Eisuke Kawakubo

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

PurposeEndovascular 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.MethodsDemographic, 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.ResultsThe 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.ConclusionsMost 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.

Fibromuscular Dysplasia of the Lower Extremities

Fibromuscular dysplasia (FMD) is a nonatherosclerotic, non-inflammatory vascular disease that mainly affects the renal and internal carotid arteries. Involvement of other sites, including arteries of the extremities, is uncommon, and only a few histologically confirmed cases have been reported. FMD of the arteries of the extremities can result in ischemia requiring surgical or endovascular reconstruction. In the present report, two cases of FMD are described: one case of femoropopliteal artery occlusive disease, and one case of nonsymptomatic progression of external iliac artery dissection, both with histological confirmation of FMD. Clinical presentation, treatment, outcome and histological findings of previously reported cases are reviewed. FMD should be considered as a cause of occlusion, stenosis, dissection or aneurysm of the peripheral arteries: although rare, it can lead to limb-threatening ischemia or life-threatening aneurysm rupture.

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.

Evaluation of the Paramalleolar Bypass for Critical Limb Ischemia Patients on Hemodialysis with Diabetes Mellitus and Chronic Renal Failure

OBJECTIVE To assess the influence of diabetes mellitus (DM) and end-stage renal failure on hemodialysis (HD) on the healing time of tissue lesions and blood flow to the foot following a paramalleolar bypass in patients with critical limb ischemia (CLI). METHODS Consecutive patients with CLI and tissue loss (24 limbs) were followed up retrospectively after paramalleolar bypass, and the healing time of tissue lesions, graft patency, limb salvage and survival rates were analyzed. The blood flow to the foot was assessed by skin perfusion pressure (SPP) pre- and postoperatively. The delta SPP was calculated as the difference between the SPP before and after bypass. The patients were divided into 3 groups: diabetic (DM, n = 9); diabetic and end-stage renal failure on hemodialysis (HD, n = 10); or neither (n = 5). RESULTS A total of 15 dorsal and 9 plantar artery bypasses were performed. The median follow-up was 7.3 months (range, 1-18 months). No patients required major amputations, and all tissue lesions healed. The mean duration to complete tissue healing of the DM, HD and neither groups was 2.2, 2.5 and 1.2 months, respectively, was and these were not statistically significant. A significant improvement in the delta SPP after paramalleolar bypass was observed in the neither group compared with both the DM and HD groups. CONCLUSION Blood flow to the foot was not sufficiently improved in CLI patients with DM and HD, despite paramalleolar bypass. This may be the cause of the prolonged tissue healing duration of CLI patients with DM and HD. (English Translation of Jpn J Vasc Surg 2012; 21: 91-95).

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 patients 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.

Barthel Index and Outcome of Open Bypass for Critical Limb Ischemia

BACKGROUND Daily activity should be an important factor to consider when deciding on a treatment strategy for critical limb ischemia (CLI), and we hypothesized that there was a close relationship between activities of daily living (ADL) and prognosis. The aim of this study was to investigate the association between ADL and outcomes of open bypass for CLI.Methods and Results:A total of 226 patients undergoing infrainguinal bypass for CLI between January 2005 and December 2015 were reviewed. They were divided into 2 groups based on Barthel index (BI) at admission (pre-BI; ≥60 and <60) and compared with respect to the incidence of early adverse events and 3-year overall survival and amputation-free survival. Adverse events were more frequently observed in patients with pre-BI <60. Patients with pre-BI <60 had worse long-term outcomes. On multivariable analysis, hypoalbuminemia, end-stage renal disease, and BI at discharge <60 were significant predictors of 3-year outcomes, whereas pre-BI <60 was not a significant predictor of either outcome. CONCLUSIONS It is not BI at admission, but BI at discharge that determines long-term outcome.

Endovascular aneurysm repair for an abdominal aortic aneurysm and a left ruptured common iliac artery aneurysm in a patient with hepatocellular carcinoma: report of a case

We performed an endovascular aneurysm repair (EVAR) for an abdominal aortic aneurysm (AAA) and a ruptured common iliac artery aneurysm (rCIAA) in a patient complicated by severe liver dysfunction due to obstructive jaundice resulting from hepatocellular carcinoma (HCC). A 68-year-old male presented with acute lower abdominal pain. Abdominal computed tomography (CT) showed a 4.5-cm infrarenal AAA, a 6.0-cm left rCIAA with retroperitoneal hematoma and a 13-cm mass in the liver, which was suspected to be HCC. His laboratory data showed severe liver dysfunction. An emergency EVAR was done under local anesthesia because of his liver dysfunction. He was transferred to another hospital without any complications.

Long-Term Results of Femorotibial Polytetrafluoroethylene Bypass with a Distal Vein Cuff for Critical Limb Ischemia

Objective: Although autologous veins are the first-choice conduit for femorotibial artery bypass, if there are no appropriate autologous veins, we perform femorotibial artery bypass using polytetrafluoroethylene (PTFE) with a distal vein cuff for patients with critical limb ischemia (CLI). This study examined the long-term outcomes of femorotibial artery bypass using PTFE with a Miller’s cuff. Materials and Methods: Using prospectively collected data for 444 distal bypasses, a retrospective analysis was conducted for 32 femorotibial PTFE bypasses with a Miller’s cuff (PTFE-Miller’s cuff) performed for patients with CLI from April 1994 to December 2016. Results: Primary and secondary patency rates of PTFE-Miller’s cuff at 3 years were 35.8% and 51.2%, respectively. Limb salvage rate of PTFE-Miller’s cuff at 3 years was 71.0%. Conclusion: Although the patency rate was low and failed to yield satisfactory results, the limb salvage rate remained relatively high. Femorotibial PTFE bypass with a Miller’s cuff was a useful technique of limb salvage for patients with CLI in whom an appropriate autologous vein could not be used.

Late Onset of Thoracic Aortic Disease Events after Abdominal Aortic Aneurysm Repair: Effect on Survival and Possible Associated Factors

We investigated the possible relation between thoracic aortic disease events and long-term survival in patients after open Abdominal Aortic Aneurysm (AAA) repair, as well as factors associated with event occurrence. Pre-AAArepair demographic, comorbid, and laboratory variables in 48 patients who had an aortic dissection or thoracic aortic aneurysm up to 25 years after AAA repair were compared with the same variables in 522 patients without such an event. Survival rates at 5 and 10 years were 87% and 53%, respectively, in patients with a thoracic aortic event and 74% and 56% in those without an event (P=.7). Multivariate analysis showed that the risk of thoracic aortic events was increased by a high hemoglobin level, a high Fibrinogen Degradation Product (FDP) level, and a larger AAA diameter. The only factors significantly associated with thoracic aortic events were an AAA diameter of ≥ 55 mm and a high FDP level.