[SUBFASCIAL ENDOSCOPIC PERFORATOR VEIN SURGERY IN THE TREATMENT OF SEVERE VARICOSE VEINS].

Surgical treatment of severe varicose veins (CEAP classification : C4b-C6) should involve not only interruption of incompetent superficial veins to prevent venous regurgitation due to valve incompetence but also interruption of incompetent perforator veins. Subfascial endoscopic perforator vein surgery (SEPS) is performed via a small skin incision and involves interruption of perforator veins by the insertion of an endoscope into the subfascial space. SEPS produces good surgical outcomes: it is accurate in detecting and transecting perforator veins; has a low frequency of surgical wound complications; prevents lipodermatosclerosis and formation of pigmented skin lesions; and is minimally invasive compared with Linton's operation. Thus, SEPS is an excellent procedure for patients with incompetent perforator veins. SEPS has been covered by the Japanese national health insurance system since April 2014, and it is expected that SEPS will be further developed and become more widespread in use.

Analysis of reactive oxygen metabolites (ROMs) after cardiovascular surgery as a marker of oxidative stress.

The transient systemic low perfusion that occurs during cardiovascular surgery leads to oxidative stress and the production of free radicals. A systemic increase of various markers of oxidative stress has been shown to occur during cardiopulmonary bypass (CPB). However, these markers have not been adequately evaluated because they seem to be reactive and short-lived. Here, oxidative stress was measured using the free radical analytical system (FRAS 4) assessing the derivatives of reactive oxygen metabolites (d-ROMs) and biological antioxidant potential (BAP). Blood samples were taken from 21 patients undergoing elective cardiovascular surgery. CPB was used in 15 patients, and abdominal aortic aneurysm (AAA) surgery without CPB was performed in 6. Measurements of d-ROMs and BAP were taken before surgery, 1 day, 1 week, and 2 weeks after surgery, and oxidative stress was evaluated. The d-ROM level increased gradually after cardiovascular surgery up to 2 weeks. Over time, the d-ROM level after surgery involving CPB became higher than that after AAA surgery. This difference reached statistical significance at 1 week and lasted to 2 weeks. The prolongation of CPB was prone to elevate the d-ROM level whereas the duration of the aortic clamp in AAA surgery had no relation to the d-ROM level. The BAP was also elevated after surgery, and was positively correlated with the level of d-ROMs. In this study, patients who underwent cardiovascular surgery involving CPB had significant oxidative damage. The production of ROMs was shown to depend on the duration of CPB. Damage can be reduced if CPB is avoided. When CPB must be used, shortening the CPB time may be effective in reducing oxidative stress.

Regression of abdominal aortic aneurysms by simultaneous inhibition of nuclear factor kappaB and ets in a rabbit model.

Because current therapy to treat abdominal aortic aneurysm (AAA), and particularly to manage small AAA, is limited to elective surgical repair, we explored less invasive molecular therapy by simultaneous inhibition of the transcription factors nuclear factor (NF)kappaB and ets using a decoy strategy. Both NFkappaB and ets were shown to be markedly activated in human AAA. In addition, NFkappaB- and ets-positive cells were increased in the aneurysm wall, and a part of the expression of NFkappaB and ets was detected in migrating macrophages. Thus, we used chimeric decoy oligodeoxynucleotides (ODNs) containing consensus sequences of both NFkappaB and ets binding sites to treat AAA. Inhibitory effects of chimeric decoy ODNs on matrix metalloproteinase-1 and -9 expression were confirmed by ex vivo experiments using a human aorta organ culture. To examine the regressive effect in a rabbit already-formed AAA model, transfection by wrapping a delivery sheet containing chimeric decoy ODNs around the aneurysm was performed 1 week after incubation with elastase. Importantly, treatment with chimeric decoy ODNs significantly decreased the size of AAA. Interestingly, significant preservation of elastic fibers was observed with chimeric decoy ODN treatment, accompanied by a reduction of matrix metalloproteinase-2 and -9 and induction of macrophage apoptosis. Regression of AAA was also associated with an increase in elastin and collagen type I and III synthesis in the aneurysm wall. Minimally invasive molecular therapy targeted to the inhibition of NFkappaB and ets is expected to be useful for AAA through the rebalance of matrix synthesis and degradation.

Surgical management of extensive dissecting thoracic aortic aneurysm via the semi-clamshell approach.

BACKGROUND: We retrospectively evaluated the initial clinical experience of the surgical management of extensive dissecting thoracic aortic aneurysm (TAA) via the semi-clamshell approach. METHODS: Thirteen patients (3 women and 10 men, mean age 67 ± 15 years) who underwent elective surgical intervention for extensive dissecting TAA via semi-clamshell approach in our institute between May 2007 and April 2017 participated in this study. Regarding surgical techniques, left thoracotomy with transverse sternotomy was initially performed via the third or fourth intercostal space following an incision from the right sternal borderline to the anterior axillary line on the left sternal borderline. Cardiopulmonary bypass was then established and extensive graft replacement was conducted with hypothermia. RESULTS: Extensive total arch replacement (TAR) was performed on 4 patients, TAR with descending thoracic aortic replacement (DTAR) on 4, distal hemiarch replacement with DTAR on 3, and extensive graft replacement from the ascending to descending thoracic aorta on 2. There was one (7.7%) case of surgical and hospital mortality due to low-output syndrome. None of our patients developed respiratory failure requiring secondary tracheotomy; however, new-onset cerebrovascular infarction was noted in 2 (15.4%). No mediastinitis or serious infectious complications were observed after surgery. With a mean follow-up period of 45.1 ± 44.1 months, a Kaplan-Meier analysis revealed that 1- and 5-year survival rates were both 92.3%, respectively. CONCLUSIONS: The surgical management of extensive dissecting TAA by semi-clamshell approach may contribute to acceptable early clinical outcomes in high-risk patients, and represents an alternative surgical option in the current endovascular era.

Toe-Brachial Index in the Second Toe: Substitutability to Toe-Brachial Index in the Great Toe and Ankle-Brachial Index.

Objective: Toe-brachial index (TBI) is usually measured in the great toe (TBI-1). However, this is not always possible. To determine the usefulness of TBI measurement in the second toe (TBI-2), we examined the relation between systolic pressure in the second toe (toe pressure [TP-2]) and that in the great toe (TP-1) and evaluated the association between TBI and ankle-brachial index (ABI). Materials and Methods: We retrospectively analyzed patients who underwent a series of measurements of TBI-2, TBI-1, and ABI using an automatic oscillometric device at Kawasaki Medical School Hospital, Japan in 2012. Results: We evaluated 114 feet without severe ischemia symptoms in 57 patients (median age: 73 years). TP-2 was similar to TP-1 (correlation coefficient [r] = 0.769, 95% confidence interval [CI]: 0.681-0.836, p <0.001). ABI showed a mild correlation with TBI-2 (r = 0.463, 95% CI: 0.303-0.598, p <0.001) and a moderate correlation with TBI-1 (r = 0.586, 95% CI: 0.450-0.696, p <0.001). The TBIs of 0.65 and 0.5 corresponded to the ABIs of about 1.0 and 0.9, respectively, in both toes. Conclusion: TBI-2 measurement can be considered as an acceptable substitute to TBI-1 or ABI measurement to assess the patients in whom ABI and TBI-1 cannot be measured.

Long-Term Results of Obturator Bypass.

OBJECTIVE: We evaluated the long-term outcomes of obturator bypass. MATERIAL AND METHODS: A total of 16 patients (13 males and 3 females; 17 limbs) who underwent obturator bypass surgery at our department between April 1995 and March 2008 were included. RESULTS: Their ages ranged from 50 to 90 with a mean of 74 years. Inguinal infections observed in the 16 patients consisted of vascular graft infections in 13 patients, hemostatic device infections following endovascular therapy in two patients, and femoral artery infections following coronary angiography in one patient. The cumulative patency rate was 69% for 3 years and 43% for 5 years. The cumulative survival rate was 64% for 3 years and 55% for 5 years. CONCLUSION: Obturator bypass surgery was successfully performed with favorable results for arterial infections and vascular graft infections in the inguinal region.

Positioning for Endovenous Laser Ablation: Comparative Study with Thigh Stripping.

We performed a comparative study of surgical outcomes and venous functions between endovenous laser ablation with a 980-nm diode laser (EV group) and thigh stripping (ST group). There were no severe complications and initial success rates were 100% in both groups. In the EV group, preoperative symptoms improved in 94.3% of cases, the venous occlusion rate was 98%, and endovenous heat induced thrombosis had occurred in 11.9% (Class 3: 0.7%) at 12 months after the operation. Although comparative study of postoperative venous function by air plethysmography showed significant improvement in both groups, there was less recovery of postoperative venous function in the EV than in the ST group. (This article is a translation of J Jpn Coll Angiol 2015; 55: 13-20.).

Ankle-Brachial Index, Toe-Brachial Index, and Pulse Volume Recording in Healthy Young Adults.

OBJECTIVE: To clarify the characteristics of ankle-brachial index (ABI), toe-brachial index (TBI), and pulse volume recording (PVR) of the ankle with brachial-ankle pulse wave velocity (baPWV) in healthy young adults. MATERIAL AND METHODS: We analyzed ABI, TBI, baPWV, and PVR in the ankle of healthy adults aged 20 to 25 years (median, 20 years) using an automatic oscillometric device between 2002 and 2013. The ABI, baPWV, and PVR in 1282 legs of 641 subjects (301 men and 340 women) and the TBI in 474 toes of 237 subjects (117 men and 120 women) were evaluated. RESULTS: The measured values showed no bilateral differences. ABI and baPWV were higher in men than in women, but TBI was similar in both sexes. ABI <1.0 was observed in 18.1% of the legs in men and in 25.6% in women. TBI <0.7 was observed in 16.2% of the toes in men and 19.1% in women. For ankle PVR, the % mean arterial pressure was higher in women than in men. The upstroke time was <180 ms in most subjects. CONCLUSIONS: For young people, ABI <1.0 or TBI <0.7 may not always indicate vascular abnormalities. When evaluating circulatory indexes, age and sex should be considered.

Bypass vs. Endovascular Therapy of Infrapopliteal Lesions for Critical Limb Ischemia.

OBJECTIVE: This study was conducted to determine whether to perform endovascular intervention or bypass surgery as a treatment option for critical limb ischemia (CLI) with lesions in the popliteal artery or below. SUBJECTS AND METHODS: A total of 150 patients (164 limbs) with CLI underwent endovascular intervention or bypass surgery for lesions in the popliteal artery or below at our department between May 1995 and June 2011. Therapeutic outcomes were examined by surgical technique. An indication for endovascular intervention was established with the combination of (1) poor general condition, and (2) a stenotic or occlusive lesion ≤5 cm. RESULTS: The bypass group (group B) comprised 119 patients (99 males, 20 females) with 131 affected limbs at 46 to 89 years of age (mean: 70 years). The endovascular intervention group (group E) comprised 31 patients (25 males, 6 females) with 33 affected limbs at 47 to 89 years of age (mean: 72 years). There was no significant difference in patient demography between the two groups. Regarding preoperative complications, hypertension was observed in 54% and 61% of the subjects in groups B and E, respectively, diabetes in 36% and 55%, renal dysfunction in 29% and 58%, ischemic heart disease in 27% and 32%, and cerebrovascular disorder in 18% and 23%; renal dysfunction accounted for a significantly higher percentage in group E. As for early postoperative complications, subjects in group B experienced wound infections (6 patients), hemorrhage (2), thrombosis (2), pneumonia (1), and another complication (1), and those in group E experienced wound infections (1) and another complication (1). The hospital mortality rate was 0.8% (1 patient) for group B and 0% for group E. The 3-year cumulative primary patency rate was 72% for group B and 54% for group E; the rate was significantly higher for group B. The 3-year secondary patency rate was 82% for group B and 60% for group E. The 3-year limb salvage rate was 86% for group B and 82% for group E; there was no significant difference between the two groups. The 5-year survival rate was 57% for group B and 42% for group E; the survival rate was significantly lower for group E. CONCLUSION: For the study population of CLI patients with lesions in the popliteal artery or below, the patency rate was higher for the bypass group than for the endovascular intervention group, whereas there was no difference in the limb salvage rate. Based on the findings in prognosis for survival, the indication for endovascular intervention at our department is believed to be appropriate. (English translation of Jpn J Vasc Surg 2013; 22: 715-718).

Collective therapy and therapeutic strategy for critical limb ischemia.

OBJECTIVE: To determine a treatment strategy based on the outcomes of various previous interventions for critical limb ischemia in arteriosclerosis obliterans (ASO). MATERIAL AND METHODS: We examined outcomes of 292 ASO patients who had had critical limb ischemia between May 1995 and July 2009. Patients underwent the following procedures in 167 cases: aortofemoral bypass (n = 14), femorofemoral crossover bypass (n = 29), femoropopliteal bypass (n = 104) and femorotibial bypass (n = 40). Other procedures included bypass only (n = 147), bypass combined with thromboendarterectomy (n = 10), bypass combined with endovascular therapy (n = 6), bypass combined with lumbar sympathectomy (n = 2), endovascular therapy combined with thromboendarterectomy (n = 4), endovascular therapy (n = 19), lumbar sympathectomy (n = 6), conservative therapy (n = 65), and major amputation (n = 31). We also calculated P3 risk scores and measured transcutaneous oxygen pressure (tcPO2) and skin perfusion pressure (SPP) before and after therapy. RESULTS: The limb salvage rate was 87% at 2 years in the arterial reconstruction group. In the low-risk group (a P 3 risk score of 3), the 1-year amputation-free survival rate was 96%. In the medium-risk group (a P 3 risk score of 4-7), the 1-year amputation-free survival rate was 88%. In the high-risk group (a P 3 risk score of 8), the 1-year amputation-free survival rate was 66%. The hospital death rate in the arterial reconstruction group was 3.2%, all of whom were patients who underwent bypass. The survival rate at 5 years was 65% and 36% in the conservative therapy only group. Ulcers healed in 140 out of 144 patients. The 4 patients with unhealed infections had tcPO2 or SPP values of more than 30 mmHg after treatment. Major amputations were performed in 4 of 5 patients who had tcPO2 or SPP values from 20 to 30 mmHg after treatment. Major amputations were performed in all 6 patients who had tcPO2 or SPP values of less than 20 mmHg after treatment. CONCLUSION: In cases with tcPO2 or SPP values of more than 30 mmHg, an ulcer will probably heal, except in infected cases. We suggest that, if these values are less than 30 mmHg, complete revascularization should be performed. The P3 risk score was useful in predicting limb salvage in the current series. Hybrid therapy in bypass and endovascular therapy must be performed in cases where patients are in a generally poor condition. It is important to attempt amelioration in limb salvage and to control the operative mortality rate with sufficient perioperative control. (English Translation of Jpn J Vasc Surg 2011;20:905-911).

Assessment of the characteristics and detectability of skin perfusion pressure measured using a thermostatic heating probe.

OBJECTIVES: To assess the characteristics of skin perfusion pressure (SPP) measured using a thermostatic heating probe and whether a thermostatic heating probe improves SPP detection. METHODS: We studied 8 feet of healthy young subjects and 31 feet of elderly patients suspected to have severe limb ischemia. We measured SPP at the dorsum and plantar aspects of each foot using a plain laser Doppler probe and a thermostatic heating probe heated at 44°C. Results were expressed as median. Comparisons were analyzed using a non-parametric test. RESULTS: In the healthy subjects, the SPP values at both the dorsum and the plantar aspect were not significantly different after heating. The thermostatic heating probe did not improve the SPP detection rates. In the patients with ischemic limb, the SPP values at both the dorsum and the plantar aspect significantly increased after heating (p <0.001 for both). The SPP detection rate at the dorsum remained at 96.8%; however, it was improved from 87.1% to 100% at the plantar aspect after heating. CONCLUSION: The thermostatic heating probe was shown to be useful for improving the detectability of SPP in the ischemic limbs. An SPP increase after heating may be considered as a parameter of limb ischemia.

Early outcomes of chordal reconstruction for posterior mitral leaflet prolapse.

We retrospectively reviewed 16 patients (7 men and 9 women, aged 36 to 77 years) who underwent mitral valve repair with chordal reconstruction for isolated posterior mitral leaflet prolapse. Preoperative echocardiography demonstrated moderate mitral regurgitation in 1, and severe regurgitation in 15. We routinely used expanded polytetrafluoroethylene sutures as artificial chords, and ring annuloplasty was performed in all cases (mean ring size, 30 ± 2 mm). After implanting the ring, the length of the artificial chords was adjusted repeatedly using saline solution. Early postoperative echocardiography at 7.1 ± 1.1 days after surgery showed mitral regurgitation grades reduced to none or trivial in 15/16 patients. One required reoperation for recurrent mitral regurgitation 1.5 years after surgery. In the other patients, intermediate-term echocardiography at 9.1 ± 10.1 months after surgery demonstrated that residual mitral regurgitation was less than mild. We concluded that chordal reconstruction is an effective and highly reproducible procedure for the repair of isolated posterior mitral leaflet prolapse. Artificial chords for the posterior mitral leaflet should not be too long, to avoid systolic anterior motion or recurrent mitral regurgitation after surgery.

Total aortic arch replacement for a patient with poor left ventricular function and patent coronary artery bypass grafts: how to establish effective myocardial protection.

A 66-year-old man who had previously undergone coronary artery bypass grafting (CABG) was admitted to our institution for surgical treatment of a ruptured aortic arch aneurysm. He had three patent bypassed grafts including the left internal thoracic artery (LITA) to the left anterior descending artery (LAD), complicated by left ventricular dysfunction. Coronary angiography performed 1 year after the initial surgery revealed total occlusion of the LAD. In addition, the aneurysm was located next to the LITA; therefore, there was a significant risk of injury to the LITA during intraoperative dissection. For such a complicated and challenging case, we successfully performed a total aortic arch replacement using a Y-shaped composite saphenous vein graft (SVG) for the administration of cardioplegic solution to establish effective myocardial protection. This procedure, by which effective myocardial protection can be achieved, is a useful treatment option for aortic arch surgery after CABG with a patent LITA graft.

Two-stage Surgery for Double Infected Aneurysms in the Infrarenal Abdominal and Descending Thoracic Aorta.

A 61-year-old man complaining of lumbago and high-grade fever was admitted to our institution. Computed tomography (CT) revealed a saccular aneurysm in the infrarenal abdominal aorta and blood culture results were positive for Streptococcus pneumoniae. He was diagnosed with infected abdominal aortic aneurysm, and antibiotic therapy was initiated. Follow-up CT demonstrated a rapidly-enlarging abdominal aortic aneurysm and a newly-developed descending thoracic aortic aneurysm. For this case, two-stage surgery consisting of extra-anatomical bypass and in-situ reconstruction using rifampicin-soaked Dacron graft was performed after an interval of 37 days. The patient was discharged 14 days after the second surgery without any complications.

Mucosa-associated lymphoid tissue lymphoma in the thymus of a patient with systemic lupus erythematosus.

Mucosa-associated lymphoid tissue (MALT) lymphoma arising from the thymus is extremely rare. We present a case of a 23-year-old woman with systemic lupus erythematosus (SLE) who was diagnosed with thymic MALT lymphoma. In 2004, she was diagnosed with a mediastinal tumor on chest radiography during medical follow up for SLE. An anterior mediastinal tumor with multilobular cysts was identified by computerized tomography and magnetic resonance imaging. A thymic malignancy was suspected and an extended thymectomy was performed. After histological and immunohistochemical examinations, the thymic tumor was diagnosed as a MALT lymphoma. There was no recurrence in the 2-year follow-up during which time there was no further treatment.