Hirofumi Midorikawa

Intravascular Imaging Methods for Venous Disorders.

The purposes are to assess the problems associated with intravascular imaging methods such as angioscopy and intravascular ultrasound (IVUS) and to evaluate their efficacy through the results of our observations. A total of 54 limbs in 53 patients, 50 patients with chronic venous insufficiency and 3 patients with deep vein thrombosis, were diagnosed and operated on using angioscopy (Olympus OES, order made type) and IVUS (Endosonics, model 82700). The imaging catheters were inserted through a branch of the long saphenous vein and the valves and the intraluminal views were observed. By angioscopy, intraluminal views were clearly observed in 98% of all lesions. However, observation became more difficult in iliac veins compared to in femoral and in long saphenous veins (p<0.01). Venous wall and thrombus were detected more by IVUS than by angioscopy (p<0.01), but only 21 valves (24%) were visualized by IVUS among the 88 valves observed by angioscopy. The intravascular imaging method of angioscopy is more suitable for observing valves and intraluminal views compared with IVUS, whereas IVUS is more suitable for observing the cross-sectional venous wall.

Management Strategy of Isolated Spontaneous Dissection of the Superior Mesenteric Artery

OBJECTIVE Isolated spontaneous dissection of the superior mesenteric artery (SMA) is very rare among of the visceral artery dissection and its treatment is not established. In this paper we present our experiences and consider the treatment of isolated SMA dissection. METHODS A retrospective review of our cases from 2005 was performed. Clinical symptoms, radiologic findings and results were evaluated. There were 14 cases of visceral artery dissection, in which all cases were with SMA dissection. There were 12 males and 2 females with a mean age of 57 years (range 41-78 years). RESULTS We categorized SMA dissection into the six types according to the Sakamotos and Zerbibs classification. One patient with type VI underwent emergent endovascular surgery with stent. One patient with type VI received thrombectomy and intimectomy with open surgery. One patient with type II underwent aneurysmectomy due to enlarged dissected SMA 3 months later from onset. The other eleven patients were managed conservatively. At follow-up, the diameter of SMA did not enlarged and the length of the dissection significantly decreased to 20.7 ± 15.7 mm from 38.0 ± 15.1 mm at onset (p <0.01). After treatment, imaging indicated the following changes in classification: type I, one patient; type II, 4 patients; type IV, 4 patients; complete remodeling, one patient, all without any event during the follow-up period of 5-82 months. CONCLUSION Most patients with isolated visceral artery dissection occurred in superior mesenteric artery and can be treated conservatively; however, endovascular or surgical procedures including laparotomy are indicated when there is suspicion of severe mesenteric ischemia. Because the dissection configuration will change, long term follow-up is necessary. (English translation of Jpn J Vasc Surg 2013; 22: 695-701).

Clinical results of radiofrequency endovenous obliteration for varicose veins.

PurposeRadiofrequency (RF) endovenous obliteration is performed in the United States and several European countries for the minimally invasive treatment of saphenous-type varicose veins. We evaluated the clinical results of RF endovenous obliteration to treat varicose veins at Fukushima Daiichi Hospital.MethodsWe performed endovenous obliteration of 25 great saphenous varicose veins in 20 patients, under duplex ultrasound guidance. None of the varicose veins were tortuous in the thigh area. Venous occlusion was evaluated by duplex ultrasound under cuff compression with the patient standing, preoperatively, then 1 day and 1 month postoperatively.ResultsSaphenous obstruction was confirmed in all legs 1 day and 1 month postoperatively, as complete obstruction from the saphenofemoral junction in 1, as complete obstruction with only superficial epigastric venous flow in 23, and as near complete obstruction (patent length > 5 cm) in 1. The venous obstruction was caused by shrinkage of the vein (31.2% of the area at the saphenofemoral junction, 44% at the thigh, and 57.7% at the knee) and thrombus formation. The only complications of RF endovenous obliteration were clinical superficial thrombophlebitis (13%) and temporal sensory nerve injury (4%).ConclusionRadiofrequency endovenous obliteration is as effective as, but less invasive than other treatments for saphenous varicose veins.

Prevention of paraplegia in transluminally placed endoluminal prosthetic grafts for descending thoracic aortic aneurysms

OBJECTIVE To evaluate the efficacy of a temporary balloon occlusion test for the prevention of paraplegia following transluminally placed endoluminal prosthetic grafts for descending thoracic aortic aneurysms. SUBJECTS AND METHODS Two occlusion balloons were inserted via the brachial and femoral arteries and positioned in the proximal and distal neck of the descending thoracic aortic aneurysms using fluoroscopy. After temporary occlusion of the thoracic aorta by inflation of both the proximal and distal balloons, the evoked spinal potential was measured for 15 mins. A maximum amplitude during temporary balloon occlusion test decreasing by more than 20% of the pre-balloon occlusion level was considered to be significant, enough to not perform transluminally placed endoluminal prosthetic grafts, but instead an open repair. The test was applied in 12 cases (9 males and 3 females, 50-86 years old). All aneurysms were located between the Th6 and Th12 with a maximum diameter of 40-70 mm, and average of 56 mm. RESULTS The changes in maximum amplitude of evoked spinal potential remained within 20% of the value before balloon occlusion in 11 cases. Transluminally placed endoluminal prosthetic grafts were performed in these 11 cases and no instance of paraplegia or other complication relating to the test was observed. Deployment of stent-grafts was successful in 10 cases (91%). CONCLUSION It is suggested that the preoperative measurement of evoked spinal potential during temporary balloon occlusion is clinically useful for the assessment of the risk to paraplegia occurring in transluminally placed endoluminal prosthetic grafts.

External valvuloplasty for primary valvular incompetence of the lower limbs using angioscopy

The morphology of 145 vein valves of venous stasis syndrome was studied and classified into three types by means of angioscopy. External valvuloplasty for primary valvular incompetence (PVI) was performed in 21 highest valves of the superficial femoral vein and 46 subterminal valves of the long saphenous vein under direct vision using angioscopy. Within external valvuloplasty, Technique I is total plication of the dilated vein annulus by running a suture around the vein; Technique II is plication by placing an autogenous femorofascial band; and Technique III is direct suture of valve commissure including the leading edge of the cusp from the outside vein wall using horizontal mattress suture with pledgets. Venous regurgitation was reduced from grade III–IV to grade 0–1 in descending phlebography after external valvuloplasty. Ambulatory venous pressure improved from 42% to 54% postoperatively. Reflux volume by Duplex scanning was significantly decreased after external valvuloplasty and maintained a reduced level. Surgical results of external valvuloplasty using angioscopy are satisfactory in all cases of the superficial femoral vein and in 91% of the long saphenous vein in 2–4-year follow-up. External valvuloplasty using angioscopy is a simple and reliable surgical technique. It is necessary to have a longer follow-up in order to fully evaluate the value of these external valvuloplasty techniques.

Endovascular Repair of a Kommerell's Diverticulum and Aneurysmal Right-sided Aortic Arch: A Case Report.

Right-sided aortic arch with aberrant left subclavian artery is an uncommon anomaly. We describe a case of Kommerells diverticulum involving the distal portion of a right-sided aortic arch and the origin of an aberrant left subclavian artery in a 74-year-old man with hoarseness. The patient underwent successful endovascular repair of the aneurysm with use of a Gore TAG thoracic endoprosthesis and coil embolization of the left subclavian artery. Postoperative computed tomography showed complete exclusion of the lesion, without endoleaks. Endovascular repair is feasible and can be effective in such cases.

Clinical results of open stent grafting applied using an improved endotracheal tube in the treatment of high-risk patients with distal arch aneurysms

Whereas the operative results for thoracic aortic aneurysms (TAA) have improved in recent years, the results for distal arch aneurysms (DAA) remain unsatisfactory. We report herein the initial results of open stent grafting (OSG) applied using an improved endotracheal tube for surgical treatment of high-risk DAA. OSG was used to treat DAA in five men aged 69–80 years (mean, 77 years). Four cases involved chronic obstructive pulmonary disease, and the remaining case involved both ischemic heart disease and chronic renal failure. Previous surgical repairs of an abdominal aortic aneurysm had been performed in four patients, and thoracoplasty and reconstruction of the lower extremities had been performed in the remaining patient. Under selective cerebral perfusion, OSG with revascularization of two cerebral branches was performed in two patients, whereas OSG with total arch replacement was performed in three patients. The procedure was successful in all cases. There were no complications related to cerebrospinal disorders, and complete thrombosis of the aneurismal sac was achieved in all cases. The new deployment method using an endotracheal tube offers numerous advantages, including reduced aortic wall injury and accurate placement of the stent graft in the operative field. These initial results suggest that this specific approach makes OSG a useful surgical procedure in the treatment of high-risk DAA.

Fully supported open stent grafting applied with a Matsui-Kitamura (MK) stent in treatment of distal arch aneurysm

ObjectiveOur purpose was to examine the use of fully supported open stent grafting (OSG) with a Matsui-Kitamura (MK) stent for treatment of distal arch aneurysm (DAA).MethodsSurgery was performed using a newly developed device in seven DAA patients (six men and one woman) from 58 to 86 years of age (mean, 73 years old) from August 2005 to June 2007. The aorta was transected at the arch between bracheocephalic artery and left subclavian artery under circulatory arrest with total cardiopulmonary bypass and selective cerebral perfusion; then the stent grafting (SG) system was inserted and positioned with a 14 Fr. pusher. The SG and a transected edge were then sutured and anastomosed with the arch graft. The surgery was completed by constructing three cerebral branches.ResultsThe mean SG diameter and length were 34.6 mm (range, 32–38 mm) and 150 mm (120–200 mm), respectively. The mean time of circulatory arrest time and surgery were 41 min (35–55 min) and 358 min (269–450 min), respectively. Simultaneous mitral valve replacement was performed in one patient. All surgeries were completed successfully, and complete thrombosis of the aneurysm was obtained. Paraparesis and respiratory failure occurred in one patient each, and one patient died of brainstem infarction 1 month after surgery.ConclusionThese initial results suggest that the OSG method is a useful surgical procedure for the treatment of DAA.

Graft-wall endoleak 18 months after successful endoluminal AAA repair

Purpose: To describe a case of graft-wall endoleak 18 months after successful endoluminal repair of an abdominal aortic aneurysm (AAA). Methods and Results: A 71-year-old man with infrarenal AAA was successfully treated with an endoluminal aortomonoiliac graft and femorofemoral crossover bypass with surgical ligation of the right external iliac artery. The stent-graft was made from 2 Gianturco Z-stents and a tapered thin-walled (0.1-mm) Dacron graft. Eighteen months after endografting, the patient complained of a pulsatile abdominal mass. Angiography and computed tomography showed graft-wall endoleak. Aneurysmectomy was performed, and the aneurysm was successfully replaced with a Y-shaped knitted Dacron graft. A hole in the graft wall was found 3 cm from the proximal edge of the stent-graft. Conclusions: This case suggests that the use of thin-walled graft material in endografts may not be sufficiently durable.

The Appearance of Cytokines and Adhesion Molecules in Saphenous Vein Valves in Chronic Venous Insufficiency

Objective: To evaluate the difference between competent valves and incompetent valves with regards to the development of expression of cytokines and adhesion molecules in primary varicose veins. Methods: Specimens were obtained from 13 patients with primary varicose veins during surgery. Valves were classified according to the angioscopic findings: 8 competent and 17 incompetent valves; type I (7 valves with elongated cusps) and type II (10 valves with expansion of commissures). The mRNA levels of interleukin-1β (IL-1β), interleukin-6 (IL-6), interleukin-8 (IL-8), tumour necrosis factor-α (TNF-α), transforming growth factor-β (TGF-β), intercellular adhesion molecule-1 (ICAM-1), vascular cell adhesion molecule-1 (VCAM-1) and endothelial leucocyte adhesion molecule-1 (ELAM-1) were measured by polymerase chain reaction (PCR) amplification of cDNA reverse-transcribed from RNAs. Results: In all cases there were few appearances of IL-6, IL-8 and TNF-α at the valve cusps. TGF-β and VCAM-1 levels were highly elevated in the cusps of incompetent valves compared with competent valves (p<0.05). At the venous wall IL-6 and IL-8 occurred more frequently in incompetent valves than in competent valves (p<0.05). Conclusion: This study suggests that inflammatory cytokines and adhesions molecules, especially TGF-β, IL-6, IL-8 and VCAM-1, may be related to the occurrence of valve insufficiency.