Hidetoshi Uchiyama

Intraarterial Injection of Indocyanine Green for Evaluation of Peripheral Blood Circulation in Patients with Peripheral Arterial Disease

BACKGROUND To assess the peripheral blood flow of patients with peripheral arterial disease (PAD) by indocyanine green (ICG) arteriography (ICGA) with intraarterial injection of ICG and evaluate the efficacy of the ICGA tests. METHODS This study was undertaken from a retrospective review of patients with PAD who underwent ICGA tests during digital subtraction angiography (DSA) between November 2012 and June 2013. We defined some ICGA parameters as the magnitude of intensity of ICG, the time to maximum intensity, and the time from fluorescence onset to half the maximum intensity (T1/2). The ICGA parameters were evaluated in 2 regions, named regions of interest (ROIs). ROI 1 was part of the dorsum of the foot from the Chopart joint to the Lisfranc joint. ROI 2 was in the distal region of the first metatarsal bone and compared with the ankle-brachial pressure index (ABI), ankle pressure, toe-brachial pressure index, and toe pressure. RESULTS A total of 22 limbs in 16 patients with PAD underwent ICGA tests during DSA. The T1/2 on ROI 2 was the most correlated with the ABI (ρ=-0.622, P=0.003). A value of T1/2 for ROI 2>10 sec was significantly correlated with an ABI value of <0.7 (sensitivity: 0.85, specificity: 1.0). CONCLUSIONS By measuring the value of T1/2 in ROI 2, ICGA tests can be performed to assess the peripheral blood circulation during DSA. ICGA tests might help to promptly assess the peripheral blood flow during endovascular treatment procedures.

Indocyanine Green Angiography for the Diagnosis of Peripheral Arterial Disease with Isolated Infrapopliteal Lesions

BACKGROUND In this study, we evaluated the accuracy of the indocyanine green angiography (ICGA) test to diagnose peripheral arterial disease (PAD) with isolated infrapopliteal lesions. METHODS This study was undertaken from a retrospective review of PAD patients with isolated infrapopliteal lesions who underwent ICGA between November 2012 and July 2013. We calculated the ICGA parameters while comparing the findings with the ankle-brachial index (ABI) and toe-brachial index (TBI) in patients with infrapopliteal lesions. RESULTS Twenty-three limbs with isolated infrapopliteal lesions in 14 PAD patients and 15 limbs without arterial lesions in 9 control patients were examined using ABI, TBI, and ICGA. The Td 90% (the time elapsed from the maximum intensity to 90% of the maximum intensity) correlated most significantly with the ABI value. A cutoff value of Td 90% >25 sec also significantly correlated with the presence of PAD (sensitivity, 82.6%). CONCLUSIONS ICGA might therefore be useful for assessing the peripheral perfusion quantitatively, even in PAD patients with isolated infrapopliteal lesions. The use of Td 90% on ICGA may also be effective for accurately estimating the presence of PAD.

Quantitative evaluation of microvascular dysfunction in peripheral neuropathy with diabetes by indocyanine green angiography

AIMS Peripheral neuropathy in diabetes (PND) plays a central role in foot ulceration with diabetes, and leads to an abnormal microvascular structure, including arteriovenous shunting. To assess the extent of arteriovenous shunting we performed indocyanine green angiography (ICGA) in patients with diabetes and evaluated quantitative ICGA parameters. METHODS Between November 2012 and July 2013, twenty-six limbs in 14 patients with PND and twenty-three limbs in 15 patients without PND underwent ICGA testing. The ICGA parameters, which included the time to maximum intensity (Tmax), the time from fluorescence onset to half the maximum intensity (T1/2), the time elapsed from the maximum intensity to 90% of the Imax and to 75% of the Imax (Td 90% and Td 75%, respectively) and the rate of intensity measured 60s after the Tmax to Imax (IR 60s), were compared between the patients with and without PND. RESULTS The Tmax, T1/2, Td 90%, Td 75% and IR 60s were significantly different between patients with and without PND. A value of Td 90% >30s was significantly correlated with the presence of PND (sensitivity: 0.85, specificity: 0.78). CONCLUSIONS ICGA tests can be used to quantitatively assess arteriovenous shunting in the limbs with PND. By measuring the value of the Td 90%, ICGA tests can estimate the presence of the arterio-venous shunting in PND, which might be helpful for assessing the progression of foot ulceration with diabetes, gangrene and the need for amputation.

Maggot Debridement Therapy for Peripheral Arterial Disease

INTRODUCTION Maggots are potent debriding agents capable of removing necrotic tissue and slough; however, it is still unclear which wounds are most likely to benefit from maggot debridement therapy (MDT). Thus, we performed this retrospective review to gain insight into the patient and therapy characteristics influencing outcome. PATIENTS AND METHODS We reviewed patients with foot ulcers caused by critical limb ischemia, encountered during the period between June 2005 and May 2010. The treatment outcomes were defined as effective or ineffective. RESULTS There were 16 patients with 16 leg ulcers. The patients were 13 men and 3 women, with an average age of 67.2 years (range, 47-85 years). Ten (63%) of the 16 ulcers were treated effectively. According to univariate analyses, an ankle brachial pressure index (ABI) lower than 0.6 (p = 0.03) had a negative impact on the outcome of MDT; however, outcome was not influenced by gender, obesity, ischemic heart disease, diabetes mellitus, hemodialysis, smoking, or laboratory findings. CONCLUSIONS Some patient characteristics, such as gender, obesity, ischemic heart disease, diabetes mellitus, hemodialysis, and smoking, do not seem to contraindicate eligibility for MDT. However, a limb with an ABI lower than 0.6 is less likely to benefit. (English Translation of J Jpn Coll Angiol 2011; 51: 209-213.).

Early experience with the endowedge technique and snorkel technique for endovascular aneurysm repair with challenging neck anatomy.

OBJECTIVES This study was evaluating the outcomes of endovascular aneurysm repair (EVAR) using the endowedge technique (EnT) and/or snorkel technique (SnT) for abdominal aortic aneurysms (AAAs). MATERIALS AND METHODS The patients treated with EnT and/or SnT were retrospectively reviewed between January 2010 and June 2013. All patients underwent EVAR under general anesthesia. Bilateral femoral arterial access was obtained through bilateral femoral cut-down to place the stent graft mainbody, and brachial arterial access was obtained percutaneously to perform the EnT and/or SnT. RESULTS Three patients were treated with unilateral EnT, 1 with unilateral SnT, two with bilateral SnT, and two with combined EnT/SnT. A total of 12 renal arteries was attempted to preserve, and could be successfully performed by these techniques in 11 renal arteries. After complete deployment of the endograft, intraoperative angiography showed no type Ia EL. During the median follow-up of 11 months (range: 2-22 months), no deaths nor aneurysm enlargement occurred, and all treated renal arteries were patent without further intervention. CONCLUSIONS Our findings suggest that the management of AAAs by EVAR with EnT and/or SnT could achieve an adequate proximal seal, and preserve renal artery perfusion in patients with unfavorable neck anatomy.

Anatomical variation at the sapheno-femoral junction.

OBJECTIVE The aim of this study was to assess the anatomical variations of the sapheno-femoral junction (SFJ) and the incidence of these variations. MATERIALS AND METHODS Between April 2005 and March 2010, 2552 limbs of 1563 patients with complaints of varicose veins underwent ultrasonography. Ultrasonography was used to identify the anatomical variations of the SFJ, especially the relationship to the femoral artery. RESULTS Variations were seen in six limbs (0.24%) at the SFJ. The most common anatomical variation was the great saphenous vein crossing posterior to the common femoral artery, which was present in three limbs. CONCLUSION It is important to investigate the anomalies of the SFJ using preoperative duplex ultrasound, although the incidence of such anomalies is lower than that of the sapheno-popliteal junction. An anomaly of the SFJ always should be taken into consideration in order to minimize surgical complications of varicose veins. (English translation of Jpn J Phlebol 2012; 23: 25-29).

Progression of Perianeurysmal Inflammation after Endovascular Aneurysm Repair for Inflammatory Abdominal Aortic and Bilateral Common Iliac Artery Aneurysms

The use of endovascular aneurysm repair (EVAR) to treat inflammatory abdominal aortic aneurysms (IAAAs) has been reported, and this procedure appears to be preferable to open surgical repair because of intraoperative difficulties related to inflammation. We herein report a case of IAAA and bilateral inflammatory common iliac artery aneurysms that was successfully treated with bifurcated stent grafting. The perianeurysmal inflammation worsened postoperatively, requiring the placement of a ureteric stent. EVAR is feasible in cases of inflammatory aneurysms; however, the potential for an inflammatory response should be taken into account when considering the application of EVAR in patients with IAAA.

Simultaneous assessment of blood coagulation and hematocrit levels in dielectric blood coagulometry

Background: In a whole blood coagulation test, the concentration of any in vitro diagnostic agent in plasma is dependent on the hematocrit level but its impact on the test result is unknown. Objective: The aim of this work was to clarify the effects of reagent concentration, particularly Ca2+, and to find a method for hematocrit estimation compatible with the coagulation test. Methods: Whole blood coagulation tests by dielectric blood coagulometry (DBCM) and rotational thromboelastometry were performed with various concentrations of Ca2+ or on samples with different hematocrit levels. DBCM data from a previous clinical study of patients who underwent total knee arthroplasty were re-analyzed. Results: Clear Ca2+ concentration and hematocrit level dependences of the characteristic times of blood coagulation were observed. Rouleau formation made hematocrit estimation difficult in DBCM, but use of permittivity at around 3 MHz made it possible. The re-analyzed clinical data showed a good correlation between permittivity at 3 MHz and hematocrit level (R2=0.83). Conclusions: Changes in the hematocrit level may affect whole blood coagulation tests. DBCM has the potential to overcome this effect with some automated correction using results from simultaneous evaluations of the hematocrit level and blood coagulability.

The Effect of Short Saphenous Vein Stripping in Patients with Deep Venous Reflux

OBJECT We assessed whether or not deep venous reflux (DVR) improved after short saphenous vein (SSV) stripping was performed in patients with SSV reflux and DVR. MATERIALS AND METHODS Sixty-eight patients with SSV reflux who underwent SSV striping every Monday between 2008 and 2011 at Ryougoku Ashino Clinic were enrolled in this study. Forty-six of the 68 patients were selected for the analysis because they underwent duplex ultrasound examinations before and after the operation. The DVR was classified into four categories: type 0, no reflux; type I, reflux in popliteal vein; type II, reflux from popliteal vein to the middle of the superficial femoral vein (SFV) and type III, reflux from the popliteal vein to the SFV. RESULTS There were 23, 13, 2 and 8 patients with type 0, I, II, III before operation, respectively. There were 33, 8, 1, 4 patients with type 0, I, II, III after operation, respectively. There were no changes in 29 patients, improvement in 15 and new DVR in three (type 0 to I). CONCLUSION SSV stripping is feasible in patients with DVR and the DVR might not be deteriorated even though that is performed.