Shinya Takase

Monocyte infiltration into venous valves

PURPOSE Greater saphenous veins removed at surgery for correction of venous dysfunction have few valves. Those that are present may be shrunken, deformed, or monocuspid. This study was carried out to determine whether leukocyte infiltration is associated with valve damage. METHODS Seventeen specimens were removed at surgery from five men and eight women (age, 29 to 80 years). These consisted of the proximal 15 cm of the duplex-confirmed, refluxing proximal greater saphenous vein, one proximal lesser saphenous vein, and one midportion of greater saphenous vein. The severity of venous stasis in each patient limb was classified by the CEAP formula. Twelve were class 2, two were class 3, and three were class 4. Control specimens were obtained from patients who underwent coronary artery bypass grafting. These were two men and two women, ages 72, 66, 62, and 60 years, free of venous insufficiency, with the specimens obtained from the proximal saphenous vein. Two of the control specimens contained venous valves corresponding to the test specimens. Longitudinal 10 microns paraffin sections were labeled with anti-CD64 monoclonal antibody, specific for tissue monocytes and macrophages, and studied by light microscopy. Five regions were chosen for quantification of the leukocyte infiltrate. Cells were categorized and counted directly. Volume proportions were calculated using stereologic techniques. RESULTS Three of seven specimens studied for morphologic changes had clearly shortened valve leaflets. Collagen degeneration was noted in all seven specimens. Leaflets had essentially disappeared in three and were shortened to 100 to 2100 microns in five. Specific leukocyte staining was accomplished on 10 additional specimens. All specimens showed monocyte/macrophage infiltration in valve leaflets and venous wall. These were more numerous in the valve sinus and proximal wall both on and under the endothelium. Control specimens showed no monocyte/macrophage infiltration. CONCLUSIONS These observations suggest that venous valve damage in refluxing saphenous veins is associated with a leukocyte (monocyte/macrophage) infiltrate. Cell activation and fluid dynamic factors, such as eddies recirculation, and stasis in the valve sinus may be a part of the process of leukocyte penetration of the endothelium. The magnitude of leukocyte infiltration in the vein wall and in the base of the valve leaflet may be important in the genesis of primary venous dysfunction.

New Advances in the Understanding of the Pathophysiology of Chronic Venous Insufficiency

Chronic venous insufficiency (CVI) is inseparably linked to elevated venous pressure and is accompanied by vascular, dermal, and subcutaneous tissue damage and restructuring. Abundant evidence exists both in humans and in experimental models to suggest that the tissue damage may be initiated by generation of an inflammatory reaction. inflammatory indi cators include elevation of endothelial permeability; attachment of circulating leukocytes to the endothelium; infiltration of monocytes, lymphocytes, and mast cells into the connective tissue; and development of fibrotic tissue infiltrates and several molecular markers, such as growth factor or membrane adhesion molecule generation. Indicators of an inflammatory reaction are already detectable at early stages of CVI and may be involved in the development of primary venous valve dysfunction. One of the important questions is to identify trigger mechanisms for the inflammatory reaction in CVI. Current evidence suggests that, among several possible mechanisms (hypoxia, humoral stimulation), a shift in fluid shear stress from normal physio logical levels and endothelial distension under the influence of elevated venous pressure may serve as trigger mechanisms for inflammation.

Inflammation in Chronic Venous Insufficiency: Is the Problem Insurmountable?

One of the hallmarks of venous insufficiency is an elevated venous pressure. While a number of mechanisms have been proposed for vascular and parenchymal cell damage following venous pressure elevation, such as white cell infiltration, a key question remains as to what degree venous occlusion and flow interruption per se may constitute a risk factor in venous disease. To gain an insight into this mechanism, we examined the effect of venous occlusion followed by reperfusion. A draining venule (circa 50 µm) in the rat mesentery was occluded with a micropipette (1 h) followed by reperfusion (1 h). The procedure serves to raise the microvascular pressure to about 31 mm Hg during the occlusion while the flow is completely stopped in the local venous and capillary network. Parenchymal cell death in the mesentery was monitored by propidium iodide (PI) labeling. The number of PI-positive cells significantly increased predominantly during reperfusion. A 1-week treatment with a micronized purified flavonoid fraction (100 mg/kg/day) served to significantly reduce parenchymal cell death as well as leukocyte rolling, adhesion to postcapillary venule, and migration into the tissue both during occlusion and reperfusion. The results indicate, that even in an initially symptomless tissue, flow reduction combined with microvascular pressure elevation during venous occlusion results in tissue damage not only during reperfusion (as in arterial occlusion) but also during occlusion.

Management Strategy of Isolated Spontaneous Dissection of the Superior Mesenteric Artery

OBJECTIVE Isolated spontaneous dissection of the superior mesenteric artery (SMA) is very rare among of the visceral artery dissection and its treatment is not established. In this paper we present our experiences and consider the treatment of isolated SMA dissection. METHODS A retrospective review of our cases from 2005 was performed. Clinical symptoms, radiologic findings and results were evaluated. There were 14 cases of visceral artery dissection, in which all cases were with SMA dissection. There were 12 males and 2 females with a mean age of 57 years (range 41-78 years). RESULTS We categorized SMA dissection into the six types according to the Sakamotos and Zerbibs classification. One patient with type VI underwent emergent endovascular surgery with stent. One patient with type VI received thrombectomy and intimectomy with open surgery. One patient with type II underwent aneurysmectomy due to enlarged dissected SMA 3 months later from onset. The other eleven patients were managed conservatively. At follow-up, the diameter of SMA did not enlarged and the length of the dissection significantly decreased to 20.7 ± 15.7 mm from 38.0 ± 15.1 mm at onset (p <0.01). After treatment, imaging indicated the following changes in classification: type I, one patient; type II, 4 patients; type IV, 4 patients; complete remodeling, one patient, all without any event during the follow-up period of 5-82 months. CONCLUSION Most patients with isolated visceral artery dissection occurred in superior mesenteric artery and can be treated conservatively; however, endovascular or surgical procedures including laparotomy are indicated when there is suspicion of severe mesenteric ischemia. Because the dissection configuration will change, long term follow-up is necessary. (English translation of Jpn J Vasc Surg 2013; 22: 695-701).

Angioscopic External Valvuloplasty in the Treatment of Varicose Veins

Objective: To report on the surgical treatment of varicose veins by angioscopic valvuloplasty to preserve the long saphenous vein (LSV) and the efficacy of this method compared with conventional stripping and high ligation. Methods: A total of 306 limbs in 187 patients with reflux at the sapheno-femoral junction to below knee level were operated on using intraoperative angioscopy to diagnose valve insufficiency. Angioscopic external valvuloplasty was attempted for the subterminal valves in the LSV by three techniques: total plication of the dilated annulus by running polypropylene sutures (technique 1), plication by autogenous femorofascial sleeve or Dacron-reinforced silicone (technique 2), and plication of the commissure with shortening of the cusps from outside the vein wall (technique 3). Partial stripping or segmental ligation was performed for varicose veins below knee level and the incompetent perforating veins were treated simultaneously by suprafascial ligation. Results: The subterminal valves were classified as follows: valves with elongated and atrophic cusps – type I, 136 (44%); valves with expanded and depressed commissures with cusp changes – type II, 108 (35%); valves that had cusps with other deformities – type III, 38 (13%); and absence of valves between the saphenofemoral junction and mid-thigh level, 24 limbs (8%). Valvuloplasty of the LSV was successfully performed in 62 limbs (20%). There were two cases with occlusion of the LSV (3%) and four with recurrence of varicose veins (6%) at 2–89 (mean 55, SD 21) months follow-up. Conclusions: Angioscopic external valvuloplasty is effective in the treatment of varicose veins to preserve the LSV. Further data are needed for complete evaluation of this procedure.

External valvuloplasty for primary valvular incompetence of the lower limbs using angioscopy

The morphology of 145 vein valves of venous stasis syndrome was studied and classified into three types by means of angioscopy. External valvuloplasty for primary valvular incompetence (PVI) was performed in 21 highest valves of the superficial femoral vein and 46 subterminal valves of the long saphenous vein under direct vision using angioscopy. Within external valvuloplasty, Technique I is total plication of the dilated vein annulus by running a suture around the vein; Technique II is plication by placing an autogenous femorofascial band; and Technique III is direct suture of valve commissure including the leading edge of the cusp from the outside vein wall using horizontal mattress suture with pledgets. Venous regurgitation was reduced from grade III–IV to grade 0–1 in descending phlebography after external valvuloplasty. Ambulatory venous pressure improved from 42% to 54% postoperatively. Reflux volume by Duplex scanning was significantly decreased after external valvuloplasty and maintained a reduced level. Surgical results of external valvuloplasty using angioscopy are satisfactory in all cases of the superficial femoral vein and in 91% of the long saphenous vein in 2–4-year follow-up. External valvuloplasty using angioscopy is a simple and reliable surgical technique. It is necessary to have a longer follow-up in order to fully evaluate the value of these external valvuloplasty techniques.

Successful treatment of pseudoaneurysms of celiac and superior mesenteric arteries by combined endovascular and surgical approach

Pseudoaneurysm after pancreas resection poses serious complications, including rupture and hemorrhage. Here we report a case of delayed massive hemorrhage from celiac and superior mesenteric arteries, which was successfully treated with a combined endovascular and surgical approach. The patient was a 52-year-old man who presented with pseudoaneurysms of the celiac and superior mesenteric arteries after distal pancreatectomy. Following the detection of sentinel bleeding from the abdominal drain, emergency angiography of the celiac and superior mesenteric arteries revealed stenosis of the celiac artery and pseudoaneurysms in the superior mesenteric artery. We occluded these lesions with a platinum coil, using an interventional radiological technique combined with bypass grafting between the abdominal aorta and the SMA, using the saphenous vein. However, re-bleeding into the abdominal cavity occurred from the proximal SMA pseudoaneurysm. We inserted an endoluminal stent-graft into the abdominal aorta and completed bypass grafting between the aorta and bilateral renal arteries. The hemorrhage ceased and the postoperative course was uneventful. The patient was discharged 34 days after the treatment (149 days after the initial operation). In conclusion, this combined endovascular and surgical approach is feasible and seems appropriate for pseudoaneurysms arising from proximal sites in visceral arteries.

Short-term and long-term outcomes of octogenarians after off-pump coronary artery bypass surgery

PurposeOff-pump coronary artery bypass has been reported to be associated with reduced morbidity and mortality after surgical coronary revascularization, especially in high-risk patients. The aim of this study was to clarify the efficacy of off-pump coronary artery bypass for the very elderly patients.MethodsWe compared the outcomes of octogenarians (n = 28, 82 ± 2 years) undergoing off-pump coronary artery bypass and those of the patients <80 years of age (n = 315, 67 ± 9 years) during short- and long-term periods.ResultsThere was no difference in hospital mortality between octogenarians and the younger cohort (3.8% vs. 0.6%; P = 0.11). A high rate of postoperative complications (e.g., pneumonia, transient renal dysfunction, ventricular arrhythmia) were observed in the octogenarians. The long-term survival (81% at 5 years) and the rate of freedom from cardiac death (92% at 5 years) and from cardiac events (85% at 5 years) were excellent in the octogenarians; they appeared less favorable, however, when compared with the younger group (95%, 98%, and 94% at 5 years, respectively). Most of the cardiac adverse events, including unexplained sudden death, occurred 6 months after the surgery in octogenarians.ConclusionOff-pump coronary artery bypass can be performed safely in octogenarians, with excellent early and late outcomes. Careful postoperative follow-up is required to reduce postoperative long-term adverse events. Off-pump coronary artery bypass is a feasible modality of coronary revascularization for octogenarians.

A simple technique of introducing intracoronary shunts for off-pump coronary artery bypass surgery

We describe a simple technique of introducing intracoronary shunts for off-pump coronary artery bypass. This technique, with an aid of micro-bulldog clamp, provides both a test clamp with ischemic preconditioning effect, and a quick and easy introduction of intracoronary shunt, giving a clear visualization of coronary anastomosis site and distal coronary artery perfusion. We recommend this technique as another effective modality in off-pump coronary artery bypass surgery.

Intraoperative thrombectomy for occluded carotid arteries in patients with acute aortic dissection: report of two cases

The present study describes two cases in which intraoperative thrombectomy was performed for occluded or severely stenosed carotid arteries in patients with acute aortic dissection complicated by cerebral malperfusion. A Fogarty catheter was inserted into the true lumen of the occluded branch under hypothermic circulatory arrest, and thrombi within the false lumen were removed. The arch vessels were patent on subsequent computed tomographic imaging, and no neurological complications were found postoperatively. In these cases, the choice of appropriate management strategies took into consideration the brain ischemic time and the presence or absence of cerebral infarction. This technique represents a useful option for the management of this clinical scenario.