T. Kudo

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

OBJECTIVESnWe 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.nnnMETHODSnTwenty-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).nnnRESULTSnT1/2 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).nnnCONCLUSIONSnICGA 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.

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

BACKGROUNDnThe 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.nnnMETHODSnA 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).nnnRESULTSnMedian 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%.nnnCONCLUSIONSnLocal 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.

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

INTRODUCTIONnInfection 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.nnnREPORTnWe 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.nnnDISCUSSIONnThe combination of drainage surgery and irrigation with gentian violet solution provides an alternative option to graft excision for prosthetic graft infection.

Subcutaneously implanted enteral nutrition port.

BACKGROUNDnPatients who have undergone esophagectomy with extensive lymph node dissection under thoracolapalotomy for advanced esophageal carcinomas frequently need long-term nutrition support because of their inadequate oral intake. We have used tube enterostomy feeding for these patients not only immediately after the operations but also at home to prevent the development of malnutrition. Patients who receive long-term tube enterostomy feeding often suffer from skin problems around the enteral nutrition catheters. Once the catheter is removed, the patient with anticipated malnutrition is subsequently unable to receive beneficial enteral nutrition. We have developed a new enteral access system that is placed subcutaneously. This subcutaneously implanted enteral nutrition port makes possible intermittent and long-term enteral nutrition support not only for the postoperative period but also for home care.nnnMETHODSnThis system consists of the port (Infuse-a-Port, SMAP15 Snaplock Macro-Port Venous Access System; Strato Medical Co) and the enteral nutrition tube (Enteral Tube 8F, 75 cm; Zeon Co). This system was applied to seven patients who had undergone esophagectomy. The port was placed on the lower chest subcutaneously, and the catheter was placed through the gastric tube and duodenum up to the jejunum. After the operation, a 20-gauge port needle was placed, and enteral nutrition formula (Enterued; Termo Co) was started with the enteral nutrition pump.nnnRESULTSnNo complications (eg, infection of skin, obstruction of tube) were observed from the postoperative period through the home care stage. The observation period for this implanted system ranged from 2 to 12 months. The patients were able to avoid the malnutrition anticipated after the extensive operations and continued to receive nutrition support safely and effectively at home.nnnCONCLUSIONnThis new nutrition support system is safe and efficient for patients who anticipate long-term enteral nutrition support. A subcutaneously implanted enteral nutrition port makes possible intermittent and long-term nutrition support without patient discomfort and inconvenience.

A Comparison of the Regional Circulation in the Feet between Dialysis and Non-Dialysis Patients using Indocyanine Green Angiography

Background and Aims: Peripheral artery disease in dialysis cases is more prone to critical limb ischemia compared to non-dialysis cases, with a significantly high rate of major amputation of the lower limbs. Lesions are distributed on the more distal side in dialysis critical limb ischemia cases. The aim of this study was to investigate the usefulness of indocyanine green angiography to determine differences in the regional circulation in the foot between dialysis and non-dialysis patients. Materials and Methods: The subjects included 62 cases, among which 20 were dialysis patients and 42 were non-dialysis patients. We compared the indocyanine green angiography parameters for regions of interest in the dialysis and non-dialysis groups, which included the magnitude of intensity from indocyanine green onset to maximum intensity (Imax), the time from indocyanine green onset to maximum intensity (Tmax), the time elapsed from the fluorescence onset to half the maximum intensity (T1/2), and the time from maximum intensity to declining to 90% of the maximum intensity (Td90%). These indocyanine green angiography parameters were measured at region of interest 1 (the Chopart joint), region of interest 2 (the Lisfranc joint), and region of interest 3 (the distal region of the first metatarsal bone). Results: In the comparison between the dialysis and non-dialysis groups, a significant difference was observed regarding Tmax, T1/2, and Td90%, especially in region of interest 3. Conclusion: In this study, we show that regional tissue perfusion is more deteriorated in dialysis patients compared with non-dialysis patients using indocyanine green angiography. Tmax, T1/2, and Td90% could be useful clinical parameters to compare ischemic severity of the lower limb between dialysis and non-dialysis patients.

Successful Endovascular Repair of Ruptured Isolated Bilateral Internal Iliac Artery Aneurysms

INTRODUCTIONnDue to their anatomic location, internal iliac artery aneurysms are difficult to treat surgically. An endovascular approach can be helpful, even in ruptured cases.nnnREPORTnWe report a 71-year-old male with ruptured isolated bilateral internal iliac artery aneurysms. The aneurysms were treated with embolisation of the branching arteries of the bilateral internal iliac arteries followed by placement of a stent graft covering the orifice of the bilateral internal iliac arteries. The patient tolerated this procedure well.nnnDISCUSSIONnEven in patients with ruptured aneurysms, endovascular treatment for internal iliac artery aneurysms can be a good treatment option.