

The Epidemiologic and Clinical Findings of Patients with Buerger Disease.

BACKGROUND: Buerger disease is a nonatherosclerotic peripheral arterial disease, which is mostly observed in young male smokers. Buerger disease is characterized by the observation of peripheral arterial occlusion by angiography. The condition may be caused by microembolization in the small-sized arteries of the distal extremities. Buerger disease is diagnosed based on the Shionoya's clinical diagnostic criteria, which include: (1) a history of smoking, (2) onset before the age of 50 years, (3) the presence of infrapopliteal arterial occlusions, (4) either upper limb involvement or phlebitis migrans, and (5) the absence of atherosclerotic risk factors other than smoking. Several studies have reported that oral bacterial infections (periodontitis) could activate the onset of Buerger disease. In this study, we report the epidemiologic and clinical manifestations of patients with Buerger disease. METHODS: Fifty-eight patients who were surgically treated between July 1989 and June 2014 at Tokyo Medical and Dental University Hospital were enrolled in this study. All of the patients clinically diagnosed with Buerger disease based on Shionoya's clinical diagnostic criteria. Fifty-five male and 3 female patients were treated. The mean age of the patients was 48 years (range, 21-73 years). RESULTS: All of the patients were either smokers or had a history of smoking. The mean Brinkman index score was 780 (range, 150-1,640). Their mean age at the onset of Buerger disease was 38 years (range, 21-50). The arterial lesions extended to the femoral arteries in 25% of cases, to the iliac arteries in 8% and to the abdominal aorta and/or visceral arteries in 6% of cases. Upper limb involvement, including cyanosis, paleness, and gangrene, was obvious in 84% of patients, and phlebitis migrans was recognized in 34%. The lower extremities symptoms involved intermittent claudication in 23% of the patients, rest pain in 13% of the patients, and ulceration or gangrene in 64% of the patients. Fifteen patients had undergone surgical arterial reconstruction, 4 patients had received endovascular therapy, 33 patients had undergone lumbar sympathectomy and 8 patients had undergone thoracic sympathectomy. Twenty percent of the patients needed minor limb amputations, and 4% required major limb amputations. In the patients who were examined for their oral conditions, periodontitis corresponding to grades B (moderate periodontitis), C (severe periodontitis), and D (edentulous patients) was revealed in 31%, 56%, and 13% of the patients, respectively. CONCLUSIONS: More than half of the Buerger disease patients in this study were suffering from severe periodontitis. It is possible that not only the cessation of smoking, but also the improvement of periodontal care could improve the clinical symptoms related to Buerger disease.

Progression of perianeurysmal inflammation after endovascular aneurysm repair for inflammatory abdominal aortic and bilateral common iliac artery aneurysms.

The use of endovascular aneurysm repair (EVAR) to treat inflammatory abdominal aortic aneurysms (IAAAs) has been reported, and this procedure appears to be preferable to open surgical repair because of intraoperative difficulties related to inflammation. We herein report a case of IAAA and bilateral inflammatory common iliac artery aneurysms that was successfully treated with bifurcated stent grafting. The perianeurysmal inflammation worsened postoperatively, requiring the placement of a ureteric stent. EVAR is feasible in cases of inflammatory aneurysms; however, the potential for an inflammatory response should be taken into account when considering the application of EVAR in patients with IAAA.

Bilateral Axillary Artery Aneurysms Presenting as Upper Limb Ischemia.

An axillary artery aneurysm (AxAA) is a rare entity. Although some cases with AxAA are asymptomatic, complications including local pain, neurogenic symptoms, upper limb ischemia, and rupture may occur. Therefore, an early diagnosis and treatment are necessary. We herein report a case of bilateral AxAAs, in which the right AxAA showed acute upper limb ischemia and the left AxAA were asymptomatic. Both AxAAs were successfully treated by aneurysmectomy and interposition grafting. In the endovascular era, open surgical treatment for AxAAs remains a promising procedure.

Controlled antegrade and retrograde subintimal tracking technique for endovascular treatment of the superficial femoral artery with chronic total occlusion.

Although providing endovascular treatment for chronic total occlusion (CTO) in patients with peripheral arterial disease is challenging, subintimal angioplasty (SIA) has proven to be an effective procedure. However, the SIA device may not cross CTO lesions because of the inability to achieve re-entry into the distal true lumen in some cases. We herein describe 2 cases of CTO of the superficial femoral artery (SFA) segment in which we failed to cross the site of CTO using the SIA technique and therefore employed the controlled antegrade and retrograde subintimal tracking (CART) technique to successfully treat the CTO lesions of SFA. When using the CART technique, there is no need to perform extension of the region of subintimal dissection beyond the occluded lesion, which may be useful for managing CTO lesions.

Comparison between endovascular repair and open surgery for isolated iliac artery aneurysms.

PURPOSE: This study was performed to compare endovascular repair with conventional open repair of isolated iliac artery aneurysms (IAAs). METHODS: We retrospectively reviewed the charts of all patients who underwent repair of isolated IAAs between January 2008 and June 2012. Patients with infected, mycotic and ruptured iliac aneurysms and those with concurrent infrarenal abdominal aortic aneurysms greater than 30 mm in diameter were excluded from this analysis. RESULTS: A total of 32 patients were treated with isolated IAAs. There were 20 open and 12 endovascular repairs. A comparison of the length of the operation (238 ± 84 min in the open group vs 176 ± 72 min in the endovascular group, P = 0.03) and intraoperative blood loss (1,735 ± 1,177 ml in the open group vs 503 ± 711 ml in the endovascular group, P = 0.01), revealed significant differences in favor of the endovascular procedure. Postoperative complications were less common in the endovascular group, although the difference did not reach statistical significance. CONCLUSIONS: The management of isolated IAAs with both endovascular and open repair can be accomplished with very low morbidity rates. Therefore, endovascular repair can be considered an alternative treatment for isolated IAAs.

Intraarterial injection of indocyanine green for evaluation of peripheral blood circulation in patients with peripheral arterial disease.

BACKGROUND: To assess the peripheral blood flow of patients with peripheral arterial disease (PAD) by indocyanine green (ICG) arteriography (ICGA) with intraarterial injection of ICG and evaluate the efficacy of the ICGA tests. METHODS: This study was undertaken from a retrospective review of patients with PAD who underwent ICGA tests during digital subtraction angiography (DSA) between November 2012 and June 2013. We defined some ICGA parameters as the magnitude of intensity of ICG, the time to maximum intensity, and the time from fluorescence onset to half the maximum intensity (T1/2). The ICGA parameters were evaluated in 2 regions, named regions of interest (ROIs). ROI 1 was part of the dorsum of the foot from the Chopart joint to the Lisfranc joint. ROI 2 was in the distal region of the first metatarsal bone and compared with the ankle-brachial pressure index (ABI), ankle pressure, toe-brachial pressure index, and toe pressure. RESULTS: A total of 22 limbs in 16 patients with PAD underwent ICGA tests during DSA. The T1/2 on ROI 2 was the most correlated with the ABI (ρ=-0.622, P=0.003). A value of T1/2 for ROI 2>10 sec was significantly correlated with an ABI value of <0.7 (sensitivity: 0.85, specificity: 1.0). CONCLUSIONS: By measuring the value of T1/2 in ROI 2, ICGA tests can be performed to assess the peripheral blood circulation during DSA. ICGA tests might help to promptly assess the peripheral blood flow during endovascular treatment procedures.

Indocyanine green angiography for the diagnosis of peripheral arterial disease with isolated infrapopliteal lesions.

BACKGROUND: In this study, we evaluated the accuracy of the indocyanine green angiography (ICGA) test to diagnose peripheral arterial disease (PAD) with isolated infrapopliteal lesions. METHODS: This study was undertaken from a retrospective review of PAD patients with isolated infrapopliteal lesions who underwent ICGA between November 2012 and July 2013. We calculated the ICGA parameters while comparing the findings with the ankle-brachial index (ABI) and toe-brachial index (TBI) in patients with infrapopliteal lesions. RESULTS: Twenty-three limbs with isolated infrapopliteal lesions in 14 PAD patients and 15 limbs without arterial lesions in 9 control patients were examined using ABI, TBI, and ICGA. The Td 90% (the time elapsed from the maximum intensity to 90% of the maximum intensity) correlated most significantly with the ABI value. A cutoff value of Td 90% >25 sec also significantly correlated with the presence of PAD (sensitivity, 82.6%). CONCLUSIONS: ICGA might therefore be useful for assessing the peripheral perfusion quantitatively, even in PAD patients with isolated infrapopliteal lesions. The use of Td 90% on ICGA may also be effective for accurately estimating the presence of PAD.

Treatment strategies for aortic and peripheral prosthetic graft infection.

PURPOSE: The aim of this study was to investigate the outcomes correlated with our treatment strategy for prosthetic graft infection. METHODS: Seventeen patients were treated for prosthetic graft infections between 1997 and 2009. Initially, total graft excision was applied in five cases, partial graft excision was applied in six cases and graft preservation with drainage and irrigation was applied in six cases. Among the graft-preserved cases, four patients were infected with methicillin-resistant Staphylococcus aureus (MRSA) and treated with gentian violet (GV). RESULTS: The overall survival rate was 88% at 30 days and 82% at 1 year in this series. Of the excised cases, nine patients survived; however, two patients died. Among the cases in which MRSA-infected grafts were preserved, three patients survived; however, one patient died under a septicemic state. Infected graft preservation was applied at a high rate of 36%, and the mortality rate remained at 16%, without any signs of graft reinfection. CONCLUSIONS: In the treatment of infected grafts, the patient's condition should be considered in order to select the appropriate treatment in each case. Graft preservation should be considered as an alternative treatment option, especially in high-risk patients, and GV can be effective for conservative treatment of prosthetic graft infections, including MRSA infections.