Hisao Masaki

Regression of Abdominal Aortic Aneurysms by Simultaneous Inhibition of Nuclear Factor κB and Ets in a Rabbit Model

Because current therapy to treat abdominal aortic aneurysm (AAA), and particularly to manage small AAA, is limited to elective surgical repair, we explored less invasive molecular therapy by simultaneous inhibition of the transcription factors nuclear factor (NF)&kgr;B and ets using a decoy strategy. Both NF&kgr;B and ets were shown to be markedly activated in human AAA. In addition, NF&kgr;B- and ets-positive cells were increased in the aneurysm wall, and a part of the expression of NF&kgr;B and ets was detected in migrating macrophages. Thus, we used chimeric decoy oligodeoxynucleotides (ODNs) containing consensus sequences of both NF&kgr;B and ets binding sites to treat AAA. Inhibitory effects of chimeric decoy ODNs on matrix metalloproteinase-1 and -9 expression were confirmed by ex vivo experiments using a human aorta organ culture. To examine the regressive effect in a rabbit already-formed AAA model, transfection by wrapping a delivery sheet containing chimeric decoy ODNs around the aneurysm was performed 1 week after incubation with elastase. Importantly, treatment with chimeric decoy ODNs significantly decreased the size of AAA. Interestingly, significant preservation of elastic fibers was observed with chimeric decoy ODN treatment, accompanied by a reduction of matrix metalloproteinase-2 and -9 and induction of macrophage apoptosis. Regression of AAA was also associated with an increase in elastin and collagen type I and III synthesis in the aneurysm wall. Minimally invasive molecular therapy targeted to the inhibition of NF&kgr;B and ets is expected to be useful for AAA through the rebalance of matrix synthesis and degradation.

Coronary Flow Velocity Waveforms in Aortic Stenosis and the Effects of Valve Replacement

In 6 patients with pure aortic stenosis, the flow velocity waveforms in the left anterior descending coronary artery were studied using an 80-channel 20-MHz pulsed Doppler velocimeter before and immediately after aortic valve replacement. All patients showed normal coronary arteriograms. The left anterior descending coronary artery flow velocity waveform in aortic stenosis was characterized by a reverse flow in the first half of systole and a slowly increasing diastolic inflow. After aortic valve replacement, the reverse flow in the first half of systole disappeared in all patients, but an end-systolic reverse flow was discerned in 5 of 6 patients. The increasing rate of the diastolic inflow was augmented in all patients. After aortic valve replacement, the time from onset of diastole to the diastolic peak velocity was shortened from 176.8 +/- 28.8 to 90.5 +/- 18.8 ms (p less than 0.01), and the diastolic peak velocity increased from 90.5 +/- 28.0 to 122.5 +/- 17.2 cm/s (p less than 0.05). Blood pressure and heart rate, however, did not change significantly before and after valve replacement. These changes in the left coronary artery velocity waveforms after valve replacement suggest the beneficial effects of removal of aortic stenosis on human coronary artery inflow.

Blood cyst of the pulmonary valve in an adult: Report of a case and review of the literature

We report a case of a blood cyst originating from the pulmonary valve cusp of a 43-year-old Japanese woman with pulmonary stenosis. Cineangiography revealed a pedunculated tumor on the arterial surface of the pulmonary valve. It was successfully removed by a transpulmonary artery approach. The cyst contained old blood and calcified thrombi, and its wall consisted of collagenous fibrous tissue. Immunohistochemically, a monolayer of flat cells lining the cyst was confirmed as endothelium using antibodies to von Willebrand factor and CD34, as well as UEA-I lectin. To the best of our knowledge, blood cysts of the pulmonary valve are rare and only 10 such cases have been reported, including six pediatric cases. This case is the oldest and fifth adult patient with a blood cyst found on the pulmonary valve. A possible histogenesis is discussed.

Mucosa-associated lymphoid tissue lymphoma in the thymus of a patient with systemic lupus erythematosus

Mucosa-associated lymphoid tissue (MALT) lymphoma arising from the thymus is extremely rare. We present a case of a 23-year-old woman with systemic lupus erythematosus (SLE) who was diagnosed with thymic MALT lymphoma. In 2004, she was diagnosed with a mediastinal tumor on chest radiography during medical follow up for SLE. An anterior mediastinal tumor with multilobular cysts was identified by computerized tomography and magnetic resonance imaging. A thymic malignancy was suspected and an extended thymectomy was performed. After histological and immunohistochemical examinations, the thymic tumor was diagnosed as a MALT lymphoma. There was no recurrence in the 2-year follow-up during which time there was no further treatment.

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).

Coronary flow characteristics of left coronary artery in aortic regurgitation before and after aortic valve replacement

In 6 patients with pure aortic regurgitation, the velocity waveform in the left anterior descending coronary artery (LAD) was measured using an 80-channel 20-MHz-pulse Doppler velocimeter before and immediately after aortic valve replacement. All patients showed normal coronary angiograms. Flow velocity was analyzed by both zero-cross and fast Fourier transform methods in real time. The LAD flow in severe aortic regurgitation was characterized by an increase in the systolic flow component, a small and rapidly decreased diastolic flow, an irregular velocity profile across the vessel, and a wider velocity spectrum. After aortic valve replacement, systolic flow decreased by 36.3 +/- 21.7% (p less than 0.01), whereas diastolic flow increased by 81.4 +/- 51.8% (p less than 0.05). The ratio of diastolic flow to total LAD flow increased from 63 +/- 13% to 82 +/- 7% (p less than 0.05). The velocity profile became more parabolic and had a narrow spectrum. These results suggest that operation for aortic regurgitation induces beneficial effects on the myocardial inflow immediately after valve replacement.

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).

Ankle-Brachial Index, Toe-Brachial Index, and Pulse Volume Recording in Healthy Young Adults

OBJECTIVE To clarify the characteristics of ankle-brachial index (ABI), toe-brachial index (TBI), and pulse volume recording (PVR) of the ankle with brachial-ankle pulse wave velocity (baPWV) in healthy young adults. MATERIAL AND METHODS We analyzed ABI, TBI, baPWV, and PVR in the ankle of healthy adults aged 20 to 25 years (median, 20 years) using an automatic oscillometric device between 2002 and 2013. The ABI, baPWV, and PVR in 1282 legs of 641 subjects (301 men and 340 women) and the TBI in 474 toes of 237 subjects (117 men and 120 women) were evaluated. RESULTS The measured values showed no bilateral differences. ABI and baPWV were higher in men than in women, but TBI was similar in both sexes. ABI <1.0 was observed in 18.1% of the legs in men and in 25.6% in women. TBI <0.7 was observed in 16.2% of the toes in men and 19.1% in women. For ankle PVR, the % mean arterial pressure was higher in women than in men. The upstroke time was <180 ms in most subjects. CONCLUSIONS For young people, ABI <1.0 or TBI <0.7 may not always indicate vascular abnormalities. When evaluating circulatory indexes, age and sex should be considered.

Antiphospholipid antibody syndrome and vasoocclusive diseases

One hundred and thirty-four patients with vasoocclusive diseases were retrospectively tested for three kinds of antiphospholipid antibody (aPL). The mean age at onset of the disease in 58 patients with aPL was 43 years old. Seventeen, 11, and 9 patients were positive for the aCL IgA, IgM, and IgG isotypes, respectively. The rates of anti-phospholipid syndrome (APS) in patients with arterial (n=94), venous (n= 31), or both arterial and venous (n=9) occlusion were 45%, 29%, and 78%, respectively.The rates of APS in patients with autoimmune disease (n=13), thromboangiitis obliterans (TAO) (n= 36), arteriosclerosis obliterans (ASO) with lower leg involvement (n=8) or aortic arch syndrome (n=5), Raynauds syndrome (n=15), aortitis syndrome (n= 13), ischemic heart disease (IHD) with young onset (n =12), and bilateral leg deep venous thrombosis (DVT) (n=10) were 77%, 46%, 13%, 80%, 40%, 62%, 33%, and 70%, respectively. The cumulative patency rate for reconstructive surgery in patients (n=13) with aCL was found to be considerably lower than that in those without aCL (n=13). From these results it was concluded that IgA was the most valuable aCL isotype for the diagnosis of APS and that aPL should be examined in patients with double-vessel occlusion, autoimmune disease, bilateral leg DVT, aortic arch syndrome, TAO, Raynauds syndrome, or IHD with young onset. Furthermore, prophylaxis for graft failure is more strongly recommended for patients with aCL than for those without it.

A Case of Ruptured Desceding Thoracic Aortic Aneurysm Due to Salmonella Infection

A 66-year-old male was admitted to our hospital because of pyrexia, chest pain and hemosptum. Inflammatory findings were made and salmonella enteritidis was detected by bacterial examination of sputum and stool. Enhanced chest CT examination disclosed a descending thoracic aortic aneurysm which had ruptured into the left lower lobe of the lung. Under a diagnosis of ruptured mycotic descending thoracic aortic aneurysm, an emergency operation was performed. A left posterolateral thoracotomy carried out after axillo-bilateral femoral bypass grafting. A pseudoaneurysm of the descending thoracic aorta had ruptured into the left lower lobe of the lung. After resection of the aneurysm, closure of both ends of the intact descending thoracic aorta and a left lower lobectomy were carried out. An ascending aorta-infrarenal abdominal aorta bypass was performed because of insufficient visceral arterial blood flow through the axillo-bilateral femoral bypass. The patients immediate postoperative recovery was complicated by paraplegia. Chloramphenicol and levofloxacin were administered for three months, after which his recovery followed a good course.