Tadashi Furuyama

Successful and optimized in vivo gene transfer to rabbit carotid artery mediated by electronic pulse

Several gene transfer methods, including viral or nonviral vehicles have been developed, however, efficacy, safety or handling continue to present problems. We developed a nonviral and plasmid-based method for arterial gene transfer by in vivo electronic pulse, using a newly designed T-shaped electrode. Using rabbit carotid arteries, we first optimized gene transfer efficiency, and firefly luciferase gene transfer via electronic pulse under 20 voltage (the pulse length: Pontime 20 ms, the pulse interval: Poff time 80 ms, number of pulse: 10 times) showed the highest gene expression. Exogenous gene expression was detectable for at least up to 14 days. Electroporation-mediated gene transfer of E. coli lacZ with nuclear localizing signal revealed successful gene transfer to luminal endothelial cells and to medial cells. Histological damage was recognized as the voltage was increased but neointima formation 4 weeks after gene transfer was not induced. In vivo electroporation-mediated arterial gene transfer is readily facilitated, is safe and may prove to be an alternative form of gene transfer to the vasculature.

Renal artery clamping and left renal vein division during abdominal aortic aneurysm repair.

OBJECTIVES To determine whether renal artery clamping and division of the left renal vein affects renal function in the patients who undergo repair of infrarenal abdominal aortic aneurysm (AAA). METHODS Between 1992 and 2000, 267 patients had open surgery for infrarenal AAA. Of these, 22 (8%) required temporary bilateral (15) or unilateral (7) renal artery clamping. 8 also had the left renal vein divided, three of which were re-anastomosed. RESULTS Renal artery clamping and/or renal vein divisions did not affect the incidence of complications and long term renal failure. CONCLUSIONS Clamping of the renal arteries and/or renal vein division during AAA surgery does not in itself compromise short or long term renal function.

Solitary fibrous tumor in the retroperitoneal space: Report of a case

Abstract.Solitary fibrous tumors (SFTs) are spindle-cell neoplasms originally described in the pleura. It is now known that these tumors can develop in many sites. This report describes the case of a well-circumscribed tumor located around the superior mesenteric artery (SMA), which was initially thought to be either a superior SMA aneurysm, a lymphoma, or a neurogenic tumor. Histological examination demonstrated the tumor to be composed of a cellular proliferation of ovoid to spindle cells with a fine collagenous matrix in the short fascicles. Immunohistochemical staining was strongly positive for CD34 and negative for factor VIII, cytokeratin, desmin, and muscle-specific actin (HHF-35). These findings suggested a diagnosis of SFT in the retroperitoneal space. To our knowledge, this is the first report of an SFT located around the SMA. Based on the above findings, it is important to include SFT in the differential diagnosis of retroperitoneal tumors located around the SMA.

A Team Approach to the Management of Intractable Leg Ulcers

OBJECTIVES The management of intractable leg ulcers requires a team approach which includes vascular surgeons and plastic surgeons. We retrospectively reviewed the results of the management of intractable leg ulcers by plastic surgeons. PATIENTS AND METHODS A total of 73 patients with intractable leg ulcers, (79 limbs) were treated at the Department of Plastic Surgery at our institution. Skin perfusion pressure (SPP) around the ulcer on the limb was measured before and after arterial reconstructive procedures. Local ulcer management involved intra-wound continuous negative pressure and irrigation therapy or negative pressure wound therapy. We examined the rates of wound healing and associated prognostic factors. RESULTS There were 21 limbs without ischemia (non-peripheral arterial disease [Non-PAD] group) and 58 limbs with ischemia (PAD group). The healing rates were 66% in the PAD group and 81% in the Non-PAD group, but the difference between the groups was not significant. A total of 41 limbs in the PAD group underwent revascularization, which involved bypass surgery in 18 limbs and endovascular therapy in 23 limbs. The salvage rate of the revascularized limbs was 83% at 1 year. The primary patency rates at 1 year were 87% for bypass surgery and 58% for endovascular therapy. The healing rate of the revascularized limbs was 66%, and the presence of concomitant hemodialysis, infected ulcers, and limbs without improved SPP were shown to be poor prognostic factors. Limbs treated with bypass surgery had a better healing rate than limbs treated with endovascular therapy, but the difference was not significant. CONCLUSION Good ulcer-healing rates were achieved by effective revascularization and aggressive local management. These results suggest that a team approach is useful for the management of intractable leg ulcers. (English translation of Jpn J Vasc Surg 2011; 20: 913-920).

Early Outcomes of Open Abdominal Repair Versus Endovascular Repair for Abdominal Aortic Aneurysm: Report from National Hospital Organization Network Study in Japan

OBJECTIVE Early outcomes of open abdominal repair (OS) versus endovascular repair (EVAR) for abdominal aortic aneurysm were retrospectively analyzed, after commercialized devices for EVAR had become available in Japan. PATIENTS AND METHODS A total of 781 consecutive patients (OS, n = 522; EVAR, n = 259) were treated at ten medical centers between January 2008 and September 2010. The OS group comprised patients with preoperative shock (SOS, n = 34) and without shock (NOS, n = 488). RESULTS Patients in the EVAR group were 3 years older than those in the NOS group. There was greater prevalence of hostile abdomen, on dialysis, chronic obstructive pulmonary disease on inhaled drug, and cerebrovascular disease in the EVAR group than in the NOS group. Surgical mortality was 16 cases (2.0% in all patients, EVAR: 0.8%, NOS: 1.4%, SOS: 21%). Hospital stay >30 days was documented in 52 (11%) with NOS, 11 (33%) with SOS, and 8 (3%) with EVAR. Thirty late deaths included 6 aneurysm related death and 14 cardiovascular causes at a mean follow up of 1.0 year. The survival rates freedom from all cause death at one year, were 95 ± 1% in NOS and 94 ± 2% in EVAR respectively. CONCLUSION Though significant differences in patient characteristics among three groups were noted, early results were satisfactory.

Sarcopenia is a risk factor for cardiovascular events experienced by patients with critical limb ischemia

Background: Prognosis is poor for patients with critical limb ischemia (CLI), and the most frequent cause of death is cardiovascular disease. Low grip strength is a risk factor for cardiovascular events, and sarcopenia may be associated as well. Thus, we hypothesized that sarcopenia is a risk factor for cardiovascular events experienced by patients with CLI. If this is true and appropriate therapy becomes available, the prognosis of patients with CLI will improve with appropriate risk management strategies to prevent cardiovascular events. Therefore, the aim of this study was to verify this hypothesis. Methods: We studied 114 patients who underwent revascularization and computed tomography between January 2002 and December 2012 in the Department of Surgery and Sciences at Kyushu University in Japan. Sarcopenia was defined as skeletal muscle area measured by L3‐level computed tomography scan <114.0 cm2 and <89.8 cm2 for men and women, respectively. Clinical characteristics, cardiovascular event‐free survival, <2‐year death, causes of death, and effective treatments for sarcopenia were investigated. Results: We identified 53 (46.5%) patients with sarcopenia. Three‐year cardiovascular event‐free survival rates were 43.1% and 91.2% for patients with and without sarcopenia, respectively (P < .01). During follow‐up, cardiovascular disease caused the deaths of 4 and 15 patients without and with sarcopenia (P < .01), respectively, and in particular, ischemic heart disease caused the deaths of 0 and 5 patients without or with sarcopenia (P < .05), respectively. Single antiplatelet therapy (SAPT; hazard ratio, 0.46; 95% confidence interval, 0.24‐0.82; P < .01) and statin therapy (hazard ratio, 0.38; 95% confidence interval, 0.16‐0.78; P < .01) were independent factors associated with improved cardiovascular event‐free survival. Three‐year cardiovascular event‐free survival rates for patients with sarcopenia who received SAPT, dual antiplatelet therapies, and no antiplatelet therapy were 75.3%, 21.1%, and 29.5%, respectively (P < .01). Conclusions: Sarcopenia is a risk factor for worse cardiovascular event‐free survival, and SAPT and statin therapy reduced this risk for patients with CLI. Furthermore, SAPT but not dual antiplatelet therapy increased cardiovascular event‐free survival in patients with sarcopenia.

Early Outcomes of Endovascular Aneurysm Repair for Abdominal Aortic Aneurysm: First Preliminary Report of National Hospital Organization Network Study in Japan

OBJECTIVE PATIENTS AND METHODS In order to assess the early outcomes of endovascular aneurysm repair (EVAR) for abdominal aortic aneurysm (AAA) in the Japanese population, a total of 183 patients who had EVAR at eight medical centers of the National Hospital Organization were retrospectively reviewed and registered. The mean number of registered cases in each center was 23 ± 17 (4-50 cases). Patient characteristics were male sex, 84%; mean age, 77 years; age ≥ 80 years, 40%. RESULTS In-hospital mortality was one case (0.5%). Endoleaks were observed at the end of the procedure in 35 patients (19%: type I: n = 4, II: n = 22, III, n = 3, IV: n = 6). Early morbidity included delayed wound healing or infection (n = 7), deterioration of renal dysfunction (n = 3), stroke (n = 2), postoperative bleeding (n = 2), gastrointestinal complications (n = 2), and peripheral thromboembolism (n = 2). Eleven late deaths included one of unknown cause and six cardiovascular causes at a mean follow up of 1.0 year. Survival rates of freedom from all causes of death and from aneurysm-related death at one year were 95.4% ± 1.7% and 99.5% ± 0.5%, respectively. INTERPRETATION Although registered patients carry a variety of risks, early outcomes were satisfactory. EVAR is an acceptable alternative treatment modality for treating AAA.

Treatment of Solitary Iliac Aneurysms: Clinical Review of 28 Cases

PurposeThe clinical characteristics and long-term results of patients with solitary iliac aneurysms (SIAs) were investigated.Methods28 consecutive patients who underwent repair of SIAs between 1985 and 2004 were reviewed retrospectively, and compared with those of 536 patients who underwent elective repair of an abdominal aortic aneurysm (AAA) during the same period.ResultsThe incidence of SIAs among all aorto-iliac aneurysms was 5.0%. The 28 patients with SIAs were men with a mean age of 69.1 years. There were a collective total of 42 iliac aneurysms in the 28 patients, with 12 patients having multiple aneurysms. Thirty aneurysms involved the common iliac artery, and 12 involved the internal iliac artery. Twenty-two patients had symptoms, although none of the SIAs ruptured. Four patients had coexistent iliac occlusive disease and two patients had femoral occlusive disease. The 5-and 10-year survival rates of the patients with SIAs were 90.5% and 75.4%, whereas those of the patients with AAAs were 76.3% and 54%, respectively (P = 0.089).ConclusionRoutine imaging is necessary not only to evaluate the SIAs, but also to detect multiple aneurysms or arterial occlusive disease. Close and long-term followup is mandatory for the early detection of the formation of new aneurysms.

Preoperative Cardiovascular Assessment and Late Cardiovascular Events after Elective Abdominal Aortic Aneurysm Repair

BACKGROUND Cardiovascular evaluation is performed before elective repair of abdominal aortic aneurysm (AAA) because of the high prevalence of cardiovascular disease. We investigated the association between preoperative cardiovascular evaluation and the incidence of late cardiovascular events after AAA repair. METHODS We retrospectively analyzed 438 patients who underwent elective repair of AAA. Echocardiography, serial coronary assessment using functional myocardial scanning or coronary angiography, and carotid ultrasound scanning were performed preoperatively. Coronary revascularization after serial coronary assessment was performed preoperatively or simultaneously in 21 patients, and 54 patients had a remote history of coronary revascularization. RESULTS The 5-year survival rate, incidence rate of cardiovascular events (myocardial infarction or stroke), and incidence rate of major adverse cardiovascular events (MACE; cardiovascular death or cardiovascular events) were 86.0%, 5.7%, and 11.5%, respectively. Carotid stenosis was associated with these long-term outcomes, and hypokinesis, determined by echocardiography, increased the incidence of cardiovascular events and MACE. Serial coronary assessment findings and history of previous or preoperative coronary revascularization were not associated with these long-term outcomes. CONCLUSIONS Preoperative cardiovascular evaluation and treatment are beneficial for reducing not only perioperative risk but also late cardiovascular events.

Long-term Results of Reconstructive Surgery for the Unilateral Aortoiliac Occlusive Disease and Future Risks of Contralateral Iliac Events

OBJECTIVE Our experience with unilateral iliac reconstructive surgery was retrospectively reviewed, and the long-term patency and the morphological information was disclosed. In addition, the prognosis of contralateral iliac artery was examined, because future contralateral iliac events seem to be important for durability of unilateral iliac revascularizations. MATERIALS AND METHODS 148 patients (mean age, 66.9 years; 88% male) who had undergone unilateral aortoiliac reconstruction without contralateral iliac lesions were evaluated. The unilateral aortoiliac reconstructive procedures included 112 (76%) aorto or iliofemoral bypasses, 27 (18%) femorofemoral bypasses, and 9 (6%) axillofemoral bypasses. The indications for arterial reconstruction were disabling claudication and limb salvage in 125 (84%) and 23 (16%) patients, respectively. Preoperative arteriograms were reviewed to determine the Inter-Society Consensus (TASC II) classification categorizing iliac artery lesions. Contralateral iliac events were defined as any arterial reconstructive procedure, intervention, amputation for progression of contralateral iliac disease, or repair of abdominal aortic aneurysm (AAA). The Kaplan-Meier survival analysis was used to predict long-term results in patients grouped based on various factors which were compared using univariate and multivariate analyses. RESULTS In the 148 patients, unilateral iliac reconstructive procedures were undertaken in 83 (56%) patients with TASC II type D lesions, 34 (23%) patients with TASC II type C lesions, and 31 (21%) patients with TASC II type B lesions. Overall primary and secondary patency rates were 93.8% and 96.5% at 3 years and 90.0% and 93.9% at 5 years. A multivariate analysis disclosed critical limb ischemia influencing primary patency rates, and type of aortoiliac reconstruction or gender influencing secondary patency rates. TASC II classification did not affect primary or secondary patency rates. During the follow-up period, 15 contralateral iliac events occurred, including 11 aortoiliac reconstructive or interventional procedures, 3 repairs of AAA, and one case of bilateral thigh amputation due to acute aortic occlusion. The overall probability of contralateral iliac events was 2.2% at 3 years and 5.9% at 5 years. CONCLUSION The long-term patency following unilateral iliac reconstructive surgery was satisfactory, and not affected by morphology of the iliac artery. Also, the future risk of contralateral iliac events appeared to be low.