Hyangkyoung Kim

Ten-Year Comparative Analysis of Bovine Pericardium and Autogenous Vein for Patch Angioplasty in Patients Undergoing Carotid Endarterectomy

BACKGROUND To evaluate early and late clinical outcomes of carotid endarterectomy (CEA) with bovine pericardium patch in comparison with autogenous vein. METHODS During a 10-year period, 456 CEAs were performed using patch closure of the arteriotomy with bovine pericardium (252 cases) and autogenous vein (204 cases). Retrospectively, surgical outcomes were evaluated and compared regarding CEA-related parameters, early and late mortality and morbidity rates, and the incidence of restenosis and aneurysmal dilatation between patients with bovine pericardium patch closure and those with autogenous vein closure. RESULTS The two groups were comparable regarding basic demographics, clinical data, and anatomic data, except the incidence of coronary or peripheral arterial diseases. In patients with bovine pericardium patch closure, the total operating time and carotid clamping duration were statistically significantly shorter than in those with autogenous vein closure (P < 0.01). During the early postoperative period, 10 major (stroke and death) complications (2.2%) occurred without statistically significant difference between the two groups. The incidence of early minor postoperative complications was less with bovine pericardium patch closure (5.6% vs. 10.8%; P < 0.05). With a mean follow-up of 62 months for bovine pericardium patch closure and 67 months for autogenous vein closure, the incidence of restenosis was similar, but aneurysmal dilatation was higher in patients with autogenous vein closure with a statistically significant difference (0% vs. 2.0%; P < 0.05). CONCLUSION CEA with bovine pericardium patch angioplasty showed excellent early and late clinical outcomes. Our results demonstrated bovine pericardium to be a suitable patch material for routine use in CEA.

Risk Factors for Stroke During Surgery for Carotid Body Tumors

The article by Gwon et al. [1] describes 17 carotid body tumor (CBT) resections, resulting in four patients (23.5%) having a postoperative stroke and one case of permanent cranial nerve damage. The article once again shows that CBT surgery can be challenging because of neurovascular structures that are adjacent to or involved in the tumor. This is particularly true for larger CBTs that encompass the carotid arteries, as evidenced by the fact that three of four strokes were encountered after resection of a Shamblin III [2] tumor. When considering the very high percentage of postoperative stroke in the reported series, it should be stressed that CBTs are benign and slow-growing tumors in which conservative management should always be considered. Furthermore, the authors state that preoperative embolization of CBT feeder vessels was performed to minimize intraoperative blood loss. Unfortunately, blood loss was not reported and it is therefore unclear whether embolization had indeed contributed to a decrease thereof in comparison to recent literature. Next, the authors conclude that embolization did not reduce the risk of stroke. Whether this statement is justified, considering the careful preoperative planning and subsequent selection bias, is questionable. However, the current data and the series we previously published [3] suggest that a decrease in blood loss might reduce perioperative morbidity. This can be achieved effectively by creating a craniocaudal dissection route whereby the tumor feeder vessels are ligated before the tumor and internal carotid artery are manipulated. In our experience, and from previous imaging studies from our institution [4], the main tumor feeder seems to be the ascending pharyngeal artery that branches from the external carotid artery at the dorsal side of the tumor and usually feeds the tumor from its cranial side. This area, which can also be referred to as dissection zone III as defined by Hallett et al. [5], is also the proximal site where most of the prominent neurological structures can be found. The craniocaudal approach therefore carries the advantage of early ligation of the prominent tumor feeder, less blood loss, and identification of the adjacent cranial nerves before manipulation of the CBT itself begins and substantial blood loss challenges the dissection. The effect might be comparable to early ECA division as described by the authors, which in their series had significant influence on the risk of stroke in larger tumors. Using the craniocaudal technique, we have not experienced stroke after any of 70 CBT resections over the past 20 years. Of note, all CBT patients in our institution receive heparin during dissection, allowing carotid artery clamping at any necessary stage. Taken together, the article by Gwon et al. once again stresses the need for careful, multidisciplinary evaluation before considering high-risk surgical treatment. It also shows the importance of limiting blood loss during CBT surgery. In conclusion, we strongly advocate performing craniocaudal CBT dissection in specialized, high-volume centers.

Arthroscopic reduction and internal fixation of acetabular fractures

AbstractArthroscopic reduction and screw fixation of acetabular fractures have not been reported. In this case report, arthroscopic treatment for acetabular fracture is reported for two patients. A 49-year-old man diagnosed with acetabular posterior wall fracture was treated by arthroscopic reduction and fixation using two screws. A 20-year-old woman who diagnosed with anterior column fracture was fixed using a screw using the arthroscopic technique prior to open reduction and internal fixation in the iliac bone fracture. Arthroscopic reduction and fixation in some case of acetabular fracture could be good indication with additional advantages of joint debridement and loose body removal. Level of evidence V.

Comparison of surgical and endovascular salvage procedures for juxta-anastomotic stenosis in autogenous wrist radiocephalic arteriovenous fistula.

BACKGROUND Although dysfunctional radiocephalic arteriovenous fistulas (RCAVFs) are typically treated surgically, the endovascular approach is also considered suitable. The aim of this retrospective study was to compare the cumulative patency rates following surgical and endovascular salvaging of dysfunctional RCAVFs, and to evaluate whether the maturity of vascular access sites at the time of treatment influenced the outcomes. METHODS A total of 60 patients underwent surgical or endovascular salvage treatment for juxta-anastomotic stenosis of autogenous wrist RCAVFs: 35 patients underwent proximal neo-anastomosis and 25 underwent percutaneous transluminal angioplasty (PTA). RESULTS Clinical and anatomical success rates were, respectively, 100% and 97.1% in the surgery group, and 100% and 96.0% in the angioplasty group (P = 0.81). The post-treatment restenosis rate was higher in the angioplasty group (n = 11, 46.0%) than in the surgery group (n = 8, 22.8%), without reaching statistical significance (P = 0.15). In a Kaplan-Meier analysis, the primary and assisted primary patency rates were significantly higher in the surgery group (P = 0.036 and P = 0.026, respectively), but there was no significant difference in secondary patency rates between the groups (P = 0.52). When stratified by RCAVF maturity at the time of treatment, no significant difference was noted in primary patency rates between the treatment groups. After adjusting for other variables, the relative risk of restenosis was significantly higher in the angioplasty group (hazard ratio 2.56; 95% confidence interval 1.02-6.46; P = 0.046). CONCLUSIONS Post-treatment primary and assisted primary patency rates after proximal neo-anastomosis were significantly higher than after PTA, and RCAVF maturity did not influence the outcomes.

Bilateral ischemic lumbosacral plexopathy from chronic aortoiliac occlusion presenting with progressive paraplegia

Spinal cord ischemia is rare but causes significant morbidity and mortality. Spinal cord ischemia has been reported after open and endovascular interventions of the thoracic and abdominal aorta, and, rarely, acute occlusion of aorta from in situ thrombosis or acute embolic occlusion. Acute interruption of the critical blood supply to the spinal cord or root contributes to this devastating neurologic deficit. However, gradually worsening lumbosacral plexopathy and consequent paraplegia related to chronic aortic occlusion is extremely rare. We present a case of a 58-year-old man with progressive lower limb paralysis from atherosclerotic aortoiliac occlusion without history of aortic surgery or evidence of thromboembolism.

Outcomes of Spontaneous Isolated Superior Mesenteric Artery Dissection Without Antithrombotic Use

OBJECTIVES This study aimed to show the intention to treat results of treatment for spontaneous isolated superior mesenteric artery dissection (SISMAD) without anticoagulation or antiplatelet agents and the follow-up results of SISMAD according to the configuration on computed tomography (CT) scans. DESIGN Retrospective, observational single centre study METHODS: All cases of SISMAD were enrolled consecutively from 2006 onwards. There were 25 symptomatic and four asymptomatic patients in whom SISMAD was found incidentally. The SISMAD patients were treated using a consistent therapeutic strategy without antithrombotics. SISMAD was categorized into four types based on the configuration on CT scans by Yuns classification. Follow-up CT was performed at 3 months, 6 months, and yearly thereafter. RESULTS The median follow-up duration was 57 months (13-129 months). Improvement or complete resolution on CT scans, with no symptom recurrence, was seen in 27 patients. The non-invasive approach failed in three cases and two patients underwent further intervention. No patient died during the follow-up. CONCLUSIONS Weighing the risks versus benefits of antithrombotics and considering the benign nature of SISMAD, conservative treatment without antithrombotics might be sufficient in patients without evidence of bowel ischaemia or infarction on initial CT scan.

Embolic stroke after carotid artery ligation during carotid body tumor resection

This report describes a case of a delayed cerebral embolic infarction, after internal carotid artery (ICA) ligation secondary to carotid body tumor resection. We describe a 34-year-old woman who underwent left ICA ligation during a large carotid body tumor surgery. Immediately after surgery, the patient was neurologically asymptomatic; however, she subsequently developed a cerebral embolic infarction nine hours postoperatively. After beginning antiplatelet therapy, all symptoms ultimately resolved, although over a gradual course. Since the ligation of the ICA can cause thromboembolic infarctions of the cerebrum, we contend that antiplatelet agents be administered to prevent and/or treat embolic strokes.

Effect of Active Hexose Correlated Compound (AHCC) in Alcohol-Induced Liver Enzyme Elevation

To investigate the effects of Active Hexose Correlated Compound (AHCC) supplementation and the mechanism action of AHCC in patients with alcohol-induced mildly elevated liver enzyme levels, participants were randomly allocated to the placebo, 1 g AHCC, or 3 g AHCC group and took the supplement for 12 wk. Subjects visited the hospital for clinical and biochemical measurements, for examination of adverse events, to return unused supplements, and to obtain their next supplements. Biochemical tests including liver enzymes, a questionnaire survey, and anthropometric measurements were collected at baseline and every 4 wk thereafter. Adherence and adverse events were evaluated. After 12 wk of supplementation, the percentage change in alanine aminotransferase (ALT) level was significantly different between the placebo (4.02±59.07%) and both AHCC groups (1 g AHCC: 223.89±20.59%, 3 g AHCC: 224.09±30.73%) (p=0.04). Serum levels of tumor necrosis factor-α (p<0.05) and interleukin-1β (p<0.01) were significantly lower, while those of adiponectin were higher in both AHCC groups than in the placebo group (p<0.01). AHCC supplementation for 12 wk may improve the levels of liver enzymes and circulating pro-inflammatory and anti-inflammatory cytokines in patients with alcohol-induced liver enzyme elevation with mildly elevated liver enzyme levels.

Usefulness of Doppler waveform analysis before performing a complex procedure using femoral venous access

Ultrasonography is a well‐defined and widely accepted technique in the settings of interventional procedures requiring peripheral venous access, either for the confirmation of the vein patency (with the compression test) or for guiding needle insertion. This report describes a case of unsuccessful guidewire passage through the right iliac vein in spite of successful ultrasonography‐guided puncture of the femoral vein. On repeat duplex ultrasonography, the Doppler waveform showed a continuous pattern without respiratory phasicity, which was consistent with proximal venous occlusion. Venous Doppler signal waveform analysis can be helpful for ensuring downstream patency when planning long‐distance catheterization via femoral venous access.

A three-dimensional planned osteotomy on the zygomatic arch for reduction malarplasty

During a reduction malarplasty, precise sectioning of the zygomatic arch according to the plan formulated in the diagnostic stage is very important, because differences in the locations of the osteotomies in the left and right zygomatic arch will result in facial asymmetry, and arch osteotomies that are placed at locations other than those specified during planning elicit unwanted results. A method for the precise planning and sectioning of the zygomatic arch involving the use of computed tomography (CT) and a viewer program is presented herein. Furthermore, a case in which this method was applied during reduction malarplasty via a combined intraoral and external incision is described.