Masatoshi Jibiki

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.

Effects of human atrial natriuretic peptide on renal function in patients undergoing abdominal aortic aneurysm repair.

Objective:Ischemia-reperfusion injury is an important cause of renal dysfunction after abdominal aortic aneurysm repair. Human atrial natriuretic peptide (hANP) is a potent endogenous natriuretic, diuretic, and vasorelaxant peptide. The objective of the present study was to evaluate the effects of hANP on renal function in patients undergoing abdominal aortic aneurysm repair. Design:A prospective, randomized, placebo-controlled study Setting:Intensive care unit of a university hospital. Patients:Forty patients undergoing elective abdominal aortic aneurysm repair. Interventions:The patients were randomized to receive a continuous infusion of either hANP (0.01–0.05 &mgr;g/kg/min) (n = 20) or placebo (n = 20) immediately before aortic cross-clamping. The infusion of hANP or placebo continued for 48 hrs. Measurements and Main Results:Blood and urine samples were taken before surgery, at admission to the intensive care unit, and on days 1, 2, and 3 postoperatively, for measurement of serum concentrations of sodium, creatinine, and blood urea nitrogen and plasma concentrations of ANP and brain natriuretic peptide (BNP). Urine volume and urinary concentrations of N-acetyl-&bgr;-D-glucosaminidase (NAG), sodium, and creatinine were also measured. The mean plasma concentration of ANP was significantly higher in the hANP group than in the placebo group. The mean plasma BNP concentration was significantly lower in the hANP group than in the placebo group. The mean serum concentrations of creatinine and blood urea nitrogen were significantly (p < .05) lower in the hANP group than in the placebo group. The mean urine volume and mean creatinine clearance were significantly (p < .05) higher in the hANP group than in the placebo group. The mean urinary NAG/creatinine ratio was significantly (p < .05) lower in the hANP group than in the placebo group. Conclusions:The intraoperative and postoperative infusion of low-dose hANP preserved renal function in patients undergoing abdominal aortic aneurysm repair. Further studies are needed to assess the efficacy of prophylactic hANP infusion on perioperative renal outcome.

A Quantitative Method for Evaluating Local Perfusion Using Indocyanine Green Fluorescence Imaging

BACKGROUND The purpose of this study is to introduce a new method, indocyanine green fluorescence imaging (ICG-FI), as an adjunct to distal pressure measurements in patients with peripheral arterial disease and symptomatic lower limb ischemia. METHODS A total of 34 patients with peripheral arterial disease, including 11 with claudication (Fontaine II), 7 with rest pain (FIII), and 16 with an ulcer or gangrene (FIV), were enrolled. After an intravenous injection of ICG (0.1 mg/kg), foot perfusion was recorded by an infrared light camera. Fluorescence intensity was plotted on a time-intensity curve using recorded images, allowing the calculation of new parameters. Severity of ischemia was assessed as the duration between the rising point and half value of maximum brightness (T½). The difference in the fluorescence intensity between 10 seconds after the rising point and baseline (PDE10) was compared with the transcutaneous oxygen pressure (tcPO2) at the same site (n=51). RESULTS Median T½ was 23 seconds in FII, 41 seconds in FIII (P<0.05), and 17 seconds in FIV patients. PDE10 correlated moderately with tcpO2 (r2=0.5). A cut-off value (PDE10=28) predicted a critically ischemic limb (FIII and FIV), defined as tcpO2<30 mm Hg with a sensitivity of 100% and specificity of 86.6%. CONCLUSIONS Local tissue perfusion can be quantitatively evaluated by using ICG fluorescence imaging. It is a safe, fast, noncontact method of imaging, which may be useful even at the ulcer itself and in the circumferential area.

Differential detection rate of periodontopathic bacteria in atherosclerosis

PurposePeriodontitis has been associated with atherosclerotic cardiovascular lesions. There may be a link between periodontopathic bacterial infection and atherosclerosis.MethodsIn 53 patients with atherosclerosis, periodontal disease was classified according to the probing depth of the periodontal pocket. To compare the detection rate in different arterial lesion, specimens of diseased arteries (10 primary atherosclerotic lesions, 43 anastomotic lesions) and 21 control arteries without atherosclerotic findings macroscopically and microscopically in the arterial wall, obtained during the surgical procedures were examined for the presence of five species of putative periodontal bacteria using polymerase chain reaction (PCR) analysis.ResultsFifty-one of the 53 patients (96%) had periodontitis, and 34 (64%) of those patients had severe periodontitis or were edentulous. In total, PCR analysis detected DNA specific for periodontal bacteria in 28 of the 53 specimens (52%) of atherosclerotic arterial wall. Only 5 of 21 (23%) were detected in control specimens.ConclusionsA high percentage of periodontopathic bacteria were detected in atherosclerotic arterial wall specimens from patients with atherosclerosis, especially with primary atherosclerotic lesions, and most cases had severe periodontitis.

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.

Tumor thrombectomy without bypass for low-grade malignant tumors extending into the inferior vena cava: report of two cases.

Endometrial stromal sarcoma (ESS) rarely extends into the inferior vena cava (IVC). Two cases of ESS extending into the IVC were encountered. In the first case a low-grade sarcoma and cavography revealed the tumor thrombus to extend to just below the left renal vein from the right internal iliac vein, and the IVC was patent. A tumor thrombectomy was accomplished to prevent pulmonary embolism (PE) and to achieve a good prognosis. The second case was also a low-grade sarcoma. Abdominal computed tomography scanning revealed a large thrombus extending into the IVC just below the hepatic vein. A tumor thrombectomy with an IVC resection was performed. The postoperative course was uneventful for both cases. Aggressive surgical treatment is thus recommended to excise a tumor thrombus with or without an IVC resection in patients with ESS of low-grade malignancy extending into the IVC to prevent sudden death due to PE.

A single nucleotide polymorphism in the 3'-untranslated region of MyD88 gene is associated with Buerger disease but not with Takayasu arteritis in Japanese.

Buerger disease (BD) and Takayasu arteritis (TA) are rare vascular disorders. Although their etiology and pathogenesis have not been elucidated, several studies have suggested the involvement of innate immunity. Myeloid differentiation primary-response protein 88 (MyD88) is a key signaling adaptor for all Toll-like receptors, which have a central role in innate immunity. In the present study, we evaluated the association of MyD88 with BD and TA. We conducted case–control studies in Japanese populations composing of 131 BD cases, 90 TA cases and 270 healthy controls to be genotyped for a single nucleotide polymorphism rs7744 A>G in the 3′-untranslated region of MyD88 gene. The frequency of GG genotype was significantly lower in the BD patients than in the controls (6.9 vs 15.9%, P=0.011, odds ratio=0.39, 95% confidence interval; 0.19, 0.81), although there was no significant difference in the genotype frequencies between the TA patients and controls. It was suggested that MyD88 may confer resistance to BD in Japanese. Because this is the first report of the association between MyD88 and BD, replication studies in other cohorts are required.

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.).

Drainage Surgery Followed by Postoperative Irrigation with Gentian Violet for Prosthetic Graft Infection Caused by Methicillin-resistant Staphylococcus aureus

INTRODUCTION Infection of a prosthetic graft is still associated with considerable morbidity and mortality. Conventionally, this vascular complication is treated by excising the infected graft, although prosthetic graft preservation is possible in selected cases. REPORT We report the successful treatment of prosthetic graft infection caused by methicillin-resistant Staphylococcus aureus (MRSA) in three patients, by performing drainage surgery with postoperative irrigation using gentian violet. DISCUSSION The combination of drainage surgery and irrigation with gentian violet solution provides an alternative option to graft excision for prosthetic graft infection.