Initial two-day blood pressure management after endovascular aneurysm repair improves midterm outcomes by reducing the incidence of early type II endoleak.

OBJECTIVE: The aim of this study was to evaluate midterm outcomes of our novel strategy of postoperative initial 2-day blood pressure management (BPM) after endovascular aneurysm repair (EVAR) for the prevention of subsequent type II endoleak (T2EL) in a single-center series. METHODS: Between 2008 and 2014, 137 patients who underwent EVAR for abdominal aortic aneurysm (AAA) were reviewed. Starting from 2013, the mean blood pressure was maintained between 75 and 90 mmHg for the initial 24 hours after EVAR followed by systolic pressure controlled below 120 mmHg during the next 24 hours in the treatment group (n = 76). The incidence of T2EL detected at 7 days, reintervention, and AAA sac diameter up to 5 years after EVAR were compared with those of the control group comprising of 60 consecutive patients who underwent standard EVAR without BPM prior to 2013. RESULTS: Between the treatment group and the control group, significant differences were achieved in the incidence of T2EL at 7 days (19.7% vs 40.0%; P = .009), a mean decrease of AAA sac diameter at 1-year (-5.1 ± 4.9 vs -2.2 ± 6.7 mm; P = .013) and 2-year (-5.4 ± 7.7 vs -1.7 ± 10.8 mm; P = .045). In addition, there was a significant decrease in the incidence of T2EL detected at 7 days with the use of the Gore Excluder with 22.7% in the treatment group vs 80.0% in the control group (P < .001), which resulted in a significant decrease in the aneurysm sac diameter up to 4 years after EVAR. Survival rate without AAA sac enlargement at 5 years after EVAR (83.0% vs 70.0%; P = .021) in the treatment group was significantly higher than that of the control group, whereas no significant differences were observed in the freedom rates of reintervention, T2EL-related reintervention, and all-cause mortality between the groups. CONCLUSIONS: Postoperative initial 2-day BPM had a preventive effect on AAA sac enlargement until midterm periods, by reducing the incidence of T2EL at 7 days after EVAR. The usage of Gore Excluder under BPM was especially associated with sustained positive effects until the midterm follow-up.

Injection of n-Butyl-2-Cyanoacrylate into the Abdominal Aortic Aneurysm Sac during Endovascular Aortic Repair to Prevent Type II Endoleaks Caused by Lumbar Arteries.

PURPOSE: To evaluate midterm results of whether the strategy to occlude target lumbar arteries using n-butyl-2-cyanoacrylate (nBCA) injection during endovascular aneurysm repair (EVAR) reduced the incidence of Type II endoleak (T2EL) after EVAR. MATERIALS AND METHODS: Between 2013 and 2020, 187 patients underwent EVAR; 106 in the treatment group received nBCA injection during EVAR, whereas 81 in the historical control group did not. The incidence of T2EL at 7 days, need for reintervention, and post-EVAR aneurysmal shrinkage were compared between the groups. RESULTS: Between the treatment group and the control group, significant differences were achieved in the incidence of T2EL (2.8% vs 28.4%; P < .0001) and decreased aneurysmal diameter was observed at 1 year after EVAR (-5.2 vs -3.8 mm; P = .034). In multivariate analysis, nBCA injection (odds ratio [OR], 0.04; P = .001) and younger age (OR, 0.92; P = .036) were significantly associated with a reduced incidence of T2EL. As a possible adverse event associated with nBCA injection, 2 cases of transient lower-limb motor dysfunction (1.9%) were observed. Propensity score analysis revealed that the treatment group had a significantly lower incidence of T2EL than that in the control group (P = .0002) even though there was no difference in the incidence of inferior mesenteric artery coil embolization between the groups. The survival rate without aneurysm sac enlargement (100.0% vs 69.8%; P = .014) and the reintervention-free rate (100.0% vs 63.1%; P = .034) in the treatment group were significantly higher than those in the control group. CONCLUSIONS: Concomitant nBCA injection can provide durable EVAR without T2EL, as supported by the avoidance of reintervention associated with aneurysm sac enlargement.

Thoracic Endovascular Aortic Repair on Zone 2 Landing for Uncomplicated Type B Aortic Dissection with Measurement of Intra-False Lumen Pressure.

BACKGROUND: This study aimed to evaluate the midterm results of zone 2 thoracic endovascular aortic repair (TEVAR) for uncomplicated type B aortic dissection (TBAD) by measuring the intra-false lumen pressure (IFLP) during TEVAR. METHODS: Fifteen patients (9 men; mean age, 57 years) who underwent zone 2 TEVAR for uncomplicated TBAD were reviewed. Delta systolic pressure (defined as the difference between systemic pressure and IFLP) was measured before and after primary entry closure, and aortic remodeling and thrombo-occlusion of the false lumen (FL) were evaluated 12 months after TEVAR at 5 different levels of the aorta. RESULTS: Median duration from onset to TEVAR was 34 days. The left subclavian artery was preserved in 13 patients (87%) by using stent graft fenestration. Although 1 patient (6%) had a transient cerebral infarction, there were no severe TEVAR-related complications. Entry closure significantly reduced delta systolic pressure (mm Hg) compared to preoperative pressure at all levels (distal arch: -22.2 ± 10.8 vs. -5.2 ± 9.6; Th8: -20.1 ± 12.4 vs. -6.9 ± 7.2; Th10: -14.3 ± 14.6 vs. -4.7 ± 7.5; Th12: -14.4 ± 14.5 vs. -4.9 ± 7.8; L2: -14.5 ± 14.2 vs. -3.4 ± 6.9). The percentages of aortic remodeling with expansion of the true lumen (distal arch: 82%; Th8: 80%; Th10: 54%; Th12: 45%; L2: 50%) and complete false lumen thrombosis (distal arch: 100%; Th8: 100%; Th10: 67%; Th12: 11%; L2: 0%) were approximately consistent with the change in delta systolic pressure. During a follow-up of 41 months, distal stent-induced new entry occurred in 2 patients (13%) requiring secondary intervention; however, there were no cases of FL enlargement or aorta-related mortality. CONCLUSIONS: Zone 2 TEVAR for uncomplicated TBAD may prevent TEVAR-related complications. Measuring IFLP could be a new predictive marker for assessing the extent of aortic remodeling.

TNX-1500, a crystallizable fragment-modified anti-CD154 antibody, prolongs nonhuman primate cardiac allograft survival.

Blockade of the CD40/CD154 T cell costimulation pathway is a promising approach to supplement or replace current clinical immunosuppression in solid organ transplantation. We evaluated the tolerability and activity of a novel humanized anti-CD154 monoclonal antibody, TNX-1500 (TNX), in a nonhuman primate heterotopic cardiac allogeneic (allo) transplant model. TNX-1500 contains a rupluzimab fragment antigen-binding region and an immunoglobin G4 crystallizable fragment region engineered to reduce binding to the crystallizable fragment gamma receptor IIa and associated risks of thrombosis. Recipients were treated for 6 months with standard-dose TNX (sTNX) monotherapy, low-dose TNX monotherapy (loTNX), or loTNX with mycophenolate mofetil (MMF) (loTNX + MMF). Results were compared with historical data using chimeric humanized 5c8 monotherapy dosed as for loTNX but discontinued at 3 months. Median survival time was similar for humanized 5c8 and both loTNX groups, but significantly longer with sTNX (>265 days) than with loTNX (99 days) or loTNX + MMF (88 days) (P < 0.05 for both comparisons against sTNX). Standard-dose TNX prevented antidonor alloantibody elaboration, inhibited chronic rejection, and was associated with a significantly reduced effector T cells/regulatory T cells ratio relative to loTNX with MMF. No thrombotic complications were observed. This study demonstrated that TNX was well tolerated, prolongs allograft survival, and prevents alloantibody production and cardiac allograft vasculopathy in a stringent preclinical nonhuman primate heart allotransplant model.

Effects of human TFPI and CD47 expression and selectin and integrin inhibition during GalTKO.hCD46 pig lung perfusion with human blood.

BACKGROUND: Loss of barrier function when GalTKO.hCD46 porcine lungs are perfused with human blood is associated with coagulation pathway dysregulation, innate immune system activation, and rapid sequestration of human formed blood elements. Here, we evaluate whether genetic expression of human tissue factor pathway inhibitor (hTFPI) and human CD47 (hCD47), alone or with combined selectin and integrin adhesion pathway inhibitors, delays GalTKO.hCD46 porcine lung injury or modulates neutrophil and platelet sequestration. METHODS: In a well-established paired ex vivo lung perfusion model, GalTKO.hCD46.hTFPI.hCD47 transgenic porcine lungs (hTFPI.hCD47, n = 7) were compared to GalTKO.hCD46 lungs (reference, n = 5). All lung donor pigs were treated with a thromboxane synthase inhibitor, anti-histamine, and anti-GPIb integrin-blocking Fab, and were pre-treated with Desmopressin. In both genotypes, one lung of each pair was additionally treated with PSGL-1 and GMI-1271 (P- and E-selectin) and IB4 (CD11b/18 integrin) adhesion inhibitors (n = 6 hTFPI.hCD47, n = 3 reference). RESULTS: All except for two reference lungs did not fail within 480 min when experiments were electively terminated. Selectin and integrin adhesion inhibitors moderately attenuated initial pulmonary vascular resistance (PVR) elevation in hTFPI.hCD47 lungs. Neutrophil sequestration was significantly delayed during the early time points following reperfusion and terminal platelet activation was attenuated in association with lungs expressing hTFPI.hCD47, but additional adhesion pathway inhibitors did not show further effects with either lung genotype. CONCLUSION: Expression of hTFPI.hCD47 on porcine lung may be useful as part of an integrated strategy to prevent neutrophil adhesion and platelet activation that are associated with xenograft injury. Additionally, targeting canonical selectin and integrin adhesion pathways reduced PVR elevation associated with hTFPI.hCD47 expression, but did not significantly attenuate neutrophil or platelet sequestration. We conclude that other adhesive mechanisms mediate the residual sequestration of human formed blood elements to pig endothelium that occurs even in the context of the multiple genetic modifications and drug treatments tested here.

Perioperative Outcomes of Minimally Invasive Aortic Arch Reconstruction with Branched Grafts Through a Partial Upper Sternotomy.

BACKGROUND: Ministernotomy has been advocated over recent years as an alternative technique for different cardiovascular surgical procedures to reduce the surgical trauma associated with conventional full sternotomy. In recent years, several reports have addressed minimally invasive approaches to the proximal aorta and aortic arch through a partial upper sternotomy (PUS). We reviewed our experience of minimally invasive open aortic arch reconstruction with a branched graft through a PUS. METHODS: Between February 2016 and December 2018, 22 patients underwent open arch repair through a PUS. Moderate hypothermic circulatory arrest and antegrade selective cerebral perfusion were used for organ protection. The median patient age was 76 years (range, 65-86). Renal insufficiency was observed in 14 patients (64%) and chronic lung disease, in 11 (50%). Total arch replacement was performed in 20 patients (91%), while the remaining 2 (9%) received partial arch replacement with reconstruction of two supraaortic vessels. Aortic valve replacement with a tissue valve or aortic valve repair was each performed concomitantly in one patient (5%) as a concomitant procedure. The median durations of cardiopulmonary bypass, aortic cross-clamping, and circulatory arrest were 214, 109, and 50 min, respectively. RESULTS: No early deaths, permanent neurological deficits, or spinal cord injuries occurred. One patient (5%) required intraoperative conversion to full sternotomy because of bleeding caused by a venting cannula injury. Three patients (14%) required re-exploration because of bleeding. Prolonged ventilation occurred in 2 patients (9%) with severe chronic obstructive pulmonary disease. CONCLUSIONS: Minimally invasive aortic arch reconstruction with branched grafts through a PUS can be safely performed with satisfactory perioperative outcomes.

Endovascular Aortic Aneurysm Repair without Type 2 Endoleak Using Concomitant N-Butyl-2-Cyanoacrylate Injection into the Abdominal Aortic Aneurysm Sac.

BACKGROUND: The aim of this study was to evaluate our new method to occlude target lumber arteries using N-butyl-2-cyanoacrylate (NBCA) during endovascular aneurysm repair (EVAR) for prevention of type 2 endoleak (T2E). METHODS AND RESULTS: Between 2013 and 2018, 176 patients who underwent EVAR for abdominal aortic aneurysm (AAA) were reviewed. Starting from October 2015, 83 patients (treatment group) underwent NBCA injection into the aneurysmal sac during EVAR. The incidence of T2E at 7 days and AAA sac diameter 12 months after EVAR were compared with those of the control group comprising 93 consecutive patients who underwent EVAR alone before 2015. The incidence of T2E at 7 days was significantly lower in the treatment group (2.4%) than in the control group (22.6%) (P < 0.001). AAA sac diameter at 12 months in the treatment group had a mean decrease of 6.6 mm as compared with the mean 4.4 mm in the control group (P = 0.026). In multivariate analysis, NBCA injection was significantly related to the reduction of incidence of T2E at 7 days (odds ratio = 11.8, P < 0.001) and a decrease in AAA sac diameter at 12 months (P < 0.001). There was no NBCA injection-related complication and reintervention in the treatment group. CONCLUSIONS: NBCA injection might be safe and useful to reduce the incidence of T2Es and to prevent AAA sac expansion.

Challenges in management of a giant left ventricular pseudoaneurysm complicated by intracerebral hemorrhage.

Urgent surgery is generally indicated for left ventricular (LV) pseudoaneurysms, especially for large or expanding lesions. However, management of pseudoaneurysms complicated by acute intracerebral hemorrhage is controversial. This case of a giant LV pseudoaneurysm followed a successful postoperative course after 4 weeks of conservative management followed by surgical repair and may suggest a safe and efficient management.

Thoracic Endovascular Aortic Repair on Zone 2 Landing for Type B Aortic Dissection.

BACKGROUND: Although thoracic endovascular aortic repair (TEVAR) is an effective treatment for both complicated and uncomplicated type B aortic dissection (TBAD), the occurrence of retrograde type A aortic dissection (RTAD) after TEVAR could be a disastrous complication. The aim of this study was to examine the safety of zone 2 TEVAR in the treatment of acute and subacute TBAD. METHODS: A Relay stent graft (SG) was placed proximally beyond the left subclavian artery (LSA) as zone 2 TEVAR for complicated or uncomplicated TBAD. LSA was preserved by physician-modified fenestrated TEVAR (F-TEVAR) if anatomically possible or by surgical reconstruction of debranching TEVAR (D-TEVAR) if necessary. Otherwise, LSA was simply covered. Changes in the aortic diameters after TEVAR were evaluated using CT scanning. RESULTS: Between 2013 and 2017, 22 patients (mean age: 63 ± 14 years; 16 males) with TBAD were treated with zone 2 TEVAR. Emergency TEVAR was performed in 9 patients (41%) for complicated TBAD, and elective TEVAR was performed in 13 patients (59%) for uncomplicated TBAD in subacute phases. LSA was preserved in 16 patients via 15 F-TEVAR and 1 D-TEVAR and intentionally covered in 6 patients on emergency TEVAR. Elective TEVAR succeeded in the preservation of LSA flow in all patients (emergency 33% vs. elective 100%; P < 0.01). There were no TEVAR-related complications such as stroke, spinal cord ischemia, and RTAD. Thirty-day mortality was 0%. Aortic remodeling as the expansion of true lumen and shrinkage and complete thrombosed occlusion of false lumen were prominent at the level of SG placement 12 months after TEVAR. During the follow-up period, stent-induced new entry at the distal edge of the SG occurred in 1 patient (4%); however, there was no case of aorta-related mortality. CONCLUSIONS: Zone 2 TEVAR for acute and subacute TBAD might be promising for the prevention of RTAD.

Postoperative initial 2-day blood pressure management facilitates the shrinkage of abdominal aortic aneurysm after endovascular aneurysm repair by reducing the incidence of type II endoleak.

OBJECTIVE: The aim of this study was to evaluate the effect of initial 2-day blood pressure management (BPM) after endovascular aneurysm repair (EVAR) for the incidence of subsequent type II endoleak (T2E) and shrinkage of abdominal aortic aneurysm (AAA) sac diameter. METHODS: We reviewed 136 patients who underwent EVAR for atherosclerotic AAA between July 2008 and July 2014 with one of three stent grafts (Excluder [W. L. Gore & Associates, Flagstaff, Ariz], Powerlink [Endologix Inc, Irvine, Calif], and Endurant [Medtronic Vascular, Santa Rosa, Calif]). Starting from 2013, the mean blood pressure of 76 participating patients (treatment group) was maintained at 75 to 90 mm Hg for the initial 48 hours after EVAR. The incidence of T2E at 7 days and AAA sac diameter 12 months after EVAR were evaluated using computed tomography scanning. The results so obtained were then compared with those of the control group composed of 60 consecutive patients who underwent EVAR before 2013. RESULTS: The incidence of T2E at 7 days was significantly lower in patients who received treatment (treatment group, 19.7%; control group, 40.0%; P = .013), and AAA sac diameter at 12 months in the treatment group had a mean decrease of 5.1 mm compared with the mean 2.2 mm in the control group (P = .004). In multivariate regression analysis, BPM was significantly related to the reduction of incidence of T2E at 7 days (odds ratio, 0.31; P = .007) and a decrease in AAA sac diameter at 12 months (P = .005). In addition, although the use of Endurant had less effect, the use of Excluder under controlled blood pressure conditions improved the incidence of T2E from 80% to 23% compared with those under normal postoperative management (P = .001). CONCLUSIONS: The initial 2-day postoperative BPM might have positive effects, such as lower incidence of T2E and facilitation of AAA sac shrinkage.

Influence of epicardial adipose tissue inflammation and adipocyte size on postoperative atrial fibrillation in patients after cardiovascular surgery.

Epicardial adipose tissue (EAT) is an active endocrine organ that is closely associated with occurrence of atrial fibrillation (AF). However, the role of EAT in the development of postoperative AF (POAF) remains unclear. We aimed to investigate the association between EAT profile and POAF occurrence in patients who underwent cardiovascular surgery. We obtained EAT samples from 53 patients to evaluate gene expression, histological changes, mitochondrial oxidative phosphorylation (OXPHOS) capacity in the EAT, and protein secretion in EAT-conditioned medium. EAT volume was measured using computed tomography scan. Eighteen patients (34%) experienced POAF within 7 days after surgery. Although no significant difference was observed in EAT profile between patients with and without POAF, logistic regression analysis identified that the mRNA expression levels of tumor necrosis factor-alpha (TNF-α) were positively correlated and adipocyte size in the EAT was inversely correlated with onset of POAF, respectively. Mitochondrial OXPHOS capacity in the EAT was not associated with POAF occurrence; however, it showed an inverse correlation with adipocyte size and a positive correlation with adiponectin secretion. In conclusion, changes in the secretory profile and adipocyte morphology of the EAT, which represent qualitative aspects of the adipose tissue, were present before the onset of AF.

Outcomes of Vascular Surgery Performed Jointly With Other Departments.

OBJECTIVE: The purpose of this study is to evaluate the results of vascular surgery performed at our hospital, a tertiary emergency general hospital, in patients undergoing surgery in other departments. The results of the study were reviewed. METHODS: The study included cases in which cardiovascular surgery was performed at the request of other departments over a 15-year period from January 2006 to October 2022. Patient backgrounds, departments that requested surgery, surgical procedures, use of extracorporeal circulation, and surgical techniques were reviewed. Patients with femoral artery exposure or ECMO removal during transcatheter aortic valve implantation (TAVI) requested by cardiology were excluded. RESULTS: There were 58 vascular surgery cases requested by other departments during the study period. The age was 63±14 years, 43 (74%) were male and 15 (26%) were female. The departments of the patients were urology in 29 (50%), gastroenterology in 18 (31%), orthopedics in seven (12%), emergency department in three (5%), and obstetrics and gynecology in one (2%). The following surgical procedures were performed: tumor resection and reconstruction due to tumor invasion of the inferior vena cava in 27 cases (47%), bypass to secure intraperitoneal arterial blood flow in 15 cases (26%), bypass during resection of the femoral tumor in four cases (7%), hemostasis due to trauma in three cases (5%), intraperitoneal hemostasis in three cases (5%), thrombectomy in two cases (3%), and others in four cases (7%). Extracorporeal circulation was used in six (10%) of the patients. CONCLUSION: A 15-year case study of vascular surgery supports operations requested by other departments at our hospital. All reconstructed sites were open at the time of discharge.

Coronary Artery Bypass Grafting Using the No-Touch Great Saphenous Vein Graft Harvesting Technique: A Retrospective Study.

Background We focused on coronary artery bypass grafting using the great saphenous vein and compared the no-touch great saphenous vein and conventional great saphenous vein. Methods Coronary artery bypass grafting using the great saphenous vein was performed at our hospital over a 15-year period from 2007/04 to 2022/08. The primary endpoint was the patency of the great saphenous vein at discharge, and secondary endpoints were delayed healing of the great saphenous vein harvest wound, delayed healing of the mid-thoracic wound, and factors related to coronary artery bypass surgery. Results There were 183 patients who underwent coronary artery bypass surgery using the great saphenous vein during the study period. There were 131 male patients (72%) and 52 female patients (28%) with a mean age of 69 years (38-94 years). The method of harvesting the great saphenous vein was a no-touch great saphenous vein graft (NT-SVG) in 29 cases (16%) and conventional SVG in 154 cases (84%). Patients were divided into two groups: the NT-SVG group and the standard-collection saphenous vein graft (SVG) group. We compared graft patency at discharge, healing failure of the lower leg wound, healing failure of the mid-thoracic wound, and flow by transit-time flow measurement (TTFM). Conclusion There were no significant differences in perioperative outcomes between the NT-SVG and conventional SVG groups in this study.

Repeated Epstein-Barr virus-associated hemophagocytic syndrome in a lupus nephritis patient.

A 55-year-old Japanese female was diagnosed with systemic lupus erythematosus (SLE) and developed nephrotic syndrome. She was diagnosed with lupus nephritis by a percutaneous renal biopsy. She was treated with intravenous steroid pulse therapy twice, but it proved to be ineffective. She achieved a complete remission after intravenous cyclophosphamide pulse (CPAIV) therapy. Thereafter, her lupus nephritis was well controlled and demonstrated only a low activity. However, she suffered Epstein- Barr virus (EBV)-associated hemophagocytic syndrome (HPS) twice, and in each case she was treated with anticancer drugs and achieved a complete remission. This was a rare case of lupus nephritis who showed repeated EBV-associated HPS.

Development of Wernicke's encephalopathy during initiation of hemodialysis in an elderly non-alcoholic patient.

A 79-year-old man with chronic renal failure developed general fatigue and loss of appetite. He was diagnosed with endstage renal disease and was started on hemodialysis (HD). The symptoms improved immediately, but the mental status deteriorated gradually, reaching Glasgow Coma Scale (GCS) 5. Computed tomography showed no significant intracranial lesion, but magnetic resonance images showed symmetric high-intensity changes in the periaqueductal area, suggestive of Wernicke's encephalopathy (WE). He was immediately treated with intravenous infusion of thiamine. Five days later, the mental status level improved up to GCS 14, and the above MRI findings disappeared. To our knowledge, this is the first report describing the clinical outcome of a non-alcoholic patient who developed WE during initiation of HD. WE should be suspected in patients who are on chronic HD as well as those on initiation of HD with unexplained neurological abnormalities.

Successful treatment of recurrent thoracic aortic prosthetic graft infection after omentopexy by free latissimus dorsi and rectus abdominis muscle flap.

A 50-year-old patient who underwent total aortic arch replacement for acute type A aortic dissection developed recurrent thoracic prosthetic graft infection after omentopexy for the treatment of initial postoperative graft infection of the ascending aorta and transverse aortic arch. We report the successful treatment of the disastrous complication by covering the prosthetic graft with a free latissimus dorsi muscle flap coupled with a pedicled rectus abdominis myocutaneous flap for the reduction of mediastinal dead space, following surgical disinfection with partial graft reconstruction.

Left ventricular mass index is an independent determinant of diastolic dysfunction in patients on chronic hemodialysis: a tissue Doppler imaging study.

BACKGROUND: Diastolic heart failure is the most common clinical form of heart failure. Tissue Doppler imaging (TDI) is often used to quantitate left ventricular (LV) diastolic function. The purpose of this study was to identify the determinant(s) of diastolic dysfunction in patients with end-stage renal disease on hemodialysis (HD), using the TDI method. METHODS: The study subjects were 53 patients with end-stage renal disease and preserved LV systolic function on maintenance HD. LV function was assessed by conventional echocardiography. The ratio of early trans-mitral flow velocity to early mitral annular velocity (E/e') was measured by TDI. Patients were stratified into two groups based on E/e' value (≤15 and >15 groups). Arterial stiffness was evaluated by pulse wave velocity and cardio-ankle vascular index. RESULTS: Patients of the E/e' >15 group were older (p = 0.025). There were no significant differences in blood pressure, ejection fraction, E/A, deceleration time, and pulse wave velocity between the E/e' >15 and E/e' ≤15 groups. However, there were significant differences in LV mass index (LVMI; p < 0.001) and cardio-ankle vascular index (p = 0.048) between the two groups. Multiple regression analysis identified that LVMI was an independent determinant of E/e' (p = 0.003). CONCLUSIONS: Our findings suggest that LVMI is an independent determinant of LV diastolic dysfunction in patients on HD.

Quantitative evaluation of superior mesenteric artery calcification in hemodialysis patients undergoing aortic valve replacement.

OBJECTIVE: Postoperative acute mesenteric ischemia (AMI) in the long-term hemodialysis (HD) patients could be a disastrous complication leading to high mortality. The objective is to evaluate the association between the presence of superior mesenteric artery calcification (SMAC) and early and late outcomes after aortic valve replacement (AVR) in HD patients. METHODS: Between April 2003 and December 2018, the enrolled 46 HD patients (19 women; mean age 72 years) who underwent AVR for severe aortic valve stenosis were retrospectively reviewed. 25 patients (54.3%) who had severe calcifications of superior mesenteric artery (SMA) were defined as the SMAC group, and the calcification extent of SMA was evaluated on preoperative non-contrast CT using Agaston calcium score [calcification area (cm2) × max CT value (HU)]. The operative outcomes were compared with those of the non-SMAC group comprising 21 patients (45.7%). RESULTS: The following factors in SMAC group were statistically higher compared with those of the non-SMAC group: age (73.6 ± 7.2 vs 69.3 ± 7.1 years; p = 0.04), celiac artery calcification (76.4% vs 17.6%; p < 0.001), calcium score of SMA (692.3 ± 300.0 vs 123.5 ± 180.7; p < 0.001), the incidence of AMI (24.0% vs 4.7%; p = 0.001), and hospital mortality (16.0% vs 0%; p = 0.02). In multivariate analysis, the presence of SMAC was significantly associated with AMI (OR 3.8, p = 0.05) and hospital mortality (OR 2.4, p = 0.02). Calcium score of SMA in patients complicated with AMI was significantly higher than those without AMI (815.7 ± 300.5 vs 366.9 ± 351.2; p < 0.01). CONCLUSION: Quantitative evaluation of SMAC could be a predictive marker of incidence of AMI after AVR in HD patients.

Emergency Endovascular Aneurysm Repair Coupled with Staged Omentopexy for Primary Aorto-Duodenal Fistula.

A primary aorto-duodenal fistula (ADF), a rare, spontaneous development of a communication between the aorta and duodenum, is a disastrous complication of an abdominal aortic aneurysm. A 73-year-old patient with primary ADF underwent emergent endovascular aneurysm repair (EVAR), followed by staged omentopexy, without removing a stent graft (SG). The patient received long-term treatment with antibiotics, and there has been no evidence of infection during a follow-up period of three years. Emergency EVAR coupled with omentopexy, may be a treatment option for primary ADF, even when it means leaving the SG in a potentially infectious site.

Obstructive acute renal failure related to amantadine intoxication.

We report the case of a 69-year-old woman with seizures and acute renal failure with hyperkalemia. She presented with bladder turgescence and hydronephrosis on admission and was diagnosed as obstructive acute renal failure. Urethral catheterization was performed after a single-session hemodialysis. It resulted in immediate improvement of renal function and consciousness, and subsequent disappearance of seizures. Improvement of serum creatinine level to 0.7 from 10.6 mg/dL was associated with a fall in blood level of amantadine hydrochloride from 4.40 to 0.47 microg/mL. Physicians should be aware of urinary retention in patients treated with amantadine as a first sign of intoxication that could lead if untreated to obstructive acute renal failure. And we recommend to check the overdose symptoms, even those with normal renal function, treated with amantadine.