Kimihiro Igari

Quantitative evaluation of the outcomes of revascularization procedures for peripheral arterial disease using indocyanine green angiography.

OBJECTIVES We performed indocyanine green angiography (ICGA) in patients with peripheral arterial disease (PAD), and established a method for the quantitative measurement of appropriate parameters to assess peripheral perfusion and the applicability of ICGA tests. METHODS Twenty-one patients with PAD underwent revascularization procedures with pre- and postinterventional ICGA tests. The ICGA parameters, which included the magnitude of intensity of indocyanine green, the time to maximum intensity, and the time from fluorescence onset to half the maximum intensity (T1/2) were compared with the ankle-brachial pressure index, toe -brachial pressure index, and toe pressure. We evaluated these parameters for regions of interest (ROIs). RESULTS T1/2 was the strongest parameter among all parameters of the ICGA tests. ROI 3, which included the distal region of the first metatarsal bone, correlated more significantly with the traditional measurements than the other ROIs. A value of T1/2 >20 seconds for ROI 3 was significantly correlated with a toe pressure of <50 mmHg (sensitivity: 0.77, specificity: 0.80). CONCLUSIONS ICGA can be used to assess peripheral tissue perfusion. By measuring the value of T1/2 in ROI 3, ICGA tests can be used to evaluate the outcomes of revascularization procedures.

Treatment strategy for blunt hepatic trauma: analysis of 183 consecutive cases.

BACKGROUND/AIMS Non-operative management of hemodynamically stable trauma has proven successful; however laparotomy for hemodynamically unstable patients is still insufficient. We evaluated the results of treating blunt hepatic injury and appraised the appropriate surgical procedures. METHODOLOGY We analyzed the demographics, vital status, and severity of hepatic and concomitant organ injuries of 183 consecutive patients with blunt hepatic injuries between January 2001 and December 2008, retrospectively. RESULTS Twenty five of 183 patients died before the treatment was selected. The initial management was operative for 24 and non-operative for 134, 15 of whom later required laparotomy. Of the 134 treated non-operatively, 2 died after arterial embolization for pelvic fractures. Twelve patients died postoperatively: 6 of the hepatic injury and 6 of concomitant organ injuries. Considering Liver Injury Scale of operated patients, there was no liver-related death with grades I-III; however, liver-related mortality of grades IV and V was 37.5%. The incidence of liver-related deaths after anatomical resection was 0% of patients with grade IV, but 50% of patients with grade V, despite anatomical resection being the only effective procedure for grade V. CONCLUSIONS The results of anatomical resection for grade IV is satisfactory, but additional strategies are still required for grade V.

Surgical thrombectomy and simultaneous stenting for deep venous thrombosis caused by iliac vein compression syndrome (May-Thurner syndrome).

PURPOSE Iliac vein compression syndrome (May-Thurner syndrome) is characterized by left iliac vein obstruction secondary to compression by the right common iliac artery against the fifth-lumbar vertebra, which increases incidence of deep venous thrombosis (DVT). We treated the patients with DVT due to May-Thurner syndrome (MTS) by surgical thrombectomy and simultaneous stenting, and this study is to evaluate the outcomes of this procedure. METHODS From January 2009 to December 2011, a total of 8 patients underwent surgical thrombectomy with stenting. All patients were admitted for acute DVT involving the left iliofemoral segment, and diagnosed MTS. Patients were followed-up, and stent patency was assessed by means of duplex sonography. RESULTS In all patients, the procedure was successful in achieving re-canalisation of the iliofemoral veins at the end of the operation. Perioperatively, there was no mortality and there was no case of clinically detected pulmonary embolism. Rethrombosis occurred within seven days of operation in 2 patients. During the follow-up period (mean; 16 months), 6 of 8 patients kept patent stents. CONCLUSION Venous thrombectomy with simultaneous stenting is a potent technique to treat acute iliofemoral DVT due to MTS. This technique can restore venous patency and provide relief of the acute symptoms.

Intraarterial Injection of Indocyanine Green for Evaluation of Peripheral Blood Circulation in Patients with Peripheral Arterial Disease

BACKGROUND To assess the peripheral blood flow of patients with peripheral arterial disease (PAD) by indocyanine green (ICG) arteriography (ICGA) with intraarterial injection of ICG and evaluate the efficacy of the ICGA tests. METHODS This study was undertaken from a retrospective review of patients with PAD who underwent ICGA tests during digital subtraction angiography (DSA) between November 2012 and June 2013. We defined some ICGA parameters as the magnitude of intensity of ICG, the time to maximum intensity, and the time from fluorescence onset to half the maximum intensity (T1/2). The ICGA parameters were evaluated in 2 regions, named regions of interest (ROIs). ROI 1 was part of the dorsum of the foot from the Chopart joint to the Lisfranc joint. ROI 2 was in the distal region of the first metatarsal bone and compared with the ankle-brachial pressure index (ABI), ankle pressure, toe-brachial pressure index, and toe pressure. RESULTS A total of 22 limbs in 16 patients with PAD underwent ICGA tests during DSA. The T1/2 on ROI 2 was the most correlated with the ABI (ρ=-0.622, P=0.003). A value of T1/2 for ROI 2>10 sec was significantly correlated with an ABI value of <0.7 (sensitivity: 0.85, specificity: 1.0). CONCLUSIONS By measuring the value of T1/2 in ROI 2, ICGA tests can be performed to assess the peripheral blood circulation during DSA. ICGA tests might help to promptly assess the peripheral blood flow during endovascular treatment procedures.

Indocyanine Green Angiography for the Diagnosis of Peripheral Arterial Disease with Isolated Infrapopliteal Lesions

BACKGROUND In this study, we evaluated the accuracy of the indocyanine green angiography (ICGA) test to diagnose peripheral arterial disease (PAD) with isolated infrapopliteal lesions. METHODS This study was undertaken from a retrospective review of PAD patients with isolated infrapopliteal lesions who underwent ICGA between November 2012 and July 2013. We calculated the ICGA parameters while comparing the findings with the ankle-brachial index (ABI) and toe-brachial index (TBI) in patients with infrapopliteal lesions. RESULTS Twenty-three limbs with isolated infrapopliteal lesions in 14 PAD patients and 15 limbs without arterial lesions in 9 control patients were examined using ABI, TBI, and ICGA. The Td 90% (the time elapsed from the maximum intensity to 90% of the maximum intensity) correlated most significantly with the ABI value. A cutoff value of Td 90% >25 sec also significantly correlated with the presence of PAD (sensitivity, 82.6%). CONCLUSIONS ICGA might therefore be useful for assessing the peripheral perfusion quantitatively, even in PAD patients with isolated infrapopliteal lesions. The use of Td 90% on ICGA may also be effective for accurately estimating the presence of PAD.

The Epidemiologic and Clinical Findings of Patients with Buerger Disease

BACKGROUND Buerger disease is a nonatherosclerotic peripheral arterial disease, which is mostly observed in young male smokers. Buerger disease is characterized by the observation of peripheral arterial occlusion by angiography. The condition may be caused by microembolization in the small-sized arteries of the distal extremities. Buerger disease is diagnosed based on the Shionoyas clinical diagnostic criteria, which include: (1) a history of smoking, (2) onset before the age of 50 years, (3) the presence of infrapopliteal arterial occlusions, (4) either upper limb involvement or phlebitis migrans, and (5) the absence of atherosclerotic risk factors other than smoking. Several studies have reported that oral bacterial infections (periodontitis) could activate the onset of Buerger disease. In this study, we report the epidemiologic and clinical manifestations of patients with Buerger disease. METHODS Fifty-eight patients who were surgically treated between July 1989 and June 2014 at Tokyo Medical and Dental University Hospital were enrolled in this study. All of the patients clinically diagnosed with Buerger disease based on Shionoyas clinical diagnostic criteria. Fifty-five male and 3 female patients were treated. The mean age of the patients was 48 years (range, 21-73 years). RESULTS All of the patients were either smokers or had a history of smoking. The mean Brinkman index score was 780 (range, 150-1,640). Their mean age at the onset of Buerger disease was 38 years (range, 21-50). The arterial lesions extended to the femoral arteries in 25% of cases, to the iliac arteries in 8% and to the abdominal aorta and/or visceral arteries in 6% of cases. Upper limb involvement, including cyanosis, paleness, and gangrene, was obvious in 84% of patients, and phlebitis migrans was recognized in 34%. The lower extremities symptoms involved intermittent claudication in 23% of the patients, rest pain in 13% of the patients, and ulceration or gangrene in 64% of the patients. Fifteen patients had undergone surgical arterial reconstruction, 4 patients had received endovascular therapy, 33 patients had undergone lumbar sympathectomy and 8 patients had undergone thoracic sympathectomy. Twenty percent of the patients needed minor limb amputations, and 4% required major limb amputations. In the patients who were examined for their oral conditions, periodontitis corresponding to grades B (moderate periodontitis), C (severe periodontitis), and D (edentulous patients) was revealed in 31%, 56%, and 13% of the patients, respectively. CONCLUSIONS More than half of the Buerger disease patients in this study were suffering from severe periodontitis. It is possible that not only the cessation of smoking, but also the improvement of periodontal care could improve the clinical symptoms related to Buerger disease.

Association between periodontitis and the development of systemic diseases

Periodontal diseases, common infectious diseases seen in humans, are characterized by gingival inflammation and a loss of connective tissue and bone around the roots of teeth, which leads to eventual tooth exfoliation. In the past decade, the association between periodontal diseases and the development of systemic diseases has received increasing attention. Periodontal pathogens and their products, as well as inflammatory mediators produced in periodontal tissues, can enter the bloodstream, thereby causing and/ or contributing to the development of systemic diseases. A variety of recent studies have compiled various results showing that periodontal infections are implicated in the development of various systemic diseases. This review summarizes the evolution of the focal infection theory to the current understanding of the pathophysiology of periodontal disease and presents an update of the mechanisms and relationships between chronic periodontitis and systemic diseases, including cardiovascular diseases, respiratory infections, preterm delivery of low-birth-weight fetuses and diabetes mellitus.

Quantitative evaluation of microvascular dysfunction in peripheral neuropathy with diabetes by indocyanine green angiography

AIMS Peripheral neuropathy in diabetes (PND) plays a central role in foot ulceration with diabetes, and leads to an abnormal microvascular structure, including arteriovenous shunting. To assess the extent of arteriovenous shunting we performed indocyanine green angiography (ICGA) in patients with diabetes and evaluated quantitative ICGA parameters. METHODS Between November 2012 and July 2013, twenty-six limbs in 14 patients with PND and twenty-three limbs in 15 patients without PND underwent ICGA testing. The ICGA parameters, which included the time to maximum intensity (Tmax), the time from fluorescence onset to half the maximum intensity (T1/2), the time elapsed from the maximum intensity to 90% of the Imax and to 75% of the Imax (Td 90% and Td 75%, respectively) and the rate of intensity measured 60s after the Tmax to Imax (IR 60s), were compared between the patients with and without PND. RESULTS The Tmax, T1/2, Td 90%, Td 75% and IR 60s were significantly different between patients with and without PND. A value of Td 90% >30s was significantly correlated with the presence of PND (sensitivity: 0.85, specificity: 0.78). CONCLUSIONS ICGA tests can be used to quantitatively assess arteriovenous shunting in the limbs with PND. By measuring the value of the Td 90%, ICGA tests can estimate the presence of the arterio-venous shunting in PND, which might be helpful for assessing the progression of foot ulceration with diabetes, gangrene and the need for amputation.

Combined arterial reconstruction and free tissue transfer for patients with critical limb ischemia.

OBJECTIVE The purpose of treatment for critical limb ischemia (CLI) is to prevent major amputation. The purpose of this study was to evaluate our experience of treating CLI with free tissue transfer (FTT) and revascularization. MATERIALS AND METHODS From January 2010 to December 2012, seven lower extremities in seven patients were treated with revascularization and free tissue transfer for CLI with tissue loss. All seven patients had tissue loss with a Rutherford category 6 status. Six patients underwent bypass surgery, and one patient underwent percutaneous transluminal angioplasty for revascularization. All patients also underwent free tissue transfer using the latissimus dorsi muscle simultaneously and separately in two and five patients, respectively. RESULTS Five of the seven patients exhibited flap patency and survival. One patient obtained flap survival and limb salvage, although the flap graft was occluded after the patient achieved limb salvage. One patient developed partial flap necrosis requiring skin grafting and acquired limb salvage. The flap survival rate was 85%, and the limb salvage rate was 100%. CONCLUSION FTT with arterial reconstruction for CLI achieves successful wound healing and limb salvage. Both bypass surgery and endovascular treatment are useful for maintaining the vascular supply.

Maggot Debridement Therapy for Peripheral Arterial Disease

INTRODUCTION Maggots are potent debriding agents capable of removing necrotic tissue and slough; however, it is still unclear which wounds are most likely to benefit from maggot debridement therapy (MDT). Thus, we performed this retrospective review to gain insight into the patient and therapy characteristics influencing outcome. PATIENTS AND METHODS We reviewed patients with foot ulcers caused by critical limb ischemia, encountered during the period between June 2005 and May 2010. The treatment outcomes were defined as effective or ineffective. RESULTS There were 16 patients with 16 leg ulcers. The patients were 13 men and 3 women, with an average age of 67.2 years (range, 47-85 years). Ten (63%) of the 16 ulcers were treated effectively. According to univariate analyses, an ankle brachial pressure index (ABI) lower than 0.6 (p = 0.03) had a negative impact on the outcome of MDT; however, outcome was not influenced by gender, obesity, ischemic heart disease, diabetes mellitus, hemodialysis, smoking, or laboratory findings. CONCLUSIONS Some patient characteristics, such as gender, obesity, ischemic heart disease, diabetes mellitus, hemodialysis, and smoking, do not seem to contraindicate eligibility for MDT. However, a limb with an ABI lower than 0.6 is less likely to benefit. (English Translation of J Jpn Coll Angiol 2011; 51: 209-213.).