Kuniyasu Ikeoka

Importance of the angiosome concept for endovascular therapy in patients with critical limb ischemia

Objective: We investigated the role of the angiosome concept in endovascular therapy (EVT) for limb salvage. Background: The angiosome concept is clinically useful in bypass surgery for critical limbs ischemia (CLI). However, comparison with direct and indirect flow to the site of ulceration based on angiosome concept regarding freedom from amputation has not been systematically studied for the patient with CLI undergoing EVT. Methods: We analyzed 203 limbs in 177 consecutive patients (male = 127, age = 70 ± 11 years) with ischemic ulceration that was Rutherford 5 or 6 (5 in 145 limbs and 6 in 58 limbs; pretreatment ankle‐brachial index = 0.74 ± 0.27), who underwent EVT alone without bypass surgery. We classified these patients into direct and indirect groups depending on whether feeding artery flow to the site of ulceration was successfully acquired or not acquired based on the angiosome concept. Freedom from amputation was compared between the direct and the indirect groups by Kaplan‐Meier analysis. Results: The overall limb salvage rate was 82% (167/203). Skin perfusion pressure was significantly higher in the direct group (67 ± 25 mm Hg) than in the indirect group (41 ± 20 mm Hg, P = 0.002). The limb salvage rate was also significantly (P = 0.03) higher in the direct group (86%) than in the indirect group (69%) for up to 4 years after the procedure. The number of vessels with run‐off flow did not influence the limb salvage rate in either the direct group (P = 0.84) or the indirect group (P = 0.90). Conclusion: Acquiring direct flow based on the angiosome concept is important for limb salvage by EVT in patients with CLI.© 2010 Wiley‐Liss, Inc.

Influence of stent fracture on the long-term patency in the femoro-popliteal artery: experience of 4 years.

OBJECTIVES We investigated the time course of stent patency in the femoro-popliteal artery for as long as 4 years. BACKGROUND Stent fracture has been related to poor 2-year patency in the femoro-popliteal artery. METHODS We studied 239 consecutive patients who underwent provisional de novo stenting with nitinol stents for 333 limbs (Luminexx stent [C. R. Bard, Inc., Murray Hill, New Jersey] in 91 limbs; Smart stent [Cordis Corp., Miami Lakes, Florida] in 242 limbs) from April 2004 to December 2007. Stent fracture was determined by X-ray with multiple projections. Patency was assessed by duplex ultrasonography as peak systolic velocity ratio <2.4 or by angiography (% diameter stenosis <50%). Primary patency in those with and without stent fracture at follow-up was assessed along with factors influencing stent fracture. RESULTS Primary patency was 81%, 74%, 68%, and 65% at 1, 2, 3, and 4 years, respectively. Stent fracture occurred in 14% (78 of 544) per stent and 17% (55 of 333) per limbs. Stent fracture was significantly associated with multiple stent deployments (with fracture = 2.3 +/- 0.9 stents vs. without fracture = 1.5 +/- 0.7 stents, p < 0.001) and long lesions (with fracture = 208 +/- 84 mm vs. without fracture = 121 +/- 79 mm, p < 0.001). Primary patency was 68% with fracture versus 83% without fracture at 1 year, p = 0.03; 65% versus 75% at 2 years, p = 0.05; 61% versus 69% at 3 years, p = 0.06; and 61% versus 65% at 4 years, p = 0.07. Neither type 1 nor type 3 fracture affected patency, although type 2 showed the worst patency. CONCLUSIONS Stent fracture worsened the patency during the first 2 years, but it did not apparently affect patency beyond 2 years. In particular, complete stent separation did not affect patency.

Myocardium-derived angiopoietin-1 is essential for coronary vein formation in the developing heart

The origin and developmental mechanisms underlying coronary vessels are not fully elucidated. Here we show that myocardium-derived angiopoietin-1 (Ang1) is essential for coronary vein formation in the developing heart. Cardiomyocyte-specific Ang1 deletion results in defective formation of the subepicardial coronary veins, but had no significant effect on the formation of intramyocardial coronary arteries. The endothelial cells (ECs) of the sinus venosus (SV) are heterogeneous population, composed of APJ-positive and APJ-negative ECs. Among these, the APJ-negative ECs migrate from the SV into the atrial and ventricular myocardium in Ang1-dependent manner. In addition, Ang1 may positively regulate venous differentiation of the subepicardial APJ-negative ECs in the heart. Consistently, in vitro experiments show that Ang1 indeed promotes venous differentiation of the immature ECs. Collectively, our results indicate that myocardial Ang1 positively regulates coronary vein formation presumably by promoting the proliferation, migration and differentiation of immature ECs derived from the SV.

Age‐ and sex‐related differences in diastolic function and cardiac dimensions in a hypertensive population

The prevalence of left ventricular diastolic dysfunction increases with age, particularly in hypertensive women. We aimed to determine the age‐ and sex‐related differences in diastolic function, and its relation to alterations of cardiac dimensions in a hypertensive population.

TOCILIZUMAB AMELIORATES VASCULAR INFLAMMATION AND CLINICAL SYMPTOMS IN PATIENTS WITH TAKAYASU ARTERITIS REFRACTOTRY TO GLUCOCORTICOIDS

Treatment of refractory Takayasu arteritis (TA) remains a challenging clinical issue. Patients usually respond to glucocorticoid (GC) therapy, but often relapse on tapering of the GC dose. Additionally, GCs therapy is accompanied with a variety of adverse events. The aim of this study was to assess

Dabigatran Therapy Resulting in the Resolution of Rivaroxaban-resistant Left Atrial Appendage Thrombi in Patients with Atrial Fibrillation

Patients with persistent atrial fibrillation (AF) and a large left atrium are at a high risk for thromboembolisms. Recently, direct oral anticoagulants (DOACs) have mainly been used for the prevention of cardiac embolisms caused by AF. Transesophageal echocardiography (TEE) is performed in order to exclude any left atrial appendage (LAA) thrombi. We herein report two cases of persistent AF, both of which were treated with rivaroxaban for more than two years. Since TEE identified mobile LAA thrombi with this treatment, we switched from rivaroxaban to the direct thrombin inhibitor dabigatran. Dabigatran resolved the LAA thrombi that had been refractory to rivaroxaban.

Endovascular therapy for subclavian artery restenosis due to stent strut protrusion with high-resolution angioscopy and three-dimensional optical frequency domain imaging

A 47-year-old female patient was admitted with a complaint of severe chest pain on effort. She had a history of effort angina treated using coronary artery bypass with left internal thoracic arterial bypass to the left ascending coronary artery. She also had left subclavian and vertebral arterial stenoses, which were treated with balloon-expandable stents. Exercise stress myocardial perfusion imaging revealed anterior to apex left ventricular myocardial ischemia. Cardiac ischemia due to left subclavian stenosis was diagnosed. We treated the left subclavian arterial stenosis with endovascular therapy. We observed that the vertebral Palmaz stent protruded from the ostium and the jailed subclavian artery on high-resolution angioscopy (Zemporshe with a 0.48-megapixel equivalent resolution; Taisho Biomed Instruments, Osaka, Japan) and optical frequency domain imaging (OFDI). A guide wire was successfully crossed through the Palmaz stent strut, which was confirmed using three-dimensional OFDI. The stent strut was dilated using balloon angioplasty. New imaging technologies are promising tools for improving the efficacy and safety of craniocervical intervention. <Learning objective: New imaging technologies including high-resolution angioscopy and 3D-optical frequency domain imaging have become available for endovascular therapy of peripheral artery disease. They could be used to observe stent strut deformation with high imaging quality and demonstrated successful guidewire passage through the stent strut. High-resolution angioscopic system yields images with higher quality and larger angular field than any other previous angioscopy systems.>

Pathophysiological Significance of Velocity-Based Microvascular Resistance at Maximal Hyperemia in Peripheral Artery Disease

Aim: Maximal hyperemic response, leading to examination of microvascular resistance in lower-limb lesions is not well understood. This study aimed to investigate the infrainguinal arterial physiological response through a hyperemic condition and the pathophysiological significance of microvascular resistance in peripheral artery disease. Methods: Sixteen limbs with focal stenosis of the superficial femoral artery (SFA) and 16 control limbs were analyzed. We assessed the fractional flow reserve (FFR), vascular flow reserve (VFR), and hyperemic microvascular resistance (h-MR) of the SFA with a pressure/Doppler flow sensor-tipped combination guidewire before and after endovascular therapy (EVT). Skin perfusion pressure (SPP) on both the dorsal and the plantar sides of the foot was measured at baseline before and after the endovascular procedures. Results: FFR (p < 0.05) and VFR (p < 0.05), but not h-MR, improved after EVT. There was no association between h-MR and FFR or VFR before EVT. h-MR was negatively correlated with the dorsal SPP before EVT (r = −0.589, p < 0.05). h-MR in patients with high h-MR before EVT significantly decreased after EVT (p < 0.05). Patients with high, but not those with low, h-MR before EVT exhibited a significant increase in dorsal and plantar SPP after EVT (p < 0.05, each). Conclusion: EVT for SFA stenosis improved FFR and VFR comprehensively, with no apparent change in h-MR. However, high h-MR before EVT may play a predictive role for limb perfusion improvement associated with h-MR reduction after EVT.

Sex-Related Differences in Left Ventricular Diastolic Function and Arterial Elastance during Admission in Patients with Heart Failure with Preserved Ejection Fraction: The PURSUIT HFpEF study

We previously reported that an index of afterload‐related left ventricular diastolic function, operant diastolic elastance (Ed)/effective arterial elastance (Ea) = E/e’/(0.9 × systolic blood pressure), was significantly higher in elderly hypertensive women. We aimed to determine sex‐related differences in the E/e’‐related indices for left ventricular diastolic function and their related factors during admission in patients with heart failure with preserved ejection fraction (HFpEF).

Transient manifestation of left ventricular diastolic dysfunction following ablation in patients with paroxysmal atrial fibrillation

In patients with atrial fibrillation, ablation decreases left atrial (LA) compliance, which may lead to left ventricular (LV) diastolic dysfunction. We aimed to examine serial changes in LV diastolic function after 2 ablation procedures and their related factors in patients with paroxysmal atrial fibrillation (PAF).