Yasuhiro Yunoki

Bypass vs. Endovascular Therapy of Infrapopliteal Lesions for Critical Limb Ischemia.

OBJECTIVE This study was conducted to determine whether to perform endovascular intervention or bypass surgery as a treatment option for critical limb ischemia (CLI) with lesions in the popliteal artery or below. SUBJECTS AND METHODS A total of 150 patients (164 limbs) with CLI underwent endovascular intervention or bypass surgery for lesions in the popliteal artery or below at our department between May 1995 and June 2011. Therapeutic outcomes were examined by surgical technique. An indication for endovascular intervention was established with the combination of (1) poor general condition, and (2) a stenotic or occlusive lesion ≤5 cm. RESULTS The bypass group (group B) comprised 119 patients (99 males, 20 females) with 131 affected limbs at 46 to 89 years of age (mean: 70 years). The endovascular intervention group (group E) comprised 31 patients (25 males, 6 females) with 33 affected limbs at 47 to 89 years of age (mean: 72 years). There was no significant difference in patient demography between the two groups. Regarding preoperative complications, hypertension was observed in 54% and 61% of the subjects in groups B and E, respectively, diabetes in 36% and 55%, renal dysfunction in 29% and 58%, ischemic heart disease in 27% and 32%, and cerebrovascular disorder in 18% and 23%; renal dysfunction accounted for a significantly higher percentage in group E. As for early postoperative complications, subjects in group B experienced wound infections (6 patients), hemorrhage (2), thrombosis (2), pneumonia (1), and another complication (1), and those in group E experienced wound infections (1) and another complication (1). The hospital mortality rate was 0.8% (1 patient) for group B and 0% for group E. The 3-year cumulative primary patency rate was 72% for group B and 54% for group E; the rate was significantly higher for group B. The 3-year secondary patency rate was 82% for group B and 60% for group E. The 3-year limb salvage rate was 86% for group B and 82% for group E; there was no significant difference between the two groups. The 5-year survival rate was 57% for group B and 42% for group E; the survival rate was significantly lower for group E. CONCLUSION For the study population of CLI patients with lesions in the popliteal artery or below, the patency rate was higher for the bypass group than for the endovascular intervention group, whereas there was no difference in the limb salvage rate. Based on the findings in prognosis for survival, the indication for endovascular intervention at our department is believed to be appropriate. (English translation of Jpn J Vasc Surg 2013; 22: 715-718).

Ankle-Brachial Index, Toe-Brachial Index, and Pulse Volume Recording in Healthy Young Adults

OBJECTIVE To clarify the characteristics of ankle-brachial index (ABI), toe-brachial index (TBI), and pulse volume recording (PVR) of the ankle with brachial-ankle pulse wave velocity (baPWV) in healthy young adults. MATERIAL AND METHODS We analyzed ABI, TBI, baPWV, and PVR in the ankle of healthy adults aged 20 to 25 years (median, 20 years) using an automatic oscillometric device between 2002 and 2013. The ABI, baPWV, and PVR in 1282 legs of 641 subjects (301 men and 340 women) and the TBI in 474 toes of 237 subjects (117 men and 120 women) were evaluated. RESULTS The measured values showed no bilateral differences. ABI and baPWV were higher in men than in women, but TBI was similar in both sexes. ABI <1.0 was observed in 18.1% of the legs in men and in 25.6% in women. TBI <0.7 was observed in 16.2% of the toes in men and 19.1% in women. For ankle PVR, the % mean arterial pressure was higher in women than in men. The upstroke time was <180 ms in most subjects. CONCLUSIONS For young people, ABI <1.0 or TBI <0.7 may not always indicate vascular abnormalities. When evaluating circulatory indexes, age and sex should be considered.

Collective Therapy and Therapeutic Strategy for Critical Limb Ischemia

OBJECTIVE To determine a treatment strategy based on the outcomes of various previous interventions for critical limb ischemia in arteriosclerosis obliterans (ASO). MATERIAL AND METHODS We examined outcomes of 292 ASO patients who had had critical limb ischemia between May 1995 and July 2009. Patients underwent the following procedures in 167 cases: aortofemoral bypass (n = 14), femorofemoral crossover bypass (n = 29), femoropopliteal bypass (n = 104) and femorotibial bypass (n = 40). Other procedures included bypass only (n = 147), bypass combined with thromboendarterectomy (n = 10), bypass combined with endovascular therapy (n = 6), bypass combined with lumbar sympathectomy (n = 2), endovascular therapy combined with thromboendarterectomy (n = 4), endovascular therapy (n = 19), lumbar sympathectomy (n = 6), conservative therapy (n = 65), and major amputation (n = 31). We also calculated P3 risk scores and measured transcutaneous oxygen pressure (tcPO2) and skin perfusion pressure (SPP) before and after therapy. RESULTS The limb salvage rate was 87% at 2 years in the arterial reconstruction group. In the low-risk group (a P 3 risk score of 3), the 1-year amputation-free survival rate was 96%. In the medium-risk group (a P 3 risk score of 4-7), the 1-year amputation-free survival rate was 88%. In the high-risk group (a P 3 risk score of 8), the 1-year amputation-free survival rate was 66%. The hospital death rate in the arterial reconstruction group was 3.2%, all of whom were patients who underwent bypass. The survival rate at 5 years was 65% and 36% in the conservative therapy only group. Ulcers healed in 140 out of 144 patients. The 4 patients with unhealed infections had tcPO2 or SPP values of more than 30 mmHg after treatment. Major amputations were performed in 4 of 5 patients who had tcPO2 or SPP values from 20 to 30 mmHg after treatment. Major amputations were performed in all 6 patients who had tcPO2 or SPP values of less than 20 mmHg after treatment. CONCLUSION In cases with tcPO2 or SPP values of more than 30 mmHg, an ulcer will probably heal, except in infected cases. We suggest that, if these values are less than 30 mmHg, complete revascularization should be performed. The P3 risk score was useful in predicting limb salvage in the current series. Hybrid therapy in bypass and endovascular therapy must be performed in cases where patients are in a generally poor condition. It is important to attempt amelioration in limb salvage and to control the operative mortality rate with sufficient perioperative control. (English Translation of Jpn J Vasc Surg 2011;20:905-911).

Long-Term Results of Obturator Bypass

OBJECTIVE We evaluated the long-term outcomes of obturator bypass. MATERIAL AND METHODS A total of 16 patients (13 males and 3 females; 17 limbs) who underwent obturator bypass surgery at our department between April 1995 and March 2008 were included. RESULTS Their ages ranged from 50 to 90 with a mean of 74 years. Inguinal infections observed in the 16 patients consisted of vascular graft infections in 13 patients, hemostatic device infections following endovascular therapy in two patients, and femoral artery infections following coronary angiography in one patient. The cumulative patency rate was 69% for 3 years and 43% for 5 years. The cumulative survival rate was 64% for 3 years and 55% for 5 years. CONCLUSION Obturator bypass surgery was successfully performed with favorable results for arterial infections and vascular graft infections in the inguinal region.

Total aortic arch replacement for a patient with poor left ventricular function and patent coronary artery bypass grafts: how to establish effective myocardial protection.

A 66-year-old man who had previously undergone coronary artery bypass grafting (CABG) was admitted to our institution for surgical treatment of a ruptured aortic arch aneurysm. He had three patent bypassed grafts including the left internal thoracic artery (LITA) to the left anterior descending artery (LAD), complicated by left ventricular dysfunction. Coronary angiography performed 1 year after the initial surgery revealed total occlusion of the LAD. In addition, the aneurysm was located next to the LITA; therefore, there was a significant risk of injury to the LITA during intraoperative dissection. For such a complicated and challenging case, we successfully performed a total aortic arch replacement using a Y-shaped composite saphenous vein graft (SVG) for the administration of cardioplegic solution to establish effective myocardial protection. This procedure, by which effective myocardial protection can be achieved, is a useful treatment option for aortic arch surgery after CABG with a patent LITA graft.

Assessment of the Characteristics and Detectability of Skin Perfusion Pressure Measured Using a Thermostatic Heating Probe

OBJECTIVES To assess the characteristics of skin perfusion pressure (SPP) measured using a thermostatic heating probe and whether a thermostatic heating probe improves SPP detection. METHODS We studied 8 feet of healthy young subjects and 31 feet of elderly patients suspected to have severe limb ischemia. We measured SPP at the dorsum and plantar aspects of each foot using a plain laser Doppler probe and a thermostatic heating probe heated at 44°C. Results were expressed as median. Comparisons were analyzed using a non-parametric test. RESULTS In the healthy subjects, the SPP values at both the dorsum and the plantar aspect were not significantly different after heating. The thermostatic heating probe did not improve the SPP detection rates. In the patients with ischemic limb, the SPP values at both the dorsum and the plantar aspect significantly increased after heating (p <0.001 for both). The SPP detection rate at the dorsum remained at 96.8%; however, it was improved from 87.1% to 100% at the plantar aspect after heating. CONCLUSION The thermostatic heating probe was shown to be useful for improving the detectability of SPP in the ischemic limbs. An SPP increase after heating may be considered as a parameter of limb ischemia.