[Successful treatment of very severe late-onset sinusoidal obstruction syndrome with recombinant human soluble thrombomodulin, steroids, and control of intra-abdominal pressure].

We report a case of a 16-year-old woman who achieved her third complete remission of acute lymphoblastic leukemia after undergoing allogeneic stem cell transplantation for the second time from an unrelated donor. On post-transplantation day 30, she showed weight gain, hepatomegaly, right hypochondriac pain, and ascites. On day 35, ultrasonography (US) revealed portal vein regurgitation. She was subsequently diagnosed with late-onset sinusoidal obstruction syndrome (SOS) and was transferred to the intensive care unit (ICU) on day 36 for multiple organ dysfunction syndrome (MODS) and disseminated intravascular coagulation, requiring mechanical ventilation. Her SOS was graded as very severe upon ICU admission. Recombinant human soluble thrombomodulin (380 U/kg/day) and methylprednisolone (2 mg/kg/day) therapies were initiated. Additionally, her intra-abdominal pressure had increased to 19 mmHg, which was thought to be the cause of MODS. Ascites drainage (1,000 ml/day), according to the treatment for abdominal compartment syndrome, improved her SOS and MODS. She was weaned from mechanical ventilation on the 10th day after ICU transfer, and US showed resolution of the portal vein regurgitation. She was transferred to the general ward on the 14th day. She had not experienced disease recurrence at her last visit (527 days after the second transplantation).

Modified jailed balloon technique for bifurcation lesions.

OBJECTIVES: We propose a new systematic approach in bifurcation lesions, modified jailed balloon technique (M-JBT), and report the first clinical experience. BACKGROUND: Side branch occlusion brings with a serious complication and occurs in more than 7.0% of cases during bifurcation stenting. METHODS: A jailed balloon (JB) is introduced into the side branch (SB), while a stent is placed in the main branch (MB) as crossing SB. The size of the JB is half of the MB stent size. While the proximal end of JB attaching to MB stent, both stent and JB are simultaneously inflated with same pressure. JB is removed and then guidewires are recrossed. Kissing balloon dilatation (KBD) and/or T and protrusion (TAP) stenting are applied as needed. RESULTS: Between February 2015 and February 2016, 233 patients (254 bifurcation lesions including 54 left main trunk disease) underwent percutaneous coronary intervention (PCI) using this technique. Procedure success was achieved in all cases. KBD was performed for 183 lesions and TAP stenting was employed for 31 lesions. Occlusion of SV was not observed in any of the patients. Bench test confirmed less deformity of MB stent in M-JBT compared with conventional-JBT. CONCLUSIONS: This is the first report for clinical experiences by using modified jailed balloon technique. This novel M-JBT is safe and effective in the preservation of SB patency during bifurcation stenting.

Initial and Long-Term Results of a Microcatheter-Based Retrograde Approach for the Endovascular Treatment of Chronic Total Occlusion in Iliac or Femoropopliteal Arteries.

BACKGROUND: Initial and long-term outcomes of the retrograde endovascular approach using a microcatheter for the treatment of chronic total occlusion (CTO) in the iliac or femoropopliteal (FP) arteries have not been fully elucidated. METHODS: From 2012 to 2014, 20 consecutive patients (21 limbs) underwent endovascular therapy (EVT) for CTO in the iliac or FP arteries using the microcatheter-based retrograde approach. An analysis of the initial and long-term outcomes was conducted. RESULTS: All procedures were successful. The mean follow-up duration was 27.4 ± 11.3 months. The mean patient age was 75.8 ± 9.1 years. Eighteen (85.7%) target lesions were located in the superficial femoral artery, 1 (4.8%) in the popliteal artery, and 2 (9.5%) in the iliac artery. All lesions were de novo. The mean occlusion length was 183.3 ± 95.4 mm. A stent was used in 19 (94.5%) lesions and balloon angioplasty was performed for 2 (5.5%) lesions. Retrograde puncture site complication (hematoma in popliteal artery) was reported in 1 (4.8%) patient. Postprocedure primary patency rates at 1, 2, and 3 years were 89.5%, 72.0%, and 41.2%, respectively, and the secondary patency rates at the corresponding time points were 100%, 77.2%, and 48.6%, respectively. CONCLUSIONS: Initial and long-term outcomes of EVT for CTO in iliac and FP arteries using the microcatheter-based retrograde approach are promising.

Comparison of long-term patency after endovascular therapy for superficial femoral artery occlusive disease between patients with and without hemodialysis.

OBJECTIVE: To compare long-term patency after endovascular therapy (EVT) for superficial femoral artery (SFA) occlusive disease between patients with hemodialysis (HD; HD+) and those without HD (HD-). BACKGROUND: Long-term patency after EVT for SFA occlusive disease in HD+ remains unknown. METHODS: EVT to SFA was successfully performed in 382 consecutive patients during 2004-2011. Cox proportional hazard model estimated the hazard ratio (HR) for the loss of primary patency (PP), secondary patency (SP), and amputation-free survival (AFS) in HD+. Binominal logistic regression analysis calculated the propensity score (PS) for covariates with a P value of <0.2 for HD as a dependent variable. HRs were adjusted for PS in multivariate analysis using the Cox proportional hazard model. RESULTS: PP and SP in HD+ and HD- were 47.9 and 79.4% and 68.4 and 92.5%, respectively, 4 years after EVT. There were no procedure-related amputations or in-hospital deaths. Adjusted HRs for the loss of PP, SP, and AFS were as follows: loss of PP, adjusted HR 2.010, 95% CI 1.157-3.492, P = 0.013; loss of SP, adjusted HR 2.927, 95% CI 1.236-6.933, P = 0.015; and loss of AFS, adjusted HR 1.665, 95% CI 0.994-2.791, P = 0.053. CONCLUSIONS: Although HD+ had more than double the risks for loss of PP and SP than HD-, EVT to SFA in HD+ was found to be safe with an acceptable PP and SP. © 2015 Wiley Periodicals, Inc.

Long-term outcomes of SMART stent implantation in patients with femoro-popliteal disease.

OBJECTIVES: This study aimed to determine the long-term outcomes of SMART stent implantation for femoro-popliteal (FP) lesions. BACKGROUND: The long-term results of SMART stent implantation for FP lesions remained unknown. METHODS: We studied 319 limbs in 269 patients (mean age: 73.2 ± 7.7 years) who underwent SMART stent implantation for FP lesions (mean treated-lesion length: 118.5 ± 81.0 mm) from 2004 to 2014, retrospectively. These patients were followed-up for a mean of 52.8 ± 33.8 months (median: 51.0 months). Kaplan-Meier and log-rank analyses were used to determine time to event. Hazard ratios (HRs) with 95% confidence interval (CI) were calculated through univariate and multivariate Cox proportional hazard analyses to estimate predictors of primary patency loss. RESULTS: Overall, 37.3% of lesions were TransAtlantic Inter-Society Consensus (TASC) IIC/D lesions, and 41.1% exhibited chronic total occlusion. Post-procedural primary patency rates were 87.7%, 79.4%, 68.1%, 53.7%, and 50.3%, at 1, 3, 5, 7, and 10 years, respectively; the corresponding secondary patency rates were 96.5%, 91.7%, 85.0%, 73.8%, and 67.7%, respectively. TASC IIA/B lesions had considerably better primary patency rates than C/D lesions at all time points. Multivariate analysis indicated that lesion length (with >200 mm vs. <100 mm) significantly promoted primary patency loss (HR, 2.555; 95% CI, 1.429-4.568; P = 0.002), as well as hemodialysis (HR, 1.881; 95% CI, 1.208-2.928; P = 0.005). CONCLUSIONS: Although SMART stent implantation produced favorable long-term results, TASC IIC/D FP lesions had poor outcomes. © 2016 Wiley Periodicals, Inc.

Intravascular Ultrasound-Assisted Crosser System Through the Retrograde Approach to Treat a Trans-Atlantic Inter-Society Consensus D Lesion in the Superficial Femoral Artery After Graft Failure.

BACKGROUND: The crosser system is useful to treat chronic total occlusion (CTO) lesions refractory to guidewire recanalization. However, the Inter-Society Consensus for the Management of Peripheral Arterial Disease recommends bypass graft surgery for Trans-Atlantic Inter-Society Consensus (TASC) type D femoropopliteal (FP) lesions. This approach may not be practical in patients with previous graft failure. In these patients, endovascular therapy with the crosser system may be appropriate. However, there are few reports of the crosser system to treat CTO after failure of FP bypass grafts. CASE REPORT: A 74-year-old man with a history of 2 FP bypass grafts presented with left lower-limb ischemic rest pain. Ankle-brachial pressure index (ABPI) in the left leg was 0.45. Angiography revealed a TASC type D lesion in the left superficial femoral artery (SFA). A bidirectional approach was used, but the very stiff dedicated CTO guidewire could not pass through the lesion. Therefore, after confirming that the guidewire was in the true lumen by intravascular ultrasound (IVUS), we used a CROSSER(®) 14S catheter (Bard Peripheral Vascular Inc., Tempe, AZ) through the retrograde route in the popliteal artery. The lesion was crossed, and a stent was successfully implanted. The patient's symptoms of rest pain resolved with an improved ABPI in the left leg of 0.82 after the procedure. CONCLUSIONS: The crosser system assisted by IVUS through the retrograde approach was useful to treat CTO in the SFA after failure of FP bypass grafts.

Renal artery intervention using a virtual 4.5-Fr guiding catheter.

A 6.5-Fr guiding catheter (Parent Plus 45, Medikit, Tokyo, Japan), composed of a hydrophilic sheathless guiding catheter and a dilator, has recently been developed for the treatment of renal artery stenosis. Because of its unique sheathless configuration, its outer diameter is comparable to that of a conventional 4.5-Fr introducer sheath, with the inner diameter being close in size to a 6.5-Fr guiding catheter. These features allow this sheathless system to be used as the sole guiding catheter while the arterial damage at the puncture site remains equivalent to that of a 4.5-Fr introducer sheath. We thus call this novel sheathless guiding catheter a virtual 4.5-Fr system. To demonstrate the potential of this virtual 4.5-Fr system, we report a case of renal artery stenosis successfully treated via the transradial route. This virtual 4.5-Fr system may become a viable alternative to conventional guiding catheters, and provide a favorable impact upon vascular access complications and patient morbidity.

Risk of long-term dual antiplatelet therapy following drug-eluting stent implantation in octogenarians.

OBJECTIVES: To evaluate the risk of long-term dual antiplatelet therapy (DAT) following drug-eluting stent (DES) implantation in octogenarians. BACKGROUND: DES implantation requires DAT; however, DAT-associated risk in octogenarians remains unclear. METHODS: Two-hundred and six consecutive octogenarians (130 men, 83.3 ± 3.4 years) underwent stent implantation (104 bare metal stents [BMSs] and 102 DESs) and 38.0 ± 13.2 months of follow-up. RESULTS: Significantly more DES patients received DAT. The incidence of bleeding events was similar in the DES and BMS groups for 1 year (total: 10.8% vs 5.8%, P = 0.19; major: 4.9% vs 2.9%, P = 0.70). However, after 2 years, significantly more bleeding events occurred in the DES group than the BMS group (total: 2 years, 21.6% vs 9.6%, P = 0.02; 3 years, 29.4% vs 11.5%, P = 0.001; 4 years, 31.4% vs 15.4%, P = 0.007; major: 2 years, 12.7% vs 3.8%, P = 0.04; 3 years, 18.6% vs 5.8%, P = 0.005; 4 years, 19.6% vs 6.7%, P = 0.006). Overall, significantly more total bleeding events (31.4% vs 15.4%, P = 0.007) and major bleeding events (19.2% vs 6.7%, P = 0.006) were observed in the DES group than in the BMS group. The adjusted hazard ratios and 95% confidence intervals (CI) were as follows: total bleeding events, 2.203 (95% CI: 1.065-4.556; P = 0.033); major bleeding events, 4.324 (1.506-12.414; P = 0.007). CONCLUSIONS: DAT was associated with an increased risk of bleeding events in octogenarians after 2 years. DAT discontinuation should be considered for octogenarians 1-year post-DES implantation.

Protective effect of propofol compared with sevoflurane on liver function after hepatectomy with Pringle maneuver: A randomized clinical trial.

While the Pringle maneuver reduces intraoperative blood loss in hepatectomies, this technique can also be hepatotoxic. Hepatectomies require general anesthesia with propofol or volatile anesthetics like sevoflurane, agents known to offer multi-organ protection. However, their clinical effect after liver resection is unclear. We aimed to assess the effect of the two anesthetics on post-hepatectomy liver damage via measuring liver function tests. Fifty-six patients who underwent elective hepatectomies with the Pringle maneuver due to metastatic hepatic masses were preoperatively randomized to be anesthetized by sevoflurane or propofol. The primary and secondary outcomes were the postoperative peak levels of aspartate transaminase (AST) and alanine transaminase (ALT), respectively. Patients anesthetized by propofol exhibited significantly lower transaminases than those given sevoflurane (AST, p = 0.005; ALT, p = 0.006). The former agent significantly affected postoperative transaminases (AST hazard ratio -192.2, 95% confidence interval [-332.1 to -52.4], p = 0.00; ALT hazard ratio -140.2, 95% confidence interval [-240.0 to -40.7], p = 0.007). In conclusion, propofol had a greater hepatoprotective effect than sevoflurane as assessed by postoperative transaminases after hepatectomy with Pringle maneuver for metastatic liver tumors.

Pituitary apoplexy precipitating diabetes insipidus after living donor liver transplantation.

Pituitary apoplexy occurring after surgery is a rare but life-threatening acute clinical condition that follows extensive hemorrhagenous necrosis within a pituitary adenoma. Pituitary apoplexy has been reported to occur spontaneously in the majority of cases or in association with various inducing factors. Reported is a case of pituitary apoplexy complicated by diabetes insipidus following living donor liver transplantation (LDLT). To the best of our knowledge, this has not been previously reported. A 56-year-old woman with nonalcoholic steatohepatitis underwent LDLT from her daughter. The patient also required dopamine support and transfusions because of massive intraoperative bleeding. Postoperatively, her coagulopathy continued, and she underwent a second laparotomy because of unknown bleeding on postoperative day 7, when she needed transfusions and dopamine support to maintain her vital signs. She complained of severe headache, excessive thirst, frequent urination, and diplopia from postoperative day 10. She also had polyuria greater than 300 ml/h and was diagnosed with pituitary apoplexy precipitating diabetes insipidus on postoperative day 13. She was treated conservatively without surgery because of the hormonally inactive status and slight mass effect of her tumor. It is important for anesthesiologists and critical care personnel in LDLT settings to take into consideration this complication as a differential diagnosis.

Transradial Coronary Interventions for Complex Chronic Total Occlusions.

OBJECTIVES: The aims of this study were to assess whether the transradial approach can be applied to treat complex chronic total occlusion (CTO) and to determine the predictors of transradial percutaneous coronary intervention (PCI) failure. BACKGROUND: Consistent data on the outcomes of transradial PCI for treating CTO are scarce. METHODS: Consecutive patients who were not receiving hemodialysis and had undergone PCI for CTO were enrolled. The clinical and angiographic characteristics, procedural details, and outcomes of the transradial and transfemoral procedures were examined. RESULTS: In total, 280 and 305 CTO PCI procedures involved transradial and transfemoral access, respectively. The technical success rates did not significantly differ in the entire cohort analysis and the propensity score-matched analysis (74.6% vs. 72.5%; p = 0.51 and 70.6% vs. 73.3%; p = 0.57). When only cases with J-CTO (Multicenter Chronic Total Occlusion Registry of Japan) scores of ≥3 were examined, the transradial group had a significantly lower success rate than the transfemoral group (35.7% vs. 58.2%; p = 0.04). The use of guiding catheter size <7 F (odds ratio [OR]: 5.50; p = 0.008), calcification (OR: 3.20; p = 0.001), occlusion length >20 mm (OR: 2.97; p < 0.001), and age (OR: 1.04; p = 0.03) were associated with transradial CTO PCI failure. CONCLUSIONS: Transradial PCI for CTO may be feasible in noncomplex cases, although complex cases still pose a challenge. In cases of transradial PCI for CTO, if possible, guiding catheter size ≥7 F should be selected regardless of lesion morphology. Furthermore, the transfemoral approach should be preferentially considered for complex CTO, particularly in cases with calcification.

Long-Term Outcomes of Successful Endovascular Therapy Via the Retrograde Approach for Below-the-Knee Chronic Total Occlusion in Patients With Critical Limb Ischemia After a Failed Antegrade Approach.

OBJECTIVE: This study evaluated long-term results following successful endovascular therapy (EVT) for chronic total occlusion (CTO) below the knee (BTK) using the retrograde approach after a failed antegrade approach. METHODS: Nineteen patients (19 limbs) with critical limb ischemia (CLI) who underwent successful EVT for BTK-CTO using the retrograde approach after a failed antegrade approach during 2010-2014 were studied. RESULTS: Mean duration of the follow-up period was 25.5 ± 17.9 months, and mean age was 76.0 ± 8.6 years. Patients on hemodialysis accounted for 10 cases (52.6%). Patients with Rutherford class 4 constituted 3 cases (15.8%) , while 8 patients each (42.1%) were categorized as Rutherford class 5 and class 6, respectively. All lesions were de novo CTOs. The mean occlusion length was 203.7 ± 114.7 mm. Vascular access for the retrograde approach was obtained via distal puncture in 9 cases (47.4%), whereas the transcollateral approach was employed in 10 cases (52.6%). The amputation-free survival rates at 1, 2, 3, 4, and 5 years after the index procedure were 78.6%, 66.9%, 66.9%, 50.2%, and 50.2%, respectively. CONCLUSION: Successful EVT for BTK-CTO using various techniques via the retrograde approach provides promising long-term results in patients with CLI.

Diagnostic performance of 320-slice computed tomography coronary angiography for symptomatic patients in clinical practice.

OBJECTIVE: Multi-slice computed tomography (MSCT) coronary angiography has been reported as an effective alternative to invasive conventional coronary angiography (CCA) for the diagnosis of coronary artery disease (CAD). However, in previous reports, the diagnostic accuracy of MSCT has not been significant enough to be of benefit in symptomatic patients. The aim of this study was to identify the usefulness of 320-slice computed tomography coronary angiography (320-CTA) for symptomatic patients in terms of the diagnostic accuracy of 320-CTA and the prevalence of vasospastic angina pectoris (VSAP) within the study cohort. METHODS: We retrospectively analyzed 513 consecutive symptomatic patients with suspected CAD who had undergone 320-CTA and CCA. We determined the diagnostic accuracy of 320-CTA using CCA as the reference standard. Ergonovine provocation tests were performed on patients without significant coronary artery stenosis on CCA. RESULTS: Of the total cohort of 513 symptomatic patients, 39% had obstructive CAD. The patient based analysis of the accuracy of 320-CTA showed a sensitivity of 91.0%, a specificity of 71.0%, a positive predictive value of 66.5%, and a negative predictive value of 92.5%. Of the 314 symptomatic patients who did not have significant coronary artery stenosis on CCA, 58 (18%) were diagnosed with VSAP using ergonovine provocation tests. DISCUSSION: The negative and positive predictive values indicate that 320-CTA cannot replace CCA for symptomatic patients. Indeed, a combination of CCA and ergonovine provocation tests should be taken into consideration for symptomatic patients.

Beneficial Effect of Endovascular Therapy and Low-Density Lipoprotein Apheresis Combined Treatment in Hemodialysis Patients With Critical Limb Ischemia due to Below-Knee Arterial Lesions.

To assess the clinical benefit of combined treatment of below-knee endovascular therapy (BK-EVT) plus low-density lipoprotein apheresis (LDLA) compared with BK-EVT monotherapy, we retrospectively evaluated the clinical outcome of hemodialysis (HD) patients with critical limb ischemia (CLI) due to isolated BK arterial lesions who underwent BK-EVT or BK-EVT plus short-term LDLA. Between October 2011 and September 2014, 62 HD patients underwent isolated BK-EVT monotherapy (BK-EVT group), and 25 HD patients underwent BK-EVT plus LDLA (BK-EVT + LDLA group). LDLA was started within 1 week after BK-EVT and performed four times in total within next 2 weeks. Major adverse limb events (MALE) including major amputation and re-intervention, and all-cause mortality were examined by Kaplan-Meier method and the log-rank test. Baseline characteristics were not different other than low ABI and low dorsal SPP in BK-EVT + LDLA group. Cumulative MALE-free rate was significantly improved in BK-EVT + LDLA group over the BK-EVT group (72.0% and 45.1% respectively at 30 months after treatment, P = 0.04). All-cause mortality did not differ between the two groups. Major causes of death were heart failure and sepsis in both groups. Short-term LDLA hybrid treatment immediately after BK-EVT might improve the outcome of ischemic limbs after re-vascularization therapy.

Long-Term Outcomes of Self-Expandable Nitinol Stent Implantation With Intraluminal Angioplasty to Treat Chronic Total Occlusion in the Superficial Femoral Artery (TransAtlantic Inter-Society Consensus Type D Lesions).

OBJECTIVES: To evaluate the long-term outcomes of self-expandable nitinol stent implantation with intraluminal angioplasty for chronic total occlusion (CTO) in the superficial femoral artery (SFA) of patients with TransAtlantic Inter-Society Consensus (TASC) D lesions. METHODS: From 2004 to 2011, self-expandable nitinol stent implantation in SFA was performed successfully in 72 consecutive limbs of 68 patients with TASC D lesions. These patients were assessed for an average of 38.8 ± 25.6 months. The procedure was performed using a 0.014" or 0.018" guidewire and intraluminal angioplasty. RESULTS: Patients with hemodialysis constituted 20.6% of cases. The mean occlusion length was 244.6 ± 34.1 mm. A bidirectional approach was performed in 69.4% of cases. Primary patency rates were 77.9%, 71.9%, 67.2%, and 51.5% at 1 year, 2 years, 3 years, and 5 years, respectively. Secondary patency rates were 88.6%, 78.7%, 71.1%, and 56.0% at 1 year, 2 years, 3 years, and 5 years, respectively. Cox regression multivariate analysis for hemodialysis pertaining to loss of primary and secondary patency resulted in hazard ratio = 2.555 (95% confidence interval, 1.108-5.891; P=.03) for loss of primary patency and hazard ratio = 3.615 (95% confidence interval, 1.380-9.471; P=.01) for loss of secondary patency. CONCLUSION: Long-term patency of self-expandable nitinol intraluminal stent implantation with intraluminal angioplasty to treat CTO (TASC D) in SFA is promising. Hemodialysis was the only independent predictor for loss of primary and secondary patency.

Long-term risks for patency loss in patients with hemodialysis after bare self-expandable nitinol stent implantation to femoropopliteal artery occlusive lesions.

BACKGROUND: Although patients receiving hemodialysis (HD+) have significantly different backgrounds, including a history of progressive atherosclerotic disease, compared with those not receiving hemodialysis (HD-), there are no studies evaluating the risks for loss of primary patency (PP) and need for target lesion revascularization (TLR) in HD+ patients following bare self-expandable nitinol stent (BSNS) implantation to femoropopliteal (FP) artery occlusive lesions, after adjusting for differences using propensity score (PS) analysis in observed characteristics between groups. METHODS: We studied 531 limbs of 432 Japanese patients (HD+, n=107; HD-, n=325) who received BSNS implantation to FP lesions between 2004 and 2014. Patients were followed-up for an average of 44.3±33.6months. We compared the long-term results between HD+ and HD- patients using the Cox-proportional hazard model with adjustment for inverse probability treatment weight (IPTW) of PS, which was calculated for covariates with HD as a dependent variable. RESULTS: PP rate in HD+ vs. HD- patients at 9years after the procedure was 19.1% vs. 47.9%, with a freedom from TLR rate of 47.6% vs. 62.9%, respectively. Adjusted HRs in HD+ patients with 95% confidence intervals (CIs) were as follows: loss of PP: HR 1.64, 95% CI 1.052-2.557, P=0.03; TLR: HR 1.862, 95% CI 1.104-3.139, P=0.02. CONCLUSIONS: The present study suggests that HD+ patients have an increased risk for loss of PP and need for TLR after BSNS implantation to FP lesions.

Co-existence of carotid artery disease, renal artery stenosis, and lower extremity peripheral arterial disease in patients with coronary artery disease.

In atherosclerosis, carotid artery stenosis (CAS), renal artery stenosis (RAS), lower extremity peripheral arterial disease (PAD), and coronary artery disease (CAD) are common pathologic lesions; their interrelationship is, however, unclear. We studied concomitant multiple atherosclerotic lesions in patients with CAD to understand their prevalence and relations. A cross-sectional analysis was performed on data from consecutive patients who underwent nonemergent coronary angiography. Simultaneous carotid and renal artery Doppler studies and ankle-brachial systolic pressure measurements were reviewed to diagnose concomitant lesions and their severity. The study included 1,734 patients (aged 71 ± 9 years; 70% men), with prevalences of CAS, RAS, lower extremity PAD, and CAD of 6%, 7%, 13%, and 72%, respectively. In patients with CAD (n = 1,253), the prevalences of CAS, RAS, and lower extremity PAD were 7%, 9%, and 16%, respectively; 24% CAD patients had ≥1 additional atherosclerotic lesion. Significant interactions among the prevalences of these lesions were found. In addition, the extent of CAD and the prevalences of CAS, RAS, and lower extremity PAD were significantly correlated. Multivariate analysis supported these relationships. In conclusion, the prevalences of CAS, RAS, lower extremity PAD, and CAD were strongly interrelated in the study population; CAD severity was related to that of other atherosclerotic lesions. Additional systematic screening of other concomitant atherosclerotic lesions is recommended, especially in CAD patients having multivessel disease, left main disease, and/or already diagnosed with other concomitant atherosclerotic lesions.

Comparison of short- and long-term outcomes of percutaneous coronary intervention for chronic total occlusions between patients aged ≥75 years and those aged <75 years.

Few reports are available on the safety and efficacy of percutaneous coronary intervention (PCI) for chronic total occlusions (CTOs) in older patients. In the present study, 284 patients who underwent PCI for CTOs were retrospectively evaluated by comparing the characteristics of 67 patients aged ≥75 years (the older group) and 217 patients aged <75 years (the younger group). Technical success was achieved in 77% of the patients in the older group and 79% of those in the younger group (p = 0.66). No significant differences were observed between the 2 groups in terms of the incidence of procedural complications. In the older group, a comparison between the patients with successful and failed PCI revealed significantly superior 3-year cardiac survival (97.6% vs 76.9%, p = 0.005). The 3-year cardiac survival of those with successful PCI was similar to that observed in the younger group. On multivariate analysis, successful PCI was found to be associated with a lower incidence of cardiac death in the older group (hazard ratio 0.09, 95% confidence interval 0.01 to 0.91, p = 0.042). In conclusion, this single-center, observational study suggests that PCI for CTOs can be performed with a high rate of procedural success and acceptably low mortality and morbidity in older patients, resulting in improved cardiac survival. Thus, PCI for CTO lesions should be included among the treatment strategies for older patients.

Heme breakdown and ischemia/reperfusion injury in grafted liver during living donor liver transplantation.

Living donor liver transplantation (LDLT) requires ischemia/reperfusion (I/R), which can cause early graft injury. However, the detailed mechanism of I/R injury remains unknown. Heme oxygenase-1 (HO-1) is a rate-limiting enzyme in heme catabolism and results in the production of iron, carbon monoxide (CO), and biliverdin IXα. Furthermore, in animals, HO-1 has a protective effect against oxidative stress associated with I/R injury. However, in humans, the molecular mechanism and clinical significance of HO-1 remain unclear. We previously demonstrated that exhaled CO levels increase during LDLT, and postulated that this may indicate I/R injury. In this study, we elucidate the origin of increased exhaled CO levels and the role of HO-1 in I/R injury during LDLT. We studied 29 LDLT donors and recipients each. For investigation of HO-1 gene expression by polymerase chain reaction and HO-1 localization by immunohistological staining, liver biopsies from the grafted liver were conducted twice, once before and once after I/R. Exhaled CO levels and HO-1 gene expression levels significantly increased after I/R. In addition, HO-1 levels significantly increased after I/R in Kupffer cells. Furthermore, we found a significant positive correlation between exhaled CO levels and HO-1 gene expression levels. These results indicated that increased heme breakdown in the grafted liver is the source of increased exhaled CO levels. We also found a significant relationship between HO-1 gene expression levels and alanine aminotransferase (ALT) levels; i.e., the higher the HO-1 gene expression levels, the higher the ALT levels. These results suggest that HO-1-mediated heme breakdown is caused by I/R during LDLT, since it is associated with increased exhaled CO levels and liver damage.