Kentaro Inoue

Sarcopenia is a risk factor for cardiovascular events experienced by patients with critical limb ischemia

Background: Prognosis is poor for patients with critical limb ischemia (CLI), and the most frequent cause of death is cardiovascular disease. Low grip strength is a risk factor for cardiovascular events, and sarcopenia may be associated as well. Thus, we hypothesized that sarcopenia is a risk factor for cardiovascular events experienced by patients with CLI. If this is true and appropriate therapy becomes available, the prognosis of patients with CLI will improve with appropriate risk management strategies to prevent cardiovascular events. Therefore, the aim of this study was to verify this hypothesis. Methods: We studied 114 patients who underwent revascularization and computed tomography between January 2002 and December 2012 in the Department of Surgery and Sciences at Kyushu University in Japan. Sarcopenia was defined as skeletal muscle area measured by L3‐level computed tomography scan <114.0 cm2 and <89.8 cm2 for men and women, respectively. Clinical characteristics, cardiovascular event‐free survival, <2‐year death, causes of death, and effective treatments for sarcopenia were investigated. Results: We identified 53 (46.5%) patients with sarcopenia. Three‐year cardiovascular event‐free survival rates were 43.1% and 91.2% for patients with and without sarcopenia, respectively (P < .01). During follow‐up, cardiovascular disease caused the deaths of 4 and 15 patients without and with sarcopenia (P < .01), respectively, and in particular, ischemic heart disease caused the deaths of 0 and 5 patients without or with sarcopenia (P < .05), respectively. Single antiplatelet therapy (SAPT; hazard ratio, 0.46; 95% confidence interval, 0.24‐0.82; P < .01) and statin therapy (hazard ratio, 0.38; 95% confidence interval, 0.16‐0.78; P < .01) were independent factors associated with improved cardiovascular event‐free survival. Three‐year cardiovascular event‐free survival rates for patients with sarcopenia who received SAPT, dual antiplatelet therapies, and no antiplatelet therapy were 75.3%, 21.1%, and 29.5%, respectively (P < .01). Conclusions: Sarcopenia is a risk factor for worse cardiovascular event‐free survival, and SAPT and statin therapy reduced this risk for patients with CLI. Furthermore, SAPT but not dual antiplatelet therapy increased cardiovascular event‐free survival in patients with sarcopenia.

Radial forces of stents used in thoracic endovascular aortic repair and bare self-expanding nitinol stents measured ex vivo – Rapid rescue for obstruction of the innominate artery using bare self-expanding nitinol stents

Purpose Our objective was to compare the radial forces of several stents ex vivo to identify stents suitable for rescue of the unexpected coverage of aortic arch branches in thoracic endovascular aortic repair. Methods We measured the radial forces of two types of self-expanding bare nitinol stents (E-luminexx and Epic) used singly or as double-walled pairs, and of three endoprostheses used in thoracic endovascular aortic repair (TEVAR, Gore c-TAG, Relay, and Valiant) by compressing the stent using an MTS Instron universal testing machine (model #5582). We also examined the compressive effects of the TEVAR endoprostheses and the bare nitinol stents on each other. Results The radial force was greater in the center than at the edge of each stent. In all stents tested, the radial force decreased incrementally with increasing stent diameter. The radial force at the center was two times greater when using two stents than with a single stent. In the compression test, only E-luminexx used as a pair was not compressed after compressing a Relay endoprosthesis by 12 mm. Conclusion Two E-luminexx stents are appropriate to restore the blood flow if a TEVAR endoprosthesis covers the innominate artery following innominate–carotid–left subclavian arterial bypass.

Elective endovascular vs. open repair for abdominal aortic aneurysm in octogenarians.

Purpose The purpose of this study was to investigate the operative mortality and short-term and midterm outcomes of treatment of abdominal aortic aneurysm in Japanese patients over 80 years of age. Methods Between January 2007 and December 2011, 207 patients underwent elective repair of infrarenal abdominal aortic aneurysms. Comorbidities, operative morbidity and mortality, midterm outcomes were analyzed retrospectively. Results The average age (endovascular aneurysm repair, 84.4 ± 0.3; open, 82.8 ± 0.3, P < 0.01) and the percentage of hostile abdomen (endovascular aneurysm repair, 22.2%; open repair, 11.1%, P < 0.05) were higher in the endovascular aneurysm repair group. Percentage of outside IFU was higher in open repair (endovascular aneurysm repair, 38.5%; open repair, 63.3%, P < 0.01). The cardiac complication (endovascular aneurysm repair, 0%; open repair, 5.6%, P < 0.01) and length of postoperative hospital stay (endovascular aneurysm repair, 10.3 ± 0.8 days; open, 18.6 ± 1.6 days, P < 0.05) were significantly lower in the endovascular aneurysm repair group. There were no differences in operative mortality (endovascular aneurysm repair, 0%; open, 1.1%, P = 0.43) and the aneurysm-related death was not observed. The rate of secondary interventions (EVAR, 5.1%; open repair, 0%, P < 0.01) and midterm mortality rate were much higher in the endovascular aneurysm repair group. Conclusions Endovascular aneurysm repair is less invasive than open repair and useful for treating abdominal aortic aneurysm in octogenarians; however, open repair can be acceptable treatment in the inappropriate case treated by endovascular aneurysm repair.

Preoperative Cardiovascular Assessment and Late Cardiovascular Events after Elective Abdominal Aortic Aneurysm Repair

BACKGROUND Cardiovascular evaluation is performed before elective repair of abdominal aortic aneurysm (AAA) because of the high prevalence of cardiovascular disease. We investigated the association between preoperative cardiovascular evaluation and the incidence of late cardiovascular events after AAA repair. METHODS We retrospectively analyzed 438 patients who underwent elective repair of AAA. Echocardiography, serial coronary assessment using functional myocardial scanning or coronary angiography, and carotid ultrasound scanning were performed preoperatively. Coronary revascularization after serial coronary assessment was performed preoperatively or simultaneously in 21 patients, and 54 patients had a remote history of coronary revascularization. RESULTS The 5-year survival rate, incidence rate of cardiovascular events (myocardial infarction or stroke), and incidence rate of major adverse cardiovascular events (MACE; cardiovascular death or cardiovascular events) were 86.0%, 5.7%, and 11.5%, respectively. Carotid stenosis was associated with these long-term outcomes, and hypokinesis, determined by echocardiography, increased the incidence of cardiovascular events and MACE. Serial coronary assessment findings and history of previous or preoperative coronary revascularization were not associated with these long-term outcomes. CONCLUSIONS Preoperative cardiovascular evaluation and treatment are beneficial for reducing not only perioperative risk but also late cardiovascular events.

Late Type III Endoleak of a Powerlink Stent Graft : Report of a Case

We herein report a case of a late type III endoleak caused by disconnection of the aorta extension and main body of a Powerlink four years after implantation. Migration of the main body caused a disconnection of the main body and extension despite the fact that the size of the aneurysm had been decreasing. The endoleak was successfully repaired using the interpolation of an Endurant aortic extender. In case of necessity of implantation of the extension, first implantation of extension before deploying the main body may help to prevent type III endoleaks caused by disconnection of the stentgraft in patients treated with the Powerlink system. To our knowledge, this is the first reported case of a late type III endoleak caused by a Powerlink device.

Impact of high preoperative steroid doses on postoperative complications among patients on prolonged preoperative steroid therapy.

Corticosteroids are essential to maintain the organic homeostasis. Steroid, glucocorticoid or its synthetic analog is widely used for inflammatory and autoimmune diseases. Prolonged steroid therapy is reported to cause the susceptibility to infection, impaired wound healing and psychoneurosis, however whether the quantity of taking the preoperative steroid is associated the postoperative complication is still unknown. The aim of this study was to elucidate whether the steroid dose in patients on prolonged preoperative steroid therapy is associated postoperative morbidity and mortality. Twenty-five patients taking steroid for various illnesses and underwent the surgery under general anesthesia were selected in this study. The mean +/- standard deviation and the median of the steroid dose converted into hydrocortisone (mg/day) were 39.2 +/- 31.0 and 20, respectively. Of 25 cases, postoperative complications were seen in 10 cases. The postoperative complication was severe based on the grade of Clavien and Dindo by ANOVA as the doses of taking steroid increased (p = 0.0171). The grave postoperative complication classified as Clavien and Dindo grade III occurred with 100% sensitivity and 87% specificity for the steroid dose converted into hydrocortisone > 80 mg/day. Preoperative taking the large amount of steroid (> 80 mg/day) could cause a grave complication. More careful selection of the operative procedure might improve the mobidity rate.

Effects of mucin upon growth of low birth-weight infants and their intestinal microflora.

Purified hog gastric mucin was administered to low birth‐weight infants at a dose of 7 mg per kg body weight per day and the following results were obtained:

Prognostic factor of the two-year mortality after revascularization in patients with critical limb ischemia:

Purposes The aim of this study was to evaluate the risk factors for the two-year survival after revascularization of critical limb ischemia. Methods Between 2008 and 2012, 142 patients underwent revascularization. A retrospective analysis was performed to measure the risk factor. Results A total 85 patients underwent surgical revascularization, 31 patients underwent endovascular therapy while 26 patients underwent hybrid therapy. By multivariate analysis, the following variables were considered to be risk factors: ejection fraction <50 % (HR, 3.14; 95% CI, 1.22–7.95; P = 0.02), serum albumin level <2.5 g/dL (HR, 3.45; 95% CI, 1.01–11.7; P = 0.04) and nonambulatory status (HR, 4.11; 95% CI, 1.79–9.70; P < 0.01). The two-year survival rate of the patients with no risk factors was 85.5%, while the patients with at least one risk factor had an unfavorable prognosis (one; 56.7%, two; 45.4%). Conclusions The nonambulatory status, serum albumin level <2.5 g/dL and ejection fraction <50% were the risk factors for the two-year mortality after revascularization in critical limb ischemia patients. These risk factors may be useful for the treatment strategy of critical limb ischemia patients.

Functional prognosis of critical limb ischemia and efficacy of restoration of direct flow below the ankle

Objective Patients with critical limb ischemia have serious systemic comorbidities and are at high risk of impairment of limb function. In this study, we assessed the prognostic factors of limbs after revascularization. Methods In this retrospective single-center cohort study, from April 2008 to December 2012, we treated 154 limbs of 121 patients with critical limb ischemia by the endovascular therapy-first approach based on the patients’ characteristics. The primary end point was amputation-free survival. Secondary end points were patency of a revascularized artery, major adverse limb events, or death. Furthermore, we investigated the ambulatory status one year after revascularization as prognosis of limb function. Results Endovascular therapy was performed in 85 limbs in 65 patients as the initial therapy (endovascular therapy group) and surgical reconstructive procedures (bypass group) were performed in 69 limbs in 56 patients. Early mortality within 30 days was not observed in either group. The primary patency rate was significantly better in the bypass group than in the endovascular therapy group (p < 0.0001). Furthermore, the secondary patency rate was similar between the two groups (p = 0.0096). There were no significant differences in amputation-free survival and major adverse limb event between the two groups. Univariate analysis showed that ulcer healing (p < 0.0001), no hypoalbuminemia (p = 0.0019), restoration of direct flow below the ankle (p = 0.0219), no previous cerebrovascular disease (p = 0.0389), and Rutherford 4 (p = 0.0469) were predictive factors for preservation of ambulatory status one year after revascularization. In multivariate analysis, ulcer healing (p < 0.0001) and restoration of direct flow below the ankle (p = 0.0060) were significant predictors. Conclusions Ulcer healing and restoration of direct flow below the ankle are independently associated with prognosis of limb functions in patients who undergo infrainguinal arterial reconstruction.

Prognostic factors of ulcer healing and amputation-free survival in patients with critical limb ischemia

Objective A multidisciplinary approach is required to treat critical limb ischemia. We determined the poor prognostic factors of ischemic ulcer healing after optimal arterial revascularization, and assessed the efficacy of the medication therapy using cilostazol, which is a selective inhibitor of phosphodiesterase 3. Methods In this retrospective, single-center, cohort study, 129 limbs that underwent infrainguinal arterial revascularization for Rutherford class 5 critical limb ischemia were reviewed. The primary end point was the ulcer healing time after arterial revascularization. The secondary end point was the amputation-free survival rate. Results Of the 129 limbs, endovascular therapy was performed in 69 limbs, and surgical reconstructive procedures were performed in 60 limbs for initial therapy. Complete ulcer healing was achieved in 95 limbs (74%). The median ulcer healing time was 90 days. In multivariate analysis, no cilostazol use significantly inhibited ulcer healing (p = 0.0114). A white blood cell count >10,000 (p = 0.0185), a major defect after debridement (p = 0.0215), and endovascular therapy (p = 0.0308) were significant poor prognostic factors for ulcer healing. Additionally, ischemic heart disease (p < 0.0001), albumin levels <3 g/dl (p = 0.0016), no cilostazol use (p = 0.0078), and a major defect after debridement (p = 0.0208) were significant poor prognostic factors for amputation-free survival rate. Conclusions Ulcer healing within 90 days after arterial revascularization is impaired by no cilostazol use, a white blood cell count >10,000, a major defect after debridement, and endovascular therapy. Furthermore, cilostazol improves amputation-free survival rate in patients with critical limb ischemia.