Raison d'etre of Tibial Artery Bypass for Intermittent Claudication in the Era of Endovascular Therapy.

BACKGROUND: There is currently no positive opinion regarding infrapopliteal revascularization for intermittent claudication (IC) in any guidelines. The aim of this study was to analyze the outcomes of infragenicular bypass and verify the adequacy of tibial artery bypass for IC. METHODS AND RESULTS: Over a 21-year period, 58 below-knee popliteal artery (BKPOP) bypasses and 35 tibial artery bypasses were performed for IC caused by arteriosclerosis obliterans. Graft patency and major amputation (MA) were examined as primary endpoints and the predictor of each outcome was estimated by multivariate analysis. The primary patency (PP), secondary patency (SP), and freedom from MA (ffMA) rates of a prosthetic/vein graft in all cases at 5 years were 19/68%, 22/86%, and 78/100% (P<0.01 in all). Limited to vein graft cases, PP and SP rates of popliteal/tibial bypass at 5 years were 73/62% (P=0.32) and 92/80% (P=0.22), respectively. In tibial artery bypass with a vein graft, the PP and SP rates of a single saphenous vein/spliced vein graft at 5 years were 71/46% (P=0.11) and 89/61% (P=0.03). A prosthetic graft was a common negative predictor for graft patency and MA by multivariate analysis. CONCLUSIONS: Tibial artery bypass is an acceptable treatment option for IC when a single saphenous vein can be harvested as a graft conduit. (Circ J 2016; 80: 1460-1469).

Ultrasound-guided percutaneous thrombin injection for post-catheterization pseudoaneurysm.

BACKGROUND: The efficacy and safety of ultrasound-guided thrombin injection (UGTI) for the treatment of post-catheterization femoral and brachial artery pseudoaneurysms (PSA) is unclear in Japan. METHODS AND RESULTS: A retrospective study of 32 consecutive patients undergoing percutaneous UGTI of post-catheterization PSA between February 2011 and February 2014 was performed. There were 23 femoral PSA and 9 brachial PSA treated with UGTI. The prevalence of CAD and smoking history were higher in the brachial PSA patients, but there were no statistically significant differences in other patient demographic factors or in the preprocedural antiplatelet therapy between the femoral and brachial PSA patients. The median dose of thrombin injected was 200 U (range, 100-600 U). The initial success rate, early recurrence rate and surgical conversion rate were 91%, 0% and 4% in the femoral PSA, and 89%, 11% and 11% in the brachial PSA, respectively. There were 2 cases of medial nerve compression in the brachial PSA group, but there were no complications in the femoral PSA group (P=0.0198). On outpatient clinical follow-up in the successfully treated patients, there were no recurrences after an average follow-up of 16 months. CONCLUSIONS: UGTI is a feasible, safe and effective less-invasive treatment for post-catheterization PSA. Brachial PSA, however, might require additional attention because of their tendency toward higher recurrence and complications.

Thoracic endovascular aortic repair and coil embolization of the pulmonary artery for primary racemose hemangioma of the bronchial artery with a bronchial-pulmonary artery fistula.

A 69-year-old male visited a doctor with dyspnea. A bronchial-pulmonary artery fistula, which is called racemose hemangioma, and dilated pulmonary artery were detected by a computed tomography (CT) scan. The bronchial-pulmonary artery fistula can cause lethal hemoptysis, therefore, we performed thoracic endovascular aortic repair (TEVAR) to seal the bronchial artery and coil embolization of the pulmonary artery. Postoperative CT showed the thrombosed racemose hemangioma of the bronchial artery. TEVAR and coil embolization of the pulmonary artery is considered to be a useful treatment option for a racemose hemangioma.

Midterm outcomes of endovascular repair for abdominal aortic aneurysms with the on-label use compared with the off-label use of an endoprosthesis.

PURPOSE: Endovascular repair of an abdominal aortic aneurysm (EVAR) is sometimes not performed in accordance with the instructions for use (IFU) of the endoprosthesis ("off-label use"). We investigated whether the off-label use of the endograft affected the outcomes of EVAR. METHODS: Demographic, anatomical, intraoperative and follow-up data on 100 patients in whom the endograft was used on-label in EVAR were compared retrospectively with the corresponding data of 50 patients with off-label endograft use. RESULTS: The endograft IFU were most often not followed in patients with challenging aortic neck anatomy or iliac access or fixation, steep neck angulation or bilateral hypogastric artery embolization. Compared with patients in whom the device was used on-label, patients with off-label use had significantly higher rates of intraoperative type I or III endoleaks and proximal aortic cuff placement or other adjunctive procedures. However, there were no midterm differences between the two groups in the rates of type 1b or II endoleaks, sac enlargement, device-limb occlusion or patient survival. CONCLUSIONS: Most midterm outcomes of EVAR in which the endografts were used off-label were similar to those associated with on-label use of the devices. Off-label use of EVAR endoprostheses is feasible, but requires the use of special techniques in patients with challenging anatomical features.

Long-Term Results of a Hybrid Revascularization Procedure for Peripheral Arterial Disease.

OBJECTIVE: To evaluate the efficacy of hybrid procedure for peripheral arterial disease (PAD), we compared the cases treated using the hybrid procedure with those treated using open revascularization (bypass alone) in our facilities. MATERIALS AND METHODS: We retrospectively reviewed 204 patients who underwent revascularization for PAD between 2007 and 2013. We divided the patients into two groups based on the type of procedure. Group 1 included patients who underwent the hybrid procedure, that is, doing endovascular therapy (EVT) either femoral or iliac resion and added the bypass procedure (infragenicular vein bypass) to the below knee artery, and group 2 included patients who underwent only bypass procedure (used autovein), that is, central anastomotic region was femoral artery region and peripheral anastomotic region was below knee artery. We evaluated various factors between the two groups, including the primary patency rate, secondary patency rate, amputation-free survival rate, and determined the efficacy of the hybrid procedure for PAD. RESULTS: In the patient's characteristics, there was significant difference between the two groups in the cases with cerebrovascular disease, only (p = 0.03). There were no significant differences in the primary or secondary patency rates, and the amputation-free survival rate. CONCLUSIONS: Primary patency rate, secondary patency rate, and amputation-free survival rate of the hybrid procedure were comparable to those of bypass (alone) procedure. The hybrid procedure is therefore an acceptable strategy for patients with PAD.

Successful treatment of an abdominal aortic aneurysm with a severely angulated and large aortic neck using a modified Zenith.

This report presents the case of an abdominal aortic aneurysm (AAA), in which the aortic neck was severely angulated. Furthermore, there was moderate stenosis and a severe angle with calcification of the suprarenal aorta. EVAR was performed with a commercial Zenith stent-graft, with a slight modification, because an open aneurysm repair was risky in general condition. No complications occurred during the follow-up period.

Delayed closure technique for a ruptured abdominal aortic aneurysm: report of three cases.

This report describes three cases of a delayed closure to prevent the occurrence of abdominal compartment syndrome (ACS) in patients presenting with ruptured abdominal aortic aneurysms (rAAA). The delayed closure technique is useful for rAAA in order to prevent ACS.

Primary aortoduodenal fistula with a history of distal gastrectomy.

Case: A 69-year-old man was transferred to our hospital because of an aortoduodenal fistula with hematemesis and pre-shock vital signs. He had a history of alcoholism, malnutrition, and distal gastrectomy and Billroth I reconstruction. Endovascular aneurysm repair was successfully carried out; however, the presence of comorbidities affected further radical treatment. Outcome: The patient survived for 2 months postoperatively. Conclusion: Endovascular aneurysm repair is a useful first-line treatment for high-risk aortoduodenal fistula patients; however, it requires improvement for long-term outcomes in complicated high-risk cases.

[Occlusion of endovascular stent-graft for abdominal aortic aneurysm three years after surgery].

A 79-year old man was admitted to our department with complaints of bilateral foot coldness, numbness and intermittent claudication. He underwent endovascular repair for abdominal aortic aneurysm three years before. An abdominal X-ray showed highly kinked endovascular stent-graft which indicated graft migration, and aortography showed occlusion of stent-graft and infrarenal aorta. An axillo-bifemoral bypass was performed and blood flow to the lower extremities was restored. Endovascular repair for AAA has been established worldwide as a less invasive treatment. Endovascular repair can be performed with low mortality and morbidity in the short period, however, in the long-term follow-up series, several late complications, such as late endoleaks, graft occlusion, AAA expansion, and even AAA rupture were encountered. Indication for endovascular repair for AAA still remains controversial because of these late complications, therefore, great attention must be paid for patient selection for endovascular repair.

Thoracic stent graft with distal fenestration for the superior mesenteric artery for treatment of thoracic aortic aneurysm.

An 86-year-old man with a 75-mm TAA that terminated just above the celiac artery was treated with a customized Zenith stent graft that had a distal fenestration for the superior mesenteric artery (SMA). Because angiography demonstrated a type IB endoleak, an additional extension stent graft was deployed, and coil embolization of the aneurysmal sac was performed. Three months later, there was no endoleak and good visceral blood flow. Placement of a fenestrated thoracic stent graft with a scallop-like fenestration for the SMA is a promising procedure for the treatment of TAAs with a short distal neck.

Clinical Results of Endovascular Abdominal Aortic Aneurysm Repair in Patients with Renal Insufficiency without Hemodialysis.

OBJECTIVE: Chronic renal insufficiency may be a relative contraindication to endovascular aneurysm repair (EVAR) for the use of contrast enhanced mediums. It is thought that more contrast enhanced media are needed in patients who are not anatomically suitable for EVAR, because of procedural difficulties. We reviewed a 2 year EVAR experience at our institution to determine whether the procedure and use of contrast enhanced mediums has any deleterious effect on renal function in patients with pre-existing chronic renal insufficiency. MATERIALS AND METHODS: EVAR was performed in 46 patients with pre-existing chronic renal insufficiency without hemodialysis. Patients were retrospectively assigned to two groups on the basis of their preoperative creatinine clearance levels. Furthermore, patients were assigned to two other groups on the basis of anatomical suitability for EVAR. The absolute change in the serum creatinine (Cr) level was reviewed in the each renal insufficiency group between the preoperative and post-operative time periods. RESULTS: No increase in the serum Cr level was noted, and no patient required temporary or permanent hemodialysis, in any of the groups. CONCLUSIONS: EVAR with contrast agents can be accomplished in patients with chronic renal insufficiency without hemodialysis; therefore,elevated Cr levels maynot be a contraindication in EVAR.

Long-term Results of Reconstructive Surgery for the Unilateral Aortoiliac Occlusive Disease and Future Risks of Contralateral Iliac Events.

OBJECTIVE: Our experience with unilateral iliac reconstructive surgery was retrospectively reviewed, and the long-term patency and the morphological information was disclosed. In addition, the prognosis of contralateral iliac artery was examined, because future contralateral iliac events seem to be important for durability of unilateral iliac revascularizations. MATERIALS AND METHODS: 148 patients (mean age, 66.9 years; 88% male) who had undergone unilateral aortoiliac reconstruction without contralateral iliac lesions were evaluated. The unilateral aortoiliac reconstructive procedures included 112 (76%) aorto or iliofemoral bypasses, 27 (18%) femorofemoral bypasses, and 9 (6%) axillofemoral bypasses. The indications for arterial reconstruction were disabling claudication and limb salvage in 125 (84%) and 23 (16%) patients, respectively. Preoperative arteriograms were reviewed to determine the Inter-Society Consensus (TASC II) classification categorizing iliac artery lesions. Contralateral iliac events were defined as any arterial reconstructive procedure, intervention, amputation for progression of contralateral iliac disease, or repair of abdominal aortic aneurysm (AAA). The Kaplan-Meier survival analysis was used to predict long-term results in patients grouped based on various factors which were compared using univariate and multivariate analyses. RESULTS: In the 148 patients, unilateral iliac reconstructive procedures were undertaken in 83 (56%) patients with TASC II type D lesions, 34 (23%) patients with TASC II type C lesions, and 31 (21%) patients with TASC II type B lesions. Overall primary and secondary patency rates were 93.8% and 96.5% at 3 years and 90.0% and 93.9% at 5 years. A multivariate analysis disclosed critical limb ischemia influencing primary patency rates, and type of aortoiliac reconstruction or gender influencing secondary patency rates. TASC II classification did not affect primary or secondary patency rates. During the follow-up period, 15 contralateral iliac events occurred, including 11 aortoiliac reconstructive or interventional procedures, 3 repairs of AAA, and one case of bilateral thigh amputation due to acute aortic occlusion. The overall probability of contralateral iliac events was 2.2% at 3 years and 5.9% at 5 years. CONCLUSION: The long-term patency following unilateral iliac reconstructive surgery was satisfactory, and not affected by morphology of the iliac artery. Also, the future risk of contralateral iliac events appeared to be low.

A New Extra-anatomical Bypass for Atypical Aortic Coarctation with Porcelain Aorta: Reno-iliac Arterial Bypass.

We report a case of atypical aortic coarctation with severe calcification of the proximal aorta treated by a new extra-anatomical bypass. This 58-year-old woman with coarctation of the infrarenal aorta had thick circular calcifications of the thoracic aorta and stenosis of the subclavian arteries. To control the progressive claudication, we performed a bypass with an externally supported PTFE graft 6mm in diameter between the right renal artery and the right common iliac artery. Postoperative ankle pressure rose to 84 mmHg (right) and 89 mmHg (left) from zero, and she could walk without pain. Renal function was preserved. Using the proximal anastomosis from the non-diseased aortic branch to avoid the calcified aorta, reno-iliac arterial bypass is a useful alternative for control of ischemic lower limbs.

Upregulation of proteinase-activated receptors and hypercontractile responses precede development of arterial lesions after balloon injury.

Thrombin and other proteinases exert vascular effects by activating the proteinase-activated receptors (PARs). The expression of PARs has been shown to be upregulated after balloon injury and in human arteriosclerosis. However, the relationship between the receptor upregulation and the alteration of vasomotor function remains to be elucidated. We herein demonstrated that the contractile responses to the PAR-1 and PAR-2 agonist were markedly enhanced in the rabbit femoral arteries after balloon injury. Neointimal thickening was established 4 wk after the injury. No histological change was observed in the sham operation, where the saphenous artery was ligated without any balloon injury. The contractile response to K(+) depolarization was significantly attenuated 1 wk after the injury and then partly recovered after 4 wk. Thrombin, PAR-1-activating peptide, trypsin, and PAR-2-activating peptide induced no significant contraction in the control. All these stimulants induced enhanced responses 1 wk after balloon injury. Such enhanced responses were seen 4 wk after the injury, except for thrombin. There was no change in the Ca(2+) sensitivity of the contractile apparatus as evaluated in the permeabilized preparations. PAR-1-activating peptide (100 mumol/l), but no other stimulants, induced an enhanced contraction in the sham operation. The expression of PAR-1 and PAR-2 slightly increased after the sham operation, whereas it markedly and significantly increased after balloon injury. Our observations suggest that balloon injury induced the receptor upregulation, thereby enhancing the contractile response before the establishment of vascular lesions. The local inflammation associated with the sham operation may also contribute to the receptor upregulation.