Predictive Factors for Limb Salvage and Foot Ulcer Recurrence in Patients with Chronic Limb-Threatening Ischemia After Multidisciplinary Team Treatment: A 6-Year Japanese Single-Center Study.

Chronic limb-threatening ischemia (CLTI) is associated with a short-term risk of limb loss. Multidisciplinary teams are often involved in CLTI treatment; however, in Asian countries, multidisciplinary teams that include podiatrists specializing in foot wounds and vascular surgeons who can perform distal bypass surgery are lacking. We investigated predictive factors for limb salvage and foot ulcer recurrence in patients with CLTI treated by a Japanese single-center intensive multidisciplinary team over 6 years. We retrospectively investigated 84 patients with CLTI and foot ulcers who had undergone revascularization and wound treatment between October 2013 and December 2019. Following postrevascularization treatment, including undertaking minor amputations, the healing rate was 77.8%, and the average wound healing time was 75 ± 68 days. To achieve adequate blood supply, 17.7% of patients were treated using a combination of endovascular revascularization and bypass surgeries. Thirty-three (44%) patients had wound recurrence and there was wound recurrence within 6 months in 58.9% of these patients. Multivariate logistic regression analysis showed that postrevascularization skin perfusion pressure was significantly associated with wound healing (odds ratio [OR] 1.13, 95% confidence interval [CI] 1.033-1.243, P = .0078). Diabetes mellitus (OR 9.72, 95% CI 1.855-50.937, P = .0071), and heart disease (OR 3.51, 95% CI 1.052-11.693, P = .0411) were significantly associated with wound recurrence (P < .05). Treatment within a single-center intensive multidisciplinary team resulted in good patient outcomes. Our study indicates that the revascularization endpoint of CLTI treatment should be marked by attainment of adequate blood supply and wound healing. The timing of revascularization and debridement is of utmost importance for the successful treatment of CLTI wounds.

Successful Open Thoracoabdominal Aortic Repair in a Patient with Severe Aorto-Iliac Occlusive Disease: A Rare Case Report.

Open repair of thoracoabdominal aortic aneurysm (TAAA) in a patient with severe aorto-iliac occlusive disease is considered to cause an extremely high risk for spinal cord injury. A 71-year-old man who had previously undergone axillo-bifemoral bypass for aorto-iliac occlusive disease presented with persistent dilation of a TAAA. Using distal perfusion via partial extracorporeal circulation at mild hypothermia, we performed segmental sequential repair of Crawford type II TAAA. Various efforts were made to avoid spinal cord injury and ischemic visceral organ damage. Consequently, the patient completely recovered without any serious complications.

A rare case of idiopathic chronic expanding pericardial hematoma presenting as pericardial tamponade: a case report and literature review.

Chronic expanding pericardial hematoma is a very rare disease that occurs after open-heart surgery. We report successful surgical treatment of a rare case of chronic expanding pericardial hematoma that developed into a large mass and presented as pericardial tamponade without apparent cause. An 82-year-old woman with no history of cardiac surgery, chest trauma, or epicardial injury presented with a 3-year history of progressive exertional dyspnea. Surgical resection of the mass via midsternotomy was planned to release the cardiac symptoms and to confirm the diagnosis of chronic expanding pericardial hematoma.

Midterm outcomes of thoracic endovascular repair for uncomplicated type B aortic dissection with double-barrel type.

OBJECTIVE: The midterm outcomes and aortic remodeling after thoracic endovascular aortic repair (TEVAR) for uncomplicated type B aortic dissection (TBAD) were evaluated. METHODS: Forty-seven patients (mean age 66 ± 12 years) who underwent TEVAR for uncomplicated TBAD with double-barrel type from January 2012 to December 2017 were retrospectively analyzed. The indication for TEVAR for entry closure was a maximum aortic diameter > 40 mm with a patent false lumen. Twenty-six patients (55.3%) had TEVAR in chronic phase, over 6 months after the onset of aortic dissection. RESULTS: There was no hospital death or serious complication. During follow-up (mean 35 ± 16 months), overall 3-year survival was 95.6 ± 3.1%. A significant trend was observed with a higher rate of shrinkage of overall aortic diameter, expansion of the true lumen, and shrinkage of the false lumen more proximally from the stent graft-covered site. Rate of aortic shrinkage in chronic with aortic diameter more than 50 mm was lower compared with the other (proximal: 33.3% vs. 80-100%, distal 0-16.7% vs. 50-52.9%). Rate of aortic dilation distally to the stent graft-covered site was 28% in chronic compared with 5% in non-chronic. Adverse events were mainly due to distal aortic dilation, and 3-year freedom from all adverse events was 79.8 ± 6.5%. CONCLUSIONS: Favorable aortic remodeling of the proximal stent graft-covered site could be expected even in the chronic phase if preoperative aortic dilation over 50 mm is unaccompanied. Careful follow-up focusing on dilation of the distal aortic segment is mandatory especially in patients who underwent TEVAR in chronic phase.

Outcomes of valve replacement with mechanical prosthesis versus bioprosthesis in dialysis patients: A 16-year multicenter experience.

OBJECTIVE: To evaluate the long-term outcomes of heart valve replacement with mechanical prosthesis (MP) versus bioprosthesis (BP) in patients on dialysis. METHODS: A retrospective review was performed at 7 hospitals. Patients on dialysis who underwent valve replacement were included. Survival, reoperation, bleeding, and embolic events were compared across the MP and BP groups. RESULTS: Between April 2000 and April 2016, 312 patients on dialysis were enrolled in our study (MP: 94 patients [30.1%], BP: 218 patients [69.9%]). Mean follow-up was 3.4 ± 3.6 years. Five-year and 10-year survival rates were similar in both groups (MP: 57.4 ± 5.5% at 5 years and 46.3 ± 6.4% at 10 years, BP: 50.2 ± 4.1% at 5 years and 38.8 ± 4.5% at 10 years, P = .305). Multivariate Cox hazard analysis demonstrated that diabetic nephropathy (hazard ratio [HR], 1.90; 95% confidence interval [CI], 1.31-2.73, P < .001), New York Heart Association functional classification ≥III (HR, 2.16; 95% CI, 1.37-3.35, P = .001), and mitral valve replacement (HR, 2.36; 95% CI, 1.58-3.49, P < .001) were significant risk factors for late death. Valve selection was not a significant risk factor. Freedom from valve-related embolic event at 5 years was significantly lower in the MP group (MP: 88.3 ± 4.3% at 5 years, BP: 97.2 ± 1.6% at 5 years, P = .007). Freedom from valve-related reoperation or hemorrhagic events was similar across both groups. CONCLUSIONS: Valve selection was not associated with late survival outcomes in patients on dialysis. However, BP may have an advantage in preventing embolic events without increasing the incidence of valve-related reoperation when compared with MP.

Aortic valve replacement and graft replacement of the ascending aorta using deep hypothermic circulatory arrest in a patient with myelodysplastic syndrome.

A 73-year-old woman with a 10-year history of myelodysplastic syndrome (MDS) had severe aortic regurgitation (AR) and an ascending thoracic aortic aneurysm (TAA) with a maximum diameter of 55 mm. By retrograde cerebral perfusion (RCP) in the patient under deep hypothermic circulatory arrest (DHCA), we replaced the ascending aorta graft and aortic valve. After surgery, we periodically administered granulocyte colony-stimulating factor (GCSF) with platelet aggregation. On postoperative day 20, the patient had a duodenal ulcer. On postoperative day 22, she had a subarachnoid hemorrhage, which was treated, nonoperatively, with a hemostatic agent. On postoperative day 126, she was discharged without sequelae, and 1.5 years after the surgery, she has had neither heart failure nor deterioration of MDS.

Surgical removal of an intravascular ultrasonography catheter captured in a stent after percutaneous coronary intervention.

A-79-year-old woman underwent percutaneous coronary intervention (PCI) to the right coronary artery (RCA) for effort angina, followed by intravascular ultrasonography (IVUS) to ascertain stent expansion. The IVUS catheter became entangled in the stent and could not be withdrawn from the outside. The patient was transferred to our hospital for its surgical removal. For the emergent surgery, we opened the stent region in the RCA and directly removed the IVUS catheter with the twisted stent. Additional coronary artery bypass grafting (CABG) involving three vessels was performed. She was discharged 42 days after surgery.

Aortic regurgitation caused by rupture of the abnormal fibrous band between the aortic valve and aortic wall.

This report documents the sudden onset of aortic regurgitation (AR) by an exceptional cause. A 68-year-old woman suddenly experienced general fatigue, and AR was diagnosed. One year later, we performed aortic valve replacement. At surgery, three aortic cusps with a larger noncoronary cusp had prolapsed along with a free-floating fibrous band that had previously anchored the cusp to the aortic wall. Its rupture had induced the sudden onset of AR. There was no sign of infectious endocarditis. We performed successful aortic valve replacement.

Successful operation for mitral regurgitation in a patient with Gilbert's syndrome.

A 72-year-old woman complaining of dyspnea on effort was diagnosed as having mitral regurgitation (MR). Asymptomatic jaundice had initially been noticed during primary school, and an examination had shown hyperbilirubinemia. After the diagnosis of constitutional jaundice, she had remained well without further examination or medical treatment. Laboratory data showed a total serum bilirubin (TB) level of 12.2 mg/dl and a direct bilirubin level of 0.6 mg/dl. Transesophageal echocardiography showed severe MR, and we replaced the mitral valve. Postoperatively, genetic analyses identified constitutional jaundice as Gilbert's syndrome with Y486D mutation. The TB level gradually decreased. Four years after operation she is doing well with moderate hyperbilirubinemia and a TB level of 5 mg/dl. She is free from heart failure.

Perivalvular leakage 25 years after initial mitral valve replacement with a Björk-Shiley prosthesis.

An 80-year-old woman had undergone initial mitral valve replacement using a Björk-Shiley mechanical valve owing to mitral stenosis 25 years earlier. Suddenly, she had anemia and an increased lactic dehydrogenase (LDH) level. Transesophageal echography (TEE) showed perivalvular leakage. In a redo operation, two side-by-side stitches of the valve on the posterior annulus were loosened without cutting and the sewing cuff at that site was floated over the annulus, leading to the perivalvular leakage. The valve was easily removed; and round, hard, degenerative calcified tissue composed of remnant mitral valve in the suture site during the initial operation was found just under the sewing cuff. After resection of this calcified round tissue, a 25-mm bioprosthesis was put in place. Her postoperative recovery was uneventful, and 47 days after surgery she was discharged without perivalvular leakage or anemia.

Surgical removal of left ventricular ball-like thrombus following large transmural acute myocardial infarction using the infarction exclusion technique: David-Komeda procedure.

A 61-year-old man, who had suffered congestive heart failure following a large transmural acute myocardial infarction (AMI) of the anterior wall, developed a mobile ball-like thrombus in the left ventricle (LV). On the third day after onset of AMI, when the patient had recovered slightly from congestive heart failure, we performed coronary artery bypass grafting and LV thrombectomy, then the fragile LV wall was successfully repaired using the infarction exclusion technique (David-Komeda procedure).

Myocardial ischemia due to compression of an unruptured thoracic aortic aneurysm in a patient with Marfan syndrome.

We report a 33-year-old woman who had a 60-mm thoracic aneurysm of the ascending aorta with Marfan syndrome and effort angina due to compression of the right coronary artery (RCA) by the aneurysm. Surgery was performed using the Bentall procedure and a coronary artery bypass graft to the RCA. Postoperatively, coronary angiography showed that the coronary flow of the RCA was restored by removing the aneurysmal compression. The patient was discharged without angina on postoperative day 21.