Shunichi Hoshino

Intravascular Imaging Methods for Venous Disorders.

The purposes are to assess the problems associated with intravascular imaging methods such as angioscopy and intravascular ultrasound (IVUS) and to evaluate their efficacy through the results of our observations. A total of 54 limbs in 53 patients, 50 patients with chronic venous insufficiency and 3 patients with deep vein thrombosis, were diagnosed and operated on using angioscopy (Olympus OES, order made type) and IVUS (Endosonics, model 82700). The imaging catheters were inserted through a branch of the long saphenous vein and the valves and the intraluminal views were observed. By angioscopy, intraluminal views were clearly observed in 98% of all lesions. However, observation became more difficult in iliac veins compared to in femoral and in long saphenous veins (p<0.01). Venous wall and thrombus were detected more by IVUS than by angioscopy (p<0.01), but only 21 valves (24%) were visualized by IVUS among the 88 valves observed by angioscopy. The intravascular imaging method of angioscopy is more suitable for observing valves and intraluminal views compared with IVUS, whereas IVUS is more suitable for observing the cross-sectional venous wall.

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.

Clinical results of radiofrequency endovenous obliteration for varicose veins.

PurposeRadiofrequency (RF) endovenous obliteration is performed in the United States and several European countries for the minimally invasive treatment of saphenous-type varicose veins. We evaluated the clinical results of RF endovenous obliteration to treat varicose veins at Fukushima Daiichi Hospital.MethodsWe performed endovenous obliteration of 25 great saphenous varicose veins in 20 patients, under duplex ultrasound guidance. None of the varicose veins were tortuous in the thigh area. Venous occlusion was evaluated by duplex ultrasound under cuff compression with the patient standing, preoperatively, then 1 day and 1 month postoperatively.ResultsSaphenous obstruction was confirmed in all legs 1 day and 1 month postoperatively, as complete obstruction from the saphenofemoral junction in 1, as complete obstruction with only superficial epigastric venous flow in 23, and as near complete obstruction (patent length > 5 cm) in 1. The venous obstruction was caused by shrinkage of the vein (31.2% of the area at the saphenofemoral junction, 44% at the thigh, and 57.7% at the knee) and thrombus formation. The only complications of RF endovenous obliteration were clinical superficial thrombophlebitis (13%) and temporal sensory nerve injury (4%).ConclusionRadiofrequency endovenous obliteration is as effective as, but less invasive than other treatments for saphenous varicose veins.

Postoperative Alteration in the Size of Dacron Vascular Prostheses Implanted in the Infrarenal Abdominal Aorta

The degree and significance of postoperative alteration in the size of Dacron grafts in the infrarenal abdominal aorta was assessed by computed tomography. We studied a total of 41 knitted Dacron fabric grafts, comprising 28 Gelseal triaxial grafts and 13 Hemashield Microvel grafts, and 29 woven Dacron fabric (Veri-Soft Woven) grafts which were used to replace the infrarenal abdominal aneurysms. These three types of Dacron fabric dilated immediately after replacement to 1.4–1.5 times the manufactured size, but did not dilate further after the surgery.

Prevention of paraplegia in transluminally placed endoluminal prosthetic grafts for descending thoracic aortic aneurysms

OBJECTIVE To evaluate the efficacy of a temporary balloon occlusion test for the prevention of paraplegia following transluminally placed endoluminal prosthetic grafts for descending thoracic aortic aneurysms. SUBJECTS AND METHODS Two occlusion balloons were inserted via the brachial and femoral arteries and positioned in the proximal and distal neck of the descending thoracic aortic aneurysms using fluoroscopy. After temporary occlusion of the thoracic aorta by inflation of both the proximal and distal balloons, the evoked spinal potential was measured for 15 mins. A maximum amplitude during temporary balloon occlusion test decreasing by more than 20% of the pre-balloon occlusion level was considered to be significant, enough to not perform transluminally placed endoluminal prosthetic grafts, but instead an open repair. The test was applied in 12 cases (9 males and 3 females, 50-86 years old). All aneurysms were located between the Th6 and Th12 with a maximum diameter of 40-70 mm, and average of 56 mm. RESULTS The changes in maximum amplitude of evoked spinal potential remained within 20% of the value before balloon occlusion in 11 cases. Transluminally placed endoluminal prosthetic grafts were performed in these 11 cases and no instance of paraplegia or other complication relating to the test was observed. Deployment of stent-grafts was successful in 10 cases (91%). CONCLUSION It is suggested that the preoperative measurement of evoked spinal potential during temporary balloon occlusion is clinically useful for the assessment of the risk to paraplegia occurring in transluminally placed endoluminal prosthetic grafts.

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.

Clinical results of open stent grafting applied using an improved endotracheal tube in the treatment of high-risk patients with distal arch aneurysms

Whereas the operative results for thoracic aortic aneurysms (TAA) have improved in recent years, the results for distal arch aneurysms (DAA) remain unsatisfactory. We report herein the initial results of open stent grafting (OSG) applied using an improved endotracheal tube for surgical treatment of high-risk DAA. OSG was used to treat DAA in five men aged 69–80 years (mean, 77 years). Four cases involved chronic obstructive pulmonary disease, and the remaining case involved both ischemic heart disease and chronic renal failure. Previous surgical repairs of an abdominal aortic aneurysm had been performed in four patients, and thoracoplasty and reconstruction of the lower extremities had been performed in the remaining patient. Under selective cerebral perfusion, OSG with revascularization of two cerebral branches was performed in two patients, whereas OSG with total arch replacement was performed in three patients. The procedure was successful in all cases. There were no complications related to cerebrospinal disorders, and complete thrombosis of the aneurismal sac was achieved in all cases. The new deployment method using an endotracheal tube offers numerous advantages, including reduced aortic wall injury and accurate placement of the stent graft in the operative field. These initial results suggest that this specific approach makes OSG a useful surgical procedure in the treatment of high-risk DAA.

Graft-wall endoleak 18 months after successful endoluminal AAA repair

Purpose: To describe a case of graft-wall endoleak 18 months after successful endoluminal repair of an abdominal aortic aneurysm (AAA). Methods and Results: A 71-year-old man with infrarenal AAA was successfully treated with an endoluminal aortomonoiliac graft and femorofemoral crossover bypass with surgical ligation of the right external iliac artery. The stent-graft was made from 2 Gianturco Z-stents and a tapered thin-walled (0.1-mm) Dacron graft. Eighteen months after endografting, the patient complained of a pulsatile abdominal mass. Angiography and computed tomography showed graft-wall endoleak. Aneurysmectomy was performed, and the aneurysm was successfully replaced with a Y-shaped knitted Dacron graft. A hole in the graft wall was found 3 cm from the proximal edge of the stent-graft. Conclusions: This case suggests that the use of thin-walled graft material in endografts may not be sufficiently durable.

The Appearance of Cytokines and Adhesion Molecules in Saphenous Vein Valves in Chronic Venous Insufficiency

Objective: To evaluate the difference between competent valves and incompetent valves with regards to the development of expression of cytokines and adhesion molecules in primary varicose veins. Methods: Specimens were obtained from 13 patients with primary varicose veins during surgery. Valves were classified according to the angioscopic findings: 8 competent and 17 incompetent valves; type I (7 valves with elongated cusps) and type II (10 valves with expansion of commissures). The mRNA levels of interleukin-1β (IL-1β), interleukin-6 (IL-6), interleukin-8 (IL-8), tumour necrosis factor-α (TNF-α), transforming growth factor-β (TGF-β), intercellular adhesion molecule-1 (ICAM-1), vascular cell adhesion molecule-1 (VCAM-1) and endothelial leucocyte adhesion molecule-1 (ELAM-1) were measured by polymerase chain reaction (PCR) amplification of cDNA reverse-transcribed from RNAs. Results: In all cases there were few appearances of IL-6, IL-8 and TNF-α at the valve cusps. TGF-β and VCAM-1 levels were highly elevated in the cusps of incompetent valves compared with competent valves (p<0.05). At the venous wall IL-6 and IL-8 occurred more frequently in incompetent valves than in competent valves (p<0.05). Conclusion: This study suggests that inflammatory cytokines and adhesions molecules, especially TGF-β, IL-6, IL-8 and VCAM-1, may be related to the occurrence of valve insufficiency.

Simultaneous open abdominal aortic replacement and thoracic stent-graft placement: report of a case.

Abstract.A 77-year-old man with severe chronic obstructive pulmonary disease was admitted to our hospital for surgical treatment of a proximal descending thoracic aortic aneurysm (dTAA) and an infrarenal abdominal aortic aneurysm (AAA). The patient had poor respiratory function; however, a simultaneous abdominal aortic replacement and thoracic stent-graft placement were successfully performed without any complications. This case report demonstrates that simultaneous abdominal aortic replacement and thoracic stent-graft placement for multiple aneurysms may be feasible and can safely be performed in selected high-risk patients, despite the many problems associated with the treatment of aortic aneurysms using stent grafts.