Hiroki Takiuchi

Bypass vs. Endovascular Therapy of Infrapopliteal Lesions for Critical Limb Ischemia.

OBJECTIVE This study was conducted to determine whether to perform endovascular intervention or bypass surgery as a treatment option for critical limb ischemia (CLI) with lesions in the popliteal artery or below. SUBJECTS AND METHODS A total of 150 patients (164 limbs) with CLI underwent endovascular intervention or bypass surgery for lesions in the popliteal artery or below at our department between May 1995 and June 2011. Therapeutic outcomes were examined by surgical technique. An indication for endovascular intervention was established with the combination of (1) poor general condition, and (2) a stenotic or occlusive lesion ≤5 cm. RESULTS The bypass group (group B) comprised 119 patients (99 males, 20 females) with 131 affected limbs at 46 to 89 years of age (mean: 70 years). The endovascular intervention group (group E) comprised 31 patients (25 males, 6 females) with 33 affected limbs at 47 to 89 years of age (mean: 72 years). There was no significant difference in patient demography between the two groups. Regarding preoperative complications, hypertension was observed in 54% and 61% of the subjects in groups B and E, respectively, diabetes in 36% and 55%, renal dysfunction in 29% and 58%, ischemic heart disease in 27% and 32%, and cerebrovascular disorder in 18% and 23%; renal dysfunction accounted for a significantly higher percentage in group E. As for early postoperative complications, subjects in group B experienced wound infections (6 patients), hemorrhage (2), thrombosis (2), pneumonia (1), and another complication (1), and those in group E experienced wound infections (1) and another complication (1). The hospital mortality rate was 0.8% (1 patient) for group B and 0% for group E. The 3-year cumulative primary patency rate was 72% for group B and 54% for group E; the rate was significantly higher for group B. The 3-year secondary patency rate was 82% for group B and 60% for group E. The 3-year limb salvage rate was 86% for group B and 82% for group E; there was no significant difference between the two groups. The 5-year survival rate was 57% for group B and 42% for group E; the survival rate was significantly lower for group E. CONCLUSION For the study population of CLI patients with lesions in the popliteal artery or below, the patency rate was higher for the bypass group than for the endovascular intervention group, whereas there was no difference in the limb salvage rate. Based on the findings in prognosis for survival, the indication for endovascular intervention at our department is believed to be appropriate. (English translation of Jpn J Vasc Surg 2013; 22: 715-718).

Calcified amorphous tumor: three-dimensional transesophageal echocardiography.

An asymptomatic 78-year-old woman was incidentally found to have a mobile mass lesion in the left atrium. Transthoracic echocardiography demonstrated an extremely mobile hyperechoic mass measuring 1.7mm in diameter, originating from the severely calcified posterior mitral annulus (Figure 1A). Three-dimensional transesophageal echocardiography also showed a mobile pedunculatedmass originating from the posterior mitral annulus (Figure 1B). From these echocardiographic findings, cardiac calcified amorphous tumor was strongly suspected. Intraoperative findings revealed a fragile mass at the posterior mitral annulus, which could be easily removed. Pathological examination showed calcification with fibrin and degenerative thrombus, consistent with a cardiac calcified amorphous tumor (Figure 2).

Early outcomes of chordal reconstruction for posterior mitral leaflet prolapse

We retrospectively reviewed 16 patients (7 men and 9 women, aged 36 to 77 years) who underwent mitral valve repair with chordal reconstruction for isolated posterior mitral leaflet prolapse. Preoperative echocardiography demonstrated moderate mitral regurgitation in 1, and severe regurgitation in 15. We routinely used expanded polytetrafluoroethylene sutures as artificial chords, and ring annuloplasty was performed in all cases (mean ring size, 30 ± 2 mm). After implanting the ring, the length of the artificial chords was adjusted repeatedly using saline solution. Early postoperative echocardiography at 7.1 ± 1.1 days after surgery showed mitral regurgitation grades reduced to none or trivial in 15/16 patients. One required reoperation for recurrent mitral regurgitation 1.5 years after surgery. In the other patients, intermediate-term echocardiography at 9.1 ± 10.1 months after surgery demonstrated that residual mitral regurgitation was less than mild. We concluded that chordal reconstruction is an effective and highly reproducible procedure for the repair of isolated posterior mitral leaflet prolapse. Artificial chords for the posterior mitral leaflet should not be too long, to avoid systolic anterior motion or recurrent mitral regurgitation after surgery.

Erratum to: Optimal timing of clopidogrel discontinuation in Japanese patients: platelet aggregation test using the VerifyNow® system

Objective The Japanese Circulation Society recommends discontinuation of antiplatelet therapy 7–14 days before major surgery. However, reports on the relationship between the timing of clopidogrel discontinuation and the risk of postoperative bleeding in Japanese subjects are lacking. We assessed the optimal timing of clopidogrel discontinuation before elective surgery using the VerifyNow® P2Y12 assay. In addition, the relationship between preoperative platelet function and risk of postoperative bleeding was evaluated.

Long-Term Results of Obturator Bypass

OBJECTIVE We evaluated the long-term outcomes of obturator bypass. MATERIAL AND METHODS A total of 16 patients (13 males and 3 females; 17 limbs) who underwent obturator bypass surgery at our department between April 1995 and March 2008 were included. RESULTS Their ages ranged from 50 to 90 with a mean of 74 years. Inguinal infections observed in the 16 patients consisted of vascular graft infections in 13 patients, hemostatic device infections following endovascular therapy in two patients, and femoral artery infections following coronary angiography in one patient. The cumulative patency rate was 69% for 3 years and 43% for 5 years. The cumulative survival rate was 64% for 3 years and 55% for 5 years. CONCLUSION Obturator bypass surgery was successfully performed with favorable results for arterial infections and vascular graft infections in the inguinal region.

En bloc resection and extended replacement of the infected aortic arch

We present the technical details of en bloc resection and extended replacement of an infected aortic arch. A 74-year-old man underwent emergent surgery under a diagnosis of impending rupture of an infected aortic arch aneurysm. The patient’s chest was entered through a median sternotomy with a left thoracotomy at the fourth intercostal space. After dissection of the left phrenic and left recurrent nerves, the infected aortic arch was widely excised en bloc under circulatory arrest with selective cerebral perfusion. It was replaced with a rifampicin-bonded prosthetic graft. The prosthesis and anastomoses were covered with a harvested omental flap. Although an appropriate approach and supportive therapy are indispensable, en bloc resection of the infected tissue is an important technique when treating infected aortic aneurysms.

Two-stage Surgery for Double Infected Aneurysms in the Infrarenal Abdominal and Descending Thoracic Aorta

A 61-year-old man complaining of lumbago and high-grade fever was admitted to our institution. Computed tomography (CT) revealed a saccular aneurysm in the infrarenal abdominal aorta and blood culture results were positive for Streptococcus pneumoniae. He was diagnosed with infected abdominal aortic aneurysm, and antibiotic therapy was initiated. Follow-up CT demonstrated a rapidly-enlarging abdominal aortic aneurysm and a newly-developed descending thoracic aortic aneurysm. For this case, two-stage surgery consisting of extra-anatomical bypass and in-situ reconstruction using rifampicin-soaked Dacron graft was performed after an interval of 37 days. The patient was discharged 14 days after the second surgery without any complications.

Assessment of the Characteristics and Detectability of Skin Perfusion Pressure Measured Using a Thermostatic Heating Probe

OBJECTIVES To assess the characteristics of skin perfusion pressure (SPP) measured using a thermostatic heating probe and whether a thermostatic heating probe improves SPP detection. METHODS We studied 8 feet of healthy young subjects and 31 feet of elderly patients suspected to have severe limb ischemia. We measured SPP at the dorsum and plantar aspects of each foot using a plain laser Doppler probe and a thermostatic heating probe heated at 44°C. Results were expressed as median. Comparisons were analyzed using a non-parametric test. RESULTS In the healthy subjects, the SPP values at both the dorsum and the plantar aspect were not significantly different after heating. The thermostatic heating probe did not improve the SPP detection rates. In the patients with ischemic limb, the SPP values at both the dorsum and the plantar aspect significantly increased after heating (p <0.001 for both). The SPP detection rate at the dorsum remained at 96.8%; however, it was improved from 87.1% to 100% at the plantar aspect after heating. CONCLUSION The thermostatic heating probe was shown to be useful for improving the detectability of SPP in the ischemic limbs. An SPP increase after heating may be considered as a parameter of limb ischemia.