Language：English   Publisher：Journal of Vascular Surgery  

Objective: Although the predictors of long-term prognosis after endovascular aneurysm repair (EVAR) have been investigated, several reports have suggested that early sac shrinkage (ESS) is associated with superior long-term prognosis. However, it was not clear whether ESS was associated with aneurysm-related mortality. The aim of this study was to define fatal adverse events and to examine their association with ESS. Methods: All consecutive patients who underwent EVAR for an abdominal aortic aneurysm at Nagoya University Hospital between June 2007 and August 2018 were identified. We defined ESS as an aneurysm diameter decrease of 10 mm or more at 1 year after EVAR, and we defined fatal adverse events as aneurysm-related death, aneurysm sac rupture, open conversion, secondary type Ia endoleak, or secondary type IIIa/b endoleak. Then, we evaluated the association between ESS and fatal adverse events and identified predictors of ESS. Results: During the study period, 553 patients were identified and included. Fatal adverse events occurred in 42 patients (7.6%), and the details of the fatal adverse events were as follows: 13 aneurysm-related deaths, 17 aneurysm sac ruptures, 14 open conversions, 13 type Ia endoleaks, and 6 type III endoleaks. ESS occurred in 146 patients (26.4%). Kaplan-Meier curves showed that the ESS group had a significantly lower incidence of fatal adverse events (P <.001). Multivariate analysis showed that there were significant differences in terms of 5 or more preoperatively patent lumbar arteries (odds ratio [OR], 0.67; P =.049; 95% confidence interval [CI], 0.45-1.00), chronic kidney disease (OR, 0.49; P <.01; 95% CI, 0.29-0.84), and Zenith endograft use (OR, 1.76; P <.01; 95% CI, 1.16-2.67). Furthermore, the percentage of cases that achieved an aneurysm diameter of less than 40 mm was significantly higher in the ESS group (76.0% vs 15.5%; P <.01). The use of Zenith endografts showed a significantly higher rate of aneurysm disappearance than the use of Endurant endografts (P <.01) and Excluder endografts (P <.01). In addition, it was found that ESS was more likely to occur with the use of Zenith endografts, even when propensity score matching was performed for the neck morphology. Conclusions: ESS was associated with a lower rate of life-threatening adverse events after EVAR. The use of Zenith endografts was a predictor of ESS and was associated with increased rates of long-term sac shrinkage and aneurysm disappearance compared with the Endurant and Excluder endografts. Using the predictors of ESS identified in this study, we may be able to expand the indications for EVAR to patients with a longer life expectancy.

DOI： 10.1016/j.jvs.2022.08.017

Web of Science

Scopus

PubMed

Language：English   Publisher：Journal of Endovascular Therapy  

Purpose: Recent studies suggested that continuous clotting renewal in thrombi plays a central role in sac enlargement after endovascular aneurysm repair (EVAR). We reviewed patients with persistent type 2 endoleak (T2EL) to estimate the impact of D-dimer level on sac enlargement. Methods: A retrospective review of elective EVAR for infrarenal abdominal aortic aneurysm performed between June 2007 and February 2020. Persistent T2EL was defined as T2EL confirmed at both the 6 and 12 month contrast-enhanced computed tomography (CECT) follow-ups. “Isolated” T2EL was defined as T2EL without other types of endoleak within 12 months. Patients with >2 year follow-up, persistent isolated T2ELs, and D-dimer level data at 1 year (DD1Y) were included. Patients with any reintervention within 12 months were excluded. The association between DD1Y and aneurysm enlargement (AnE), defined as a ≥5 mm diameter increase, within 5 years was analyzed. Among 761 conventional EVAR, 515 patients had >2 years of follow-up. Thirty-three patients with any reintervention within 12 months and 127 patients without CECT at either 6 or 12 months were excluded. Among 131 patients with persistent isolated T2ELs, 74 patients with DD1Y data were enrolled. During a 37 month median follow-up [25–60, IQR], 24 AnEs were observed. In the AnE patients, the median DD1Y was significantly higher than that in the other patients (12.30 [6.88–21.90] vs 7.62 [4.41–13.00], P=0.024). ROC curve analysis indicated that the optimal cutoff point of DD1Y for AnE was 5.5 µg/mL (AUC=0.681). In univariate analysis, angulated neck, occlusion of the inferior mesenteric artery, and DD1Y≥5.5 µg/mL were significantly associated with AnE (P= 0.037, 0.038, and 0.010). Cox regression analysis revealed that DD1Y≥5.5 µg/mL was correlated with AnE (P=0.042, HR [95% CI] 4.520 [1.056–19.349]). Conclusion: A 1 year higher D-dimer level can potentially predict AnE within 5 years in persistent T2EL patients. AnE was considered improbable when the D-dimer level was low enough. Clinical Impact: The present study suggests that a 1-year higher D-dimer level could potentially predict aneurysm expansion within 5 years in patients with persistent type 2 endoleak (T2EL). On the other hand, aneurysm expansion was considered unlikely if the D-dimer level was low enough. As there are many patients with T2EL who require regular follow-up, any predictor of future aneurysm expansion could be of great help in conserving medical resources. In patients with a low likelihood of future expansion, we might consider delaying follow-up, similar to patients with sac shrinkage.

DOI： 10.1177/15266028231170165

Web of Science

Scopus

PubMed

Language：English   Publisher：Journal of Vascular Surgery  

Background: The epicardial adipose tissue volume (EATV) is associated with cardiovascular diseases such as coronary artery disease. However, no information is available regarding the relationship between the EATV and abdominal aortic aneurysm (AAA) expansion. In the present study, we evaluated the association between the EATV and AAA growth and sought to identify the predictors of AAA expansion. Methods: Between June 2009 and December 2019, 906 patients had undergone endovascular or open repair of AAAs at our institution. Patients with previous cardiac surgery, previous ascending thoracic aortic surgery, a ruptured AAA, an infected AAA, an inflammatory AAA, a saccular aneurysm, a solitary iliac aneurysm, or reintervention after treatment of the AAA were excluded. A total of 237 patients with at least two preoperative computed tomography (CT) scans performed >180 days apart were included in the present study. The EATV within the pericardium was retrospectively quantified from the preoperative non–contrast-enhanced CT images using a three-dimensional workstation. The EATV index was defined as the EATV divided by the body surface area. The AAA expansion rate was defined as an increase in the AAA diameter annually, and the patients were divided into the slow-expansion group (expansion rate, <5 mm/y) and the fast-expansion group (expansion rate, ≥5 mm/y). The correlation between the expansion rate and the EATV index was analyzed, and the cutoff value for the EATV index was determined using a receiver operating characteristics curve. Multivariate analysis was used to assess the predictors of the AAA expansion rate. Results: The expansion rate of AAA correlated positively with the EATV index (R = 0.237; P < .001). The initial aneurysm diameter (P < .001) and EATV index (P = .009) differed significantly between the two groups. The cutoff for the EATV index was 60.3 cm3/m2 (area under the curve, 0.658; 95% confidence interval [CI], 0.568–0.749; sensitivity, 1.000; specificity, 0.309). Multivariate analysis revealed that the initial aneurysm diameter and an EATV index of >60.3 cm3/m2 were significantly associated with the AAA expansion rate. Conclusions: The results of the present study have demonstrated that the EATV index is associated with AAA expansion.

DOI： 10.1016/j.jvs.2022.04.032

Web of Science

Scopus

PubMed

Language：English   Publisher：Circulation Journal  

Background: Zinc (Zn) has been reported to play an important role in wound healing (WH). Nevertheless, the effect of Zn in chronic limb-threatening ischemia (CLTI) patients is unclear. This study investigated the effect of Zn on the clinical outcomes of CLTI patients undergoing bypass surgery. Methods and Results: This study reviewed 111 consecutive patients who underwent an infrainguinal bypass from 2012 to 2020. Patients with Zn deficiency (serum Zn level <60 μg/dL) received oral Zn supplementation and maintained a normal level until WH. This study aimed to explore: (1) the effect of Zn deficiency; and (2) Zn supplementation in Zn-deficient patients on the clinical outcomes of this cohort. Patients with Zn deficiency, Zn supplementation, and no Zn supplementation despite Zn deficiency accounted for 48, 21, and 42 patients, respectively. (1) Zn deficiency was associated with WH (HR, 0.47; 95% CI, 0.29-0.78: P=0.003), major adverse limb events (MALE) (HR, 2.53; 95% CI, 1.26-5.09: P=0.009), and major amputation or death (HR, 3.17; 95% CI, 1.51-6.63: P=0.002). (2) Zn supplementation was positively related to WH (HR, 2.30; 95% CI, 1.21-4.34: P=0.011). This result was confirmed using propensity score matching (HR, 2.24; 95% CI, 1.02-4.87: P=0.043). Conclusions: The current study revealed that Zn level was associated with clinical outcomes in CLTI patients after bypass surgery. Oral Zn supplementation could improve WH in these patients.

DOI： 10.1253/circj.CJ-21-0832

Web of Science

Scopus

PubMed

Language：English   Publisher：Annals of Vascular Surgery  

Background: Although we have witnessed several cases of late proximal type I endoleak (T1AEL) after endovascular aneurysm repair (EVAR), most patients did not have “hostile neck” preoperatively. We hypothesized that the distance between the lowest renal artery and the neck angulation point and neck length are the 2 most important factors for maintaining long-term proximal sealing. This study evaluated “neck hostility,” which is the product of the distance to the angulation point and the neck length, as a preoperative morphological risk factor for the development of late T1AEL after EVAR. Methods: A retrospective review of a prospectively assembled database was performed for all patients who had undergone EVAR at a single institution from June 2007 to May 2017. Patient demographics and preoperative imaging data were collected, and Cox regression analysis was performed to identify the risk factors for late T1AEL. Results: Of the 655 patients who underwent EVAR during the study period, 115 were excluded due to complex EVAR (n = 14), primary indications for iliac aneurysms (n = 86), primary T1AEL (n = 3), or other reasons (n = 15). Of the remaining 537 patients, twelve patients (2.2%) developed late T1AEL a median of 3.2 (interquartile range [IQR]; 3.0, 5.4) years after EVAR. Receiver operating characteristic (ROC) curve analysis revealed a neck hostility cutoff value of 8. Cox regression analysis revealed that a neck hostility value ≤8 and conical neck anatomy were risk factors for the development of late T1AEL after EVAR. Well-known hostile neck factors such as short neck, severe angulated neck, and severe calcification/thrombus in the proximal neck were not significantly different. Conclusions: The present study demonstrated a correlation between late T1AEL and the product of the angulation distance and the neck length. This factor may be useful for predicting poor late proximal outcomes after EVAR.

DOI： 10.1016/j.avsg.2021.09.049

Web of Science

Scopus

PubMed

Language：Japanese   Publisher：Vascular  

Purpose: Surgical revascularization is the standard treatment for chronic limb-threatening ischemia (CLTI). However, some patients may require reintervention. The Global Anatomic Staging System (GLASS), which evaluates the complexity of infrainguinal lesions, was proposed. This study aimed to identify predictors for graft revision and evaluate whether GLASS impacts vein graft revision. Methods: Between 2011 and 2018, CLTI patients who underwent de novo infrapopliteal bypass using autogenous veins were retrospectively analyzed. To assess anatomic complexity with GLASS, femoropopliteal, infrapopliteal, and inframalleolar/pedal (IM) disease grades were determined. The outcomes of patients with or without graft revision were compared. Cox regression analysis was performed. Results: Thirty-six of the 80 patients underwent reintervention for graft revision. Compared to the non–graft revision group, the graft revision group exhibited significantly higher rates of GLASS stage III (66% vs 81%, p = 0.046) and grade P2 IM disease (25% vs 58%, p = 0.009). Multivariate analysis revealed that IM grade P2 (hazard ratio [HR], 3.35; 95% confidence interval [CI], 1.66–6.75; p = 0.001) and spliced vein grafts (HR, 3.18; 95% CI, 1.43–7.06; p = 0.005) were significantly associated with graft revision. Conclusions: This study demonstrated that IM grade P2 and spliced vein grafts were predictors of graft revision. The GLASS stratification of IM disease grade may be useful in optimizing treatment for CLTI.

DOI： 10.1177/17085381221124706

Web of Science

Scopus

PubMed

Language：English   Publisher：Journal of Endovascular Therapy  

Purpose: An accurate distal deployment is essential for successful thoracic endovascular aortic repair (TEVAR) of a paradiaphragmatic aortic aneurysm. This study aimed to investigate the anatomical and intraoperative factors that affect the accuracy of distal deployment during TEVAR. Methods: We conducted a retrospective review of preoperative and postoperative computed tomography scans of 426 patients undergoing TEVAR at our institution between October 2008 and May 2021, of which the stent-graft was attempted to be deployed just above the celiac axis or the superior mesenteric artery in 56 patients. Based on the anatomical factors related to the malposition (deployed >10 mm away from the target vessel) and the greater curve to the straight-line ratio (G/S ratio), the patients were categorized as severe tortuosity (n=21) and mild tortuosity (n=35) groups to compare the operative and clinical outcomes. Result: Stent-graft malpositioning occurred in 21 cases. Among all anatomical variables, only the G/S ratio was significantly larger in the malpositioned cases (p=0.049). A cutoff G/S ratio value of 1.15 was determined using the receiver operating curve analysis. In the severe tortuosity group, the distal end of the stent-graft was significantly farther (median: 10.0 [interquartile range (IQR): 2.5–19.5] mm vs 3.0 [0–8.0] mm; p=0.015) from the target vessel, and the tilt angle of the stent-graft’s distal edge was larger (median: 21.4 [IQR: 15.8–24.5] vs 9.5 [5.5–12.5] degree; p<0.01) than that in the mild tortuosity group. Both groups were comparable for the incidence of a primary type Ib endoleak (p=0.454), a secondary type Ib endoleak (p=1.0), and the rate of distal reintervention (p=0.276). Conclusion: Severe tortuosity in the distal descending thoracic aorta is associated with a malpositioned and tilted distal end of the stent-graft. Clinical Impact: Thoracic endovascular aortic repair (TEVAR) for paradiaphragmatic thoracic aortic aneurysms requires accurate distal landing. In this paper, a retrospective CT analysis revealed that the greater curve to the straight-line ratio (G/S ratio) was associated to affects the malposition of the stent graft, defined as being deployed more than 10 mm away from the target vessel. Further, a comparative analysis based on the G/S ratio demonstrated that severe aortic tortuosity was associated with a more distal and tilted deployment of the stent graft.

DOI： 10.1177/15266028221141023

Web of Science

Scopus

PubMed

Language：English   Publisher：Annals of Vascular Surgery  

Background: Early spontaneous shrinkage (ESS) of abdominal aortic aneurysm (AAA) within 1 year after endovascular aortic aneurysm repair (EVAR) could be a predictor of durable success. However, late spontaneous shrinkage (LSS) during longer follow-up has not been well addressed. We compared late complications of ESS and LSS. Methods: Our series of elective EVAR for infrarenal AAA from June 2007 to December 2017 was reviewed. Patients with ≥1 year of follow-up with computed tomography (CT) studies were included. Patients with any reintervention within 1 year were excluded. Spontaneous shrinkage (SpS) was defined as a diameter reduction ≥10 mm without any reintervention. ESS was defined as SpS within 1 year, and LSS was defined as SpS occurring after 1 year of follow-up. Aneurysms that became larger than the original size after SpS were defined as re-expansion. Late complications (re-expansion, reintervention, and aneurysm-related death) and related factors were compared between ESS and LSS. Results: A total of 495 patients were enrolled. Median follow-up was 43 months [24–67, interquartile range (IQR)]. Among patients, 126 ESS and 55 LSS occurred. The cumulative rates of SpS were 25.7±2.0%, 37.4±2.4%, and 47.3±3.7% at 1, 3, and 7 years, respectively. There was 1 re-expansion and 6 reinterventions during further follow-up after SpS. The rates of freedom from late complications at 5 years were not significantly different between ESS (89.2±4.0%) and LSS (95.8±4.1%) (P = 0.465). Regression analysis revealed that the Zenith device was significantly related to ESS compared to the Excluder (P = 0.006) and Endurant (P = 0.040). More than 6 preoperative patent lumbar arteries negatively correlated with ESS (P = 0.023). However, these factors had no significant impact on LSS. Conclusions: The rates of late complications after SpS were comparable between ESS and LSS. Patients with delayed sac shrinkage with a reduction in diameter ≥10 mm should expect the same durable success as patients with quick shrinkage.

DOI： 10.1016/j.avsg.2021.02.014

Web of Science

Scopus

PubMed

Language：Japanese   Publisher：Annals of Vascular Surgery  

BACKGROUND: Although randomized studies have revealed the long-term outcomes of the endovascular repair (ER) of abdominal aortic aneurysm (AAA) compared to open repair (OR), there is controversy surrounding chronic renal decline (CRD) after ER. This study reviewed our propensity-matched cohorts of ER and OR to compare CRD rates using a time-to-event analysis. The ER groups undergoing suprarenal (SR) or infrarenal (IR) proximal fixation were also compared with the OR group. METHODS: This retrospective review of infrarenal AAA repair was conducted from June 2007-December 2017. Patients with ≥1 year of follow-up were included. Cases of supra/pararenal AAAs, infectious AAAs, rupture, or severe chronic kidney disease (CKD) (estimated glomerular filtration rate (eGFR) <15 mL/min/1.73 m2 or dependence on renal replacement therapy) were excluded. CRD was defined as eGFR decline of >20% or de novo hemodialysis during follow-up. Patients treated with ER (ER group) and OR (OR group) were propensity-score matched for age, sex, comorbidities, ejection fraction, respiratory function, and baseline eGFR. Kaplan-Meier analysis compared the freedom from CRD rates of the matched cohorts (mER and mOR groups). Patients treated with SR and IR fixation devices (SR and IR groups) were also separately matched to the OR group, followed by analysis. RESULTS: In total, 1087 patients underwent elective AAA repair. Among them, 944 (512 ER and 432 OR) were enrolled. The ER group was older than the OR group (median age 79 vs 71; P<0.001). The ER group had significantly lower baseline eGFR and more comorbidities than the OR group. Among 187 propensity-score matched pairs (187 mER and 187 mOS patients), background characteristics, including age and baseline eGFR, were comparable, but median renal function follow-up was significantly longer in the mER group than in the mOR group (48 vs 26 months; P<0.001). CRD was observed in 57 patients in the mER group and 30 patients in the mOR group. Kaplan-Meier analysis of the freedom from CRD showed no significant difference between the matched groups (P=0.268); however, in the later follow-up of >4 years, CRD was more common in the mER group. The matched analyses between the OR group and specific fixation groups, comprising 102 OR-SR and 73 OR-IR pairs, demonstrated no significant differences in CRD. CONCLUSIONS: Compared to OR, there was no significant impact of ER on CRD at up to 4 years, supporting the safety of ER in terms of the mid-term renal outcome of our present clinical practice.

DOI： 10.1016/j.avsg.2021.02.031

Web of Science

Scopus

PubMed

Language：English   Publisher：European Journal of Vascular and Endovascular Surgery  

Objective: Type I hybrid arch repair has become popular as a procedure that is less invasive than total arch replacement. The major advantage of this technique is that antegrade endograft implantation can be performed during the procedure, thereby avoiding the complications of introducing the endograft from the groin. The aim of this study was to assess the midterm outcomes of type I hybrid aortic arch repair with antegrade endograft implantation. Methods: Thirty consecutive patients who underwent type I hybrid repair with antegrade endograft implantation from 2009 to 2015 were reviewed retrospectively. Patient demographics, and peri-operative and late results were collected from a prospective database and analysed. Results: Four patients (13%) were female and the median age was 78 years. Median aneurysm size was 64 mm. Six patients (20%) developed stroke, and the 30 day mortality rate was 3%. Two patients suffered aortic dissection at the site of debranching anastomosis. The median follow up was 5.2 years. All aneurysms remained stable or had decreased in size at three years, and 82% were stable at five years. Overall survival was 79% at three years and 71% at five years. The rates of freedom from aorta related death were 86% at three and five years, respectively. During the follow up period, three additional left subclavian artery embolisations and one endograft relining due to type IIIb endoleak were required. Conclusion: Midterm outcomes of type I hybrid aortic arch repair with antegrade endograft implantation for aortic arch aneurysms are reported. Although the incidence of peri-operative stroke was high, late sac behaviour was acceptable.

DOI： 10.1016/j.ejvs.2021.02.044

Web of Science

Scopus

PubMed

Language：Japanese   Publisher：Journal of Vascular Surgery  

Background: Similar to open surgical repair, thoracic endovascular aortic repair (TEVAR) carries a risk of spinal cord ischemia (SCI). However, the generally lower incidence of SCI after TEVAR compared with that after open surgical repair, despite the inability to preserve the intercostal arteries, indicates different pathophysiologic mechanisms with the two procedures. We hypothesized that a microembolism from an aortic mural thrombus is the main cause of SCI. Thus, we evaluated the association between the density of a mural thrombus in the descending thoracic aorta and the development of SCI. Methods: A retrospective review of a prospectively assembled database was performed for all patients who had undergone surgery at a single institution from October 2008 to December 2018. Patient demographics and procedure-related variables were collected. The volume and Hounsfield unit (HU) value of mural thrombi in the whole descending thoracic aorta were estimated on preoperative computed tomography using a three-dimensional workstation. Logistic regression analysis was performed to identify the risk factors for SCI development. Results: Of the 367 patients who had undergone TEVAR during the study period, 155 were excluded because of previous arch surgery (n = 59), previous descending thoracic aortic surgery (n = 6), previous TEVAR (n = 6), unavailability of optimal preoperative computed tomography data (n = 17), double-barreled dissection (n = 40), and other reasons. The mean ± standard deviation age of the remaining 212 patients was 75.8 ± 6.4 years, and 42 (19.8%) were women. Of the 212 patients, 14 (6.6%) developed SCI after TEVAR. The low mean density of the mural thrombus, total thrombus volume, low-density (≥−100 HU but <30 HU) thrombus volume, intermediate-density (≥30 HU but <150 HU) thrombus volume, treatment length, urgent surgery, and baseline dialysis differed significantly between patients with and without SCI. Although subsequent multivariate analysis could not be performed owing to the small number of SCI events, vulnerable low-density thrombus/plaque was a stronger predictor among the aneurysm-related factors of SCI after TEVAR on univariate analysis. Well-known risk factors, such as distal coverage between T8 and L1, left subclavian artery coverage, previous abdominal aortic surgery, and prophylactic spinal drainage, did not show significant differences. Conclusions: The results from the present study have demonstrated that among aneurysm-related factors, a lower density mural thrombus/plaque in the descending thoracic aorta is a predictor of SCI development after TEVAR. These results suggest that microembolism is one of the important mechanisms of SCI after TEVAR, which might change the prophylactic strategy.

DOI： 10.1016/j.jvs.2020.09.026

Scopus

PubMed

Language：English   Publisher：Journal of Endovascular Therapy  

Purpose: To present a subgroup analysis of patients from a large real-world study evaluating the safety and effectiveness of the Zilver PTX drug-eluting stent (DES) for treating femoropopliteal in-stent restenosis (ISR). Materials and Methods: This study examined patients enrolled in the Zilver PTX Japan Post-Market Surveillance Study (ClinicalTrials.gov identifier NCT02254837), a prospective, multicenter registry of 904 symptomatic patients with 1082 femoropopliteal lesions treated with the DES at 95 institutions in Japan. Five-year outcomes, including mortality, stent radiography, freedom from target lesion revascularization (TLR), and clinical benefit, were evaluated for 177 patients (mean age 74.2±8.3 years; 118 men) with 204 ISR lesions treated with the Zilver DES. Over half of the patients (108, 61.0%) were diabetic. Mean lesion length was 17.8±10.4 cm, and a third (72, 35.3%) were total occlusions. Outcome measures were all-cause mortality, thrombosis, freedom from TLR, and clinical benefit, defined as freedom from persistent or deteriorating ischemic symptoms. Results: No device-related or procedure-related deaths or paclitaxel-related adverse events were reported. All-cause mortality was 25.1% at 5 years. Stent fracture was observed in 5 stents through 5 years. The 5-year rate of freedom from clinically-driven TLR was 73.4%, and the rate of clinical benefit was 63.6%. Improvement in Rutherford category and ankle-brachial index was sustained through 5 years. Conclusion: The safety and effectiveness of the Zilver PTX stent for the treatment of femoropopliteal ISR lesions demonstrated that this device provides a favorable treatment option in this difficult-to-treat subgroup.

DOI： 10.1177/1526602820966708

Web of Science

Scopus

PubMed

Language：Japanese   Publisher：Journal of Vascular Surgery  

Objective: Type II endoleaks (T2ELs) are the most common type of endoleak after endovascular aneurysm repair (EVAR). The iliolumbar artery arising from the hypogastric artery is often a major source of T2ELs, and transarterial embolization of the iliolumbar artery through the hypogastric artery is sometimes performed to interrupt sac expansion during follow-up. Considering the equivocal results of an association between hypogastric embolization and T2ELs in previous studies, this topic has re-emerged after the advent of iliac branch devices. This study reviewed our series to clarify whether hypogastric embolization is associated with T2ELs at 12 months after EVAR. Methods: Patients who underwent elective EVAR between June 2007 and May 2017 at our institution were retrospectively reviewed. Patients with postoperative computed tomography angiography (CTA) at 12 months were included. Patients in whom CTA revealed type I or type III endoleaks during follow-up, who required reinterventions before 12 months, and who had solitary iliac aneurysms were excluded. The primary outcome was the incidence of T2ELs at 12 months after EVAR. The associations of patients' characteristics, anatomic factors, hypogastric embolization, and type of endograft with the primary outcome were analyzed. Results: In total, 375 patients were enrolled. During the median follow-up of 59.5 months (interquartile range, 19-126 months), 40 patients died, and 50 reinterventions were performed. In 108 patients (28.8%), either hypogastric artery was embolized to extend distal landings to the external iliac artery. Bilateral and unilateral embolization was performed in nine and 99 patients, respectively. In total, 153 patients (40.8%) had T2ELs found by CTA at 12 months. In the univariate analysis, the status of hypogastric artery occlusion or embolization was not significantly different between patients with and without T2ELs. However, there were not enough patients to detect a 10% difference in T2ELs with >80% statistical power. In the multivariate analysis, significant associations with T2EL were observed for female sex (P =.049), patent inferior mesenteric artery (P =.006), and presence of five or more patent lumbar arteries (P <.001) but not for hypogastric embolization. In addition, compared with the Zenith (Cook Medical, Bloomington, Ind) endograft, the Excluder (W. L. Gore & Associates, Flagstaff, Ariz) endograft was significantly related to T2EL (P =.001). Conclusions: No significant association between hypogastric embolization and T2EL was demonstrated in this retrospective study, which lacked adequate statistical power.

DOI： 10.1016/j.jvs.2020.04.505

Web of Science

Scopus

PubMed

Language：English   Publisher：Circulation Journal  

Background: Not every elderly person is frail, and whether it would be beneficial to perform endovascular aneurysm repair (EVAR) solely because a patient is older is unclear. This study aimed to compare the results of EVAR and open surgical repair (OSR) in elderly individuals. Methods and Results: From May 1998 to March 2021, 828 EVAR patients and 886 OSR patients with abdominal aortic aneurysm (AAA) were reviewed. Patients aged ≥80 years were included among them. After propensity score matching by age, sex, and American Society of Anesthesiologists (ASA) classification, the outcomes were compared between patients who underwent EVAR and OSR. The study cohort was composed of 351 EVAR patients and 90 OSR patients. The groups had similar comorbidities, except that EVAR patients were significantly older and had higher ASA classifications. After propensity score matching, 79 pairs of patients were selected. The 30-day mortality (0 vs. 1.2%) and aneurysm-related death (ARD) rates during follow up (2.3% vs. 2.3%, respectively) were similar between the groups. Kaplan-Meier curves revealed that estimated overall survival and freedom from ARD were also similar. Conclusions: This study suggests that EVAR cannot improve survival outcomes compared with OSR if applied solely because a patient is aged ≥80 years. Not only age but also other risk factors and quality of life after surgery need to be further studied.

DOI： 10.1253/circj.CJ-21-0574

Web of Science

Scopus

PubMed

Language：English   Publisher：Journal of Vascular Surgery  

Background: In thoracic endovascular aortic repair (TEVAR), covering the celiac artery (CA) is sometimes necessary to secure the distal seal. We report the outcomes of planned CA coverage in our experience with TEVAR. Methods: Cases requiring CA coverage during TEVAR from October 2008 to September 2018 were retrospectively reviewed. Patient demographics, indications for CA coverage, communication between the CA and the superior mesenteric artery (SMA), concomitant CA embolization, and perioperative and late results were collected in a prospective database and analyzed. Results: During the study decade, 357 patients underwent TEVAR at our institution. Of these patients, 15 (4.2%) required CA coverage. All 15 patients were male, and the mean age was 72.8 years (range, 44-80 years). The mean aneurysm size was 67.5 mm (range, 50-82 mm). The etiologies included 10 degenerative aneurysms (66.7%; 2 ruptures [13.3%], 4 dissecting aneurysms [26.7%], and 1 case of type IB endoleak [6.7%]) after TEVAR. Communicating collaterals between the CA and the SMA were confirmed by preoperative computed tomography angiography in eight patients (53.3%) and by intraoperative angiography in four patients (26.7%). Seven patients (46.7%) underwent concomitant embolization of the CA. CA coverage offered a mean extension of 20.3 mm (range, 12-22 mm) in the length of the distal seal. Postoperative computed tomography angiography revealed a type IB endoleak that resolved spontaneously in one patient (6.7%). Postoperative complications included splenic infarction/pancreatitis in one patient (6.7%) and spinal cord ischemia in two patients (13.3%). There were no cases of postoperative in-hospital mortality. During the follow-up period (mean, 3.6 years; range, 0.9-8.0 years), two patients developed a new type IB endoleak. One patient underwent distal extension of the stent graft with ilio-SMA bypass, and one patient was observed conservatively in accordance with the patient's decision. There were no cases of type II endoleak via the CA. Most aneurysms (86.7%) were stable or reduced in size at the most recent follow-up. There were no cases of targeted aneurysm-related death during the follow-up period. Conclusions: Our study demonstrates the safety and efficacy of CA coverage in facilitating adequate distal sealing in selected patients undergoing TEVAR. Because the distal sealing length is not completely sufficient in most cases requiring CA coverage, the long-term efficacy of CA coverage during TEVAR should be determined in a large prospective study.

DOI： 10.1016/j.jvs.2020.02.025

Web of Science

Scopus

PubMed

Language：English   Publisher：Annals of Vascular Surgery  

Background: Endovenous laser ablation (EVLA) with concomitant phlebectomy is commonly performed in many institutions. However, phlebectomy is associated with cosmetic complications such as surgical scarring, hemorrhage, and hematoma. This study aims to compare the need for additional sclerotherapy during follow-up after EVLA with and without concomitant phlebectomy. Methods: Between November 2013 and December 2018, we performed EVLA on 1,363 limbs in 1,009 patients with symptomatic primary varicose veins, of which 954 limbs in 771 patients with great saphenous vein (GSV) or small saphenous vein (SSV) insufficiency were included in this study. Data were collected prospectively and supplemented with retrospective medical record review. Demographic and clinical characteristic profiles were collected. The outcomes of EVLA with or without concomitant phlebectomy were compared. Logistic regression was used to assess predictors for additional sclerotherapy after EVLA. Results: CEAP classification (P < 0.001), operative time (P < 0.001), laser device type (P < 0.001), length of the treated vein (P < 0.001), linear endovenous energy density (P < 0.001), and tumescent local anesthesia volume (P < 0.001) differed significantly. Pain after EVLA was significantly more frequent in the nonphlebectomy group than in the phlebectomy group (P = 0.005). During follow-up, 34 of 954 limbs (3.6%) underwent additional sclerotherapy for residual visible varicose veins after EVLA. No statistical difference was found in the rate of additional sclerotherapy between the groups (P = 0.849). Logistic regression showed that female sex (odds ratio [OR], 6.18; 95% confidence interval [CI], 1.86–20.6; P = 0.003) is significantly associated with additional sclerotherapy, and concomitant phlebectomy is not a significant predictor of additional sclerotherapy (OR, 0.844; 95% CI, 0.375–1.90; P = 0.682). Conclusions: Patient preference for additional sclerotherapy was comparable between those who underwent EVLA with and without concomitant phlebectomy. This result supports our present strategy of avoiding simultaneous phlebectomy at the time of primary EVLA.

DOI： 10.1016/j.avsg.2019.12.025

Web of Science

Scopus

PubMed

Language：Japanese  

Web of Science

Language：English   Publisher：Annals of Vascular Surgery  

Background: Several studies have analyzed risk factors that may influence the incidence of type II endoleak with sac expansion after endovascular aneurysm repair (EVAR). However, the impact of intraluminal thrombus volume on the incidence of sac expansion with type II endoleak requires further analysis. This study examined the correlation between preoperative intraluminal thrombus and the incidence of type II endoleak and late sac expansion by measuring the thrombus volume. Methods: Between June 2007 and March 2014, 423 patients underwent EVAR at our institution. Two hundred and eighty patients with preoperative and postoperative computed tomography angiography (CTA) were included in this study. Data were collected prospectively and supplemented with a retrospective review of the medical records and radiologic images, and demographic and clinical characteristic profiles were collected. Logistic regression and Cox regression analyses were used to assess each variable's association with the incidences of persistent or new endoleak and sac expansion. Results: Of the 280 patients, 46.7% (131 patients) had persistent type II endoleak, and 19.6% (55 patients) had persistent type II endoleak with significant sac expansion (≥5 mm). The mean follow-up duration was 60 months (interquartile range, 24–72 months). Cox regression analysis showed that older age (P = 0.001), intraluminal thrombus volume ratio (thrombus volume [T vol]/aortic aneurysm volume [A vol]) (P = 0.042) and IMA diameter (P = 0.004) were significant predictors of the incidence of sac expansion with persistent or new type II endoleak. The receiver operating characteristic curve analysis revealed a cutoff of 51% T vol/A vol (area under the curve [AUC]: 0.59) and 2.9 mm (area under the curve [AUC]: 0.60). The rate of freedom from sac expansion (≥5 mm) during followup was significantly higher in patients with ≥51% T vol/A vol than in those with a lower T vol/A vol (P = 0.010). Conclusions: Preoperative sac thrombus volume, IMA diameter, and older age predict the incidence of aneurysm expansion with type II endoleak after EVAR.

DOI： 10.1016/j.avsg.2019.11.045

Web of Science

Scopus

PubMed

Language：English  

DOI： 10.1253/circrep.CR-20-0003

PubMed

Language：Japanese   Publisher：Journal of Vascular Surgery  

Background: Several reports have indicated that suprarenal (SR) fixation may impair renal function after endovascular abdominal aortic aneurysm repair (EVAR). However, most were short-term or at most, 1-year observational studies; therefore, the midterm effects on renal function remain unclear. This study aimed to identify predictors of midterm renal dysfunction after EVAR and compare renal outcomes in patients after EVAR with SR and infrarenal (IR) fixation. Methods: A total of 467 patients who underwent EVAR of nonruptured IR abdominal aortic aneurysm between 2007 and 2014 were reviewed in a prospectively collected database. Patients on hemodialysis at baseline were excluded. Among the remaining patients, those with 3-year laboratory testing were included in this study. Patients who developed acute kidney injury were excluded from the late renal function estimation. Predictors of 3-year renal function decline were estimated using logistic regression analysis. In addition, patients undergoing EVAR with IR (IR group) and SR fixation devices (SR group) were propensity matched by age, sex, baseline renal function, baseline aneurysm diameter, comorbidities, smoking habits, and regular use of medicines that may act on kidney function. Changes in renal function after surgery were compared between the IR group and the SR group. Results: During the study period, 237 patients (102 IRs and 135 SRs) were followed up with laboratory testing 3 years after surgery. Logistic regression analysis revealed that the use of a SR fixation device was independently predictive of a more than 20% decrease in the estimated glomerular filtration rate at 3 years after EVAR (odds ratio, 2.06; 95% confidence interval, 1.18-3.58; P =. 011). Eleven patients who developed acute kidney injury (1 IR and 10 SRs) were excluded from the subsequent analysis. After propensity score matching, 87 pairs were selected (mean age, 77.2 ± 6.3 years; 151 males [86.8%]). The mean follow-up duration was 5.5 ± 1.8 years. In the SR group, estimated glomerular filtration rate at 3 years after surgery decreased significantly more than that in the IR group (mean of 17.8% vs 11.6%, respectively; P =. 034). Conclusions: This study suggests that, compared with EVAR with IR endograft fixation, EVAR with SR endograft fixation is associated with worse outcomes for midterm renal function.

DOI： 10.1016/j.jvs.2019.03.061

Web of Science

Scopus

PubMed

Language：English   Publisher：Journal of Vascular Surgery  

Objective: Open surgical repair (OSR) for abdominal aortic aneurysms is a more invasive approach than endovascular aneurysm repair but has more enduring results and may lead to a lower reintervention rate. Therefore, strict selection of patients should be based on assessments of both early and late outcomes. The controlling nutritional status (CONUT) score and skeletal muscle mass index (SMI) have been reported as indicators of nutritional status and muscle size, respectively. The aim of this study was to identify prognostic factors, including sarcopenia and nutritional status, for early and late outcomes. Methods: We reviewed data from 360 consecutive abdominal aortic aneurysm patients who underwent OSR from 2007 to 2014. We collected data on patients' characteristics, nutritional status (CONUT score), and muscle size (SMI). Cox proportional hazards analysis and logistic regression analysis identified independent predictors of midterm mortality and Clavien-Dindo class IV complications as late and early outcomes, respectively. Results: During the study period, 360 patients underwent elective OSR. The following characteristics were associated with midterm mortality: age >71 years (hazard ratio [HR], 4.92; 95% confidence interval [CI], 1.41-17.13; P =.01), low SMI (HR, 4.32; 95% CI, 1.16-16.13; P =.03), CONUT score indicating a moderate risk of malnutrition (vs normal status or mild risk: HR, 4.16; 95% CI, 1.03-16.76; P =.045), and estimated glomerular filtration rate <30 mL/min/1.73 m2 (HR, 3.54; 95% CI, 1.09-11.47; P =.035). Two patients died within 30 days of undergoing OSR (0.6%). A CONUT score indicating moderate risk (HR, 4.42; 95% CI, 1.01-19.28; P =.048), estimated glomerular filtration rate <30 mL/min/1.73 m2 (HR, 7.34; 95% CI, 2.20-24.51; P <.001), and diabetes mellitus (HR, 3.71; 95% CI, 1.25-11.00; P =.02) were independent predictors of Clavien-Dindo class IV complications. Conclusions: These results may be useful for identifying and optimizing treatment of high-risk patients who will not benefit from OSR so that endovascular aneurysm repair or no intervention can be recommended. Consideration of nutritional status and sarcopenia may therefore support the development of a more personalized, cost-effective treatment strategy.

DOI： 10.1016/j.jvs.2019.01.049

Web of Science

Scopus

PubMed

Language：Japanese   Publisher：Annals of Vascular Surgery  

Background: Prior studies have shown that a bird-beak configuration causes serious complications after thoracic endovascular aortic repair (TEVAR). However, factors that cause bird-beak configurations are poorly understood. The purpose of this study was to assess the influences of anatomical and device-related factors on bird-beak configuration. Methods: Sixty-eight consecutive patients (47 men, mean age, 72.8 ± 9.8 years) who underwent TEVAR with proximal fixation in zones 1 to 3 from March 2009 to February 2017 were included. Preoperative and postoperative computed tomography (CT) scans were retrospectively reviewed. Relationships between the incidence of a bird-beak configuration, preoperative aortic arch morphology, and type of stent graft were estimated. The influence of a bird-beak configuration on endograft migration over time was also estimated for 47 patients who underwent CT 12 months after TEVAR. Results: The patients' aortic arch pathologies included 52 aneurysms, 11 aortic dissections, 4 pseudoaneurysms, and 1 patent ductus arteriosus. Stent grafts with (the proximal bare stent group [PBS group]) and without (the nonbare stent group [NBS group]) a proximal bare stent were implanted in 24 and 44 patients, respectively. A bird-beak configuration was detected in 30 patients (mean length ± standard deviation [SD], 6.2 ± 3.4 mm; mean angle ± SD, 31.7 ± 14.7°) and was significantly more frequent in the NBS group (n = 29) than in the PBS group (n = 1) (P < 0.001). Proximal landing zone, aortic lengths, and aortic arch morphology, including the radius, tortuosity, and angulation of aortic arch curvature, were not associated with the bird-beak configuration. The migration distance after 1 year was significantly longer in patients with a bird-beak configuration (3.5 ± 6.1 mm) than in patients without a bird-beak configuration (0.5 ± 1.0 mm) (P = 0.015). Conclusion: This study demonstrated that in aortic arch TEVAR, the use of stent graft with a proximal bare stent may reduce bird-beak configuration, which is associated with distal migration of the stent graft during follow-up.

DOI： 10.1016/j.avsg.2018.08.081

Web of Science

Scopus

PubMed

Language：English   Publisher：Circulation Journal  

Background: The effect of left renal vein division (LRVD) during open surgery (OS) for pararenal and juxtarenal abdominal aortic aneurysm (P/JRAA) on postoperative renal function remains controversial, so we focused on chronic renal decline (CRD) and separately examined renal volume as a surrogate index of split renal function. Methods and Results: The 115 patients with P/JRAA treated with OS from June 2007 to January 2017 were reviewed: 26 patients without LRVD were matched to 27 patients with LRVD according to preoperative chronic kidney disease (CKD) stage and proximal clamp sites. The effect of LRVD on CRD was investigated by a time-to-event analysis. During a median follow-up of 23.5 months, CRD occurred in 5 patients with LRVD and in 4 patients without LRVD. Comparison of freedom from CRD showed no significant difference between the matched groups (P=0.870). The separate renal volumes were evaluated before surgery and at 1 and 2 years of follow-up using CT images from 18 patients with LRVD. At 2 years, the mean renal volume had decreased by 15% in the left kidney and by 9% in the right kidney (P=0.052 and 0.148, respectively), but the left-to-right renal volume ratio showed no significant change (P=0.647). Conclusions: LRVD had no significant effect on CRD or left renal volume relative to the right renal volume for up to 2 years.

DOI： 10.1253/circj.CJ-19-0383

Web of Science

Scopus

PubMed

Language：Japanese   Publisher：Journal of Vascular Surgery Cases and Innovative Techniques  

Buerger disease is a rare peripheral vascular disease that most frequently affects young men and is strongly correlated with tobacco use. Although several options have been suggested, no consensus exists on the management of patients with Buerger disease except for smoking cessation. Revascularization is sometimes required to salvage ischemic limbs; however, it is often not feasible because of a lack of distal target vessels. Herein, we present the cases of three patients with tissue loss and gangrene due to Buerger disease. These patients underwent dorsal metatarsal artery bypass and avoided amputation.

DOI： 10.1016/j.jvscit.2018.03.011

Web of Science

Scopus

PubMed

Language：English   Publishing type：Research paper (scientific journal)  

DOI： 10.1016/j.avsg.2017.11.071

Web of Science

Scopus

PubMed

Language：English   Publishing type：Research paper (scientific journal)  

DOI： 10.1016/j.jvs.2017.07.121

Web of Science

Scopus

PubMed

Language：English   Publisher：Circulation Journal  

Background: Most patients with critical limb ischemia (CLI) exhibit severe comorbidities accompanied by frailty. This study assessed and risk-stratified mortality after infrainguinal bypass (IB) in CLI and investigated the effects of frailty. Methods and Results: The study retrospectively reviewed 107 consecutive CLI patients who had undergone de novo IB due to atherosclerotic disease. Data regarding patient age, comorbidities, laboratory data, and functional status were collected; functional status was evaluated using the Barthel index (BI) and nutritional status was evaluated using albumin concentrations and body mass index (BMI). Mean (±SD) BI and BMI were 75±16 and 22±4 kg/m 2 , respectively. BI (hazard ratio [HR] 0.96; 95% confidence interval [CI] 0.94–0.99, P=0.004), BMI (HR 0.85; 95% CI 0.75–0.95, P=0.003), atrial fibrillation (AF; HR 5.31; 95% CI 2.12–13.30, P<0.001), and ejection fraction (EF; HR 0.94; 95% CI 0.91–0.98, P=0.003) were independent predictors of mortality. Patients were divided into 2 groups based on BI (BI >75, n=71; and BI <70, n=36). Survival after IB was significantly lower for the lower BI group (P<0.001, log-rank test). After propensity score matching, post-IB survival remained significantly lower in the lower BI group (P=0.02). Conclusions: BI, BMI, AF, and EF were independently associated with all-cause mortality after IB for CLI. BI and BMI may be useful in identifying and optimizing treatment for high-risk frail patients.

DOI： 10.1253/circj.CJ-17-0369

Web of Science

Scopus

PubMed

Language：English   Publishing type：Research paper (scientific journal)  

DOI： 10.1177/1708538117700765

Web of Science

Scopus

PubMed

Language：Japanese   Publishing type：Research paper (scientific journal)  

DOI： 10.1016/j.avsg.2016.07.073

Web of Science

Scopus

PubMed

Language：Japanese   Publisher：Surgery Today  

Purpose: This study evaluated the early and long-term results of the sole use of endovascular treatment in the treatment of inflow lesions in claudicants with both aortoiliac and femoropopliteal (FP) lesions. Methods: A retrospective study that included 100 limbs in 73 patients was performed. The patency rates of aortoiliac artery stents, the continued clinical improvement rates, the risk factors for persistent disabling claudication after inflow revascularization, and the rates of freedom from additional FP procedures were examined. Result: After inflow revascularization, almost complete relief from intermittent claudication was seen in 79 % of the limbs, while 21 % of the limbs continued to suffer from disabling claudication. A multivariate analysis showed that a run-off score of ≥7 was an independent predictor for persistent disabling claudication after aortoiliac revascularization [hazard ratio (HR) 5.11, 95 % confidence interval (CI) 1.34–19.45; P = 0.02]. The primary patency rates at 1, 3, 5, and 6 years were 96, 96, 96 and 89 %, respectively. The secondary patency rate at 6 years was 100 %. The continued clinical improvement rates at 1, 3, 5, and 6 years were 81, 78, 78 and 72 %, respectively. The rates of freedom from additional FP procedures at 1, 3, 5, and 6 years were 97, 90, 90, and 90 %, respectively. Conclusions: Aortoiliac endovascular revascularization is effective treating claudicants with both aortoiliac and femoropopliteal lesions. Furthermore, a run-off score of ≥7 appears to be a potential predictor for persistent disabling claudication.

DOI： 10.1007/s00595-016-1399-0

Web of Science

Scopus

PubMed

Language：Japanese   Publisher：Annals of Vascular Surgery  

Background In recent years, endovascular abdominal aortic aneurysm repair (EVAR) for treating abdominal aortic aneurysms (AAA) has become quite prevalent in Japan. Though little information is available about temporal changes in proximal neck angulation due to the difficulties encountered in measuring the angle. Therefore, we examined temporal changes in proximal neck angulation and its relationship to stent-graft migration after EVAR. Methods Between June 2007 and March 2010, 159 patients underwent EVAR for treatment of fusiform AAAs at our hospital. This study focuses on the 80 patients among this group whose treatment sites and subsequent stent grafts were examined by contrast computed tomographic angiography before surgery, directly after surgery (within 4 days), as well as 1 year and 2 years thereafter. We created curved planar reconstruction (CPR) images and measured the length of migration and neck angle using our method. Results At 2 years after EVAR, the average length of proximal landing zone was 21.4 ± 9.2 mm. The average length of stent migration after 2 years was 1.41 ± 2.68 mm. The average neck angle was 33.9° preoperatively and 29.9° directly after surgery yielding a significant difference. However, 1 and 2 years after surgery the average neck angle was 28.2° and 28.4°, respectively. The number of patients experiencing a change >6° in the angle of the proximal neck between the preoperative condition and that directly after surgery was 16 (34.8%) with the use of Zenith stent grafts (n = 46) and 14 (41.2%) with the use of Excluder stent grafts (n = 34). There was no correlation between the proximal neck angle and migration of the proximal stent graft. In addition, there was no correlation between the changes in proximal neck angle and the secondary intervention rate and the occurrence of endoleak. Conclusions There was a significant change in the neck angle between the preoperative condition and the immediate postoperative condition. However, there was no clear relationship found between the angle of the neck and the proximal stent-graft migration. Postoperative changes in the proximal neck angle just after EVAR and subsequent temporal changes during a 2-year follow-up period do not appear to predict stent-graft migration, secondary intervention rates, or the occurrence of endoleak.

DOI： 10.1016/j.avsg.2016.05.128

Web of Science

Scopus

PubMed

Language：English   Publishing type：Research paper (scientific journal)  

DOI： 10.1016/j.avsg.2017.01.011

Web of Science

Scopus

PubMed

Language：English   Publisher：Annals of Vascular Surgery  

Background The advent of thoracic endovascular aneurysm repair (TEVAR) has bought about a tremendous revolution in the treatment strategy for aortic arch aneurysms. We reviewed our experience using TEVAR with the hybrid approach in the treatment of aortic arch aneurysms to evaluate its feasibility, safety, and effectiveness. Methods Between October 2008 and July 2014, 61 consecutive patients (51 men; mean age 75.8 ± 7.7 years; range, 43-85 years) underwent elective treatment for aortic arch aneurysms with the hybrid approach. The 61 patients were separated into 2 groups. Thirty-five patients underwent total debranching TEVAR for zone 0 (debranching TEVAR group), 26 patients underwent long elephant trunk (ET) followed by secondary retrograde TEVAR (ET group). Preoperative, perioperative, and follow-up data were collected retrospectively in the database. Results The technical success rate was 100%. The paraplegia rates in total debranching TEVAR and long ET TEVAR and were 2.9% and 3.8%, respectively. The stroke rates in total debranching TEVAR and long ET TEVAR were 11.4% and 7.7%, respectively. The overall 30-day mortality and in-hospital mortality rates for all 61 patients were 0% and 3.4% (n = 2; both were in the total debranching TEVAR group), respectively. There were no perioperative type 1 or 3 endoleaks that required secondary intervention. The mean hospital stay was 15.8 days. The median follow-up was 309 ± 303 days. No aneurysm-related deaths occurred during follow-up. Conclusions The hybrid approach can be safely performed with good technical success and good midterm results. In future, new alternative devices for aortic arch pathologies, such as a branched stent graft that eliminates extra-anatomic bypass, should be developed.

DOI： 10.1016/j.avsg.2015.11.041

Web of Science

Scopus

PubMed

Language：English   Publisher：European Journal of Vascular and Endovascular Surgery  

Objective After multi-branched endovascular aneurysm repair (mbEVAR), renal branch occlusion is the most frequent form of branch failure. Pre-operative renal angulation and post-operative morphology of the renal branch were quantified and their impact on occlusion was analyzed. Methods Patients who underwent mbEVAR between January 2010 and December 2013 were reviewed retrospectively. Only renal branches constructed with caudally directed cuffs were included. Patients without post-operative computed (CT) angiography were excluded. The main outcome was the primary patency of the renal branches. The renal angulation and the morphology of renal branch (bridging length, renal coverage length, tortuosity index, and angulation of distal renal artery) were quantified using CT. The impacts of morphology, implanted stents, and patient characteristics were investigated by time to event analyses. Results Ninety renal arteries in 49 patients were enrolled. Median follow up was 12 months (IQR 6-20 months). Balloon expandable stent grafts were used in 93% (84/90) of renal branches. Self expandable stent grafts were used in 12. Ninety-one percent (82/90) were lined with self expandable bare stents. Ten branches occluded after 8 months (median; IQR 1-14 months). Four of them underwent re-interventions, achieving secondary patency. The median renal angulation was -10° (IQR -40 to 0). The median bridging length was 42 mm (IQR 39-46 mm) and renal coverage 17 mm (IQR 12-22 mm). Median tortuosity index was 1.11 (IQR 1.04-1.19). The angulation of the distal renal artery was 140.7 ± 20.5°. In multivariate analysis, a tortuosity index > 1.11 was identified as the only significant predictor for occlusion (hazard ratio: 4.94; 95% CI: 1.01-24.30, p =.04). Conclusions High tortuosity was a significant predictor for the occlusion of renal branches, but renal angulation, bridging length, and the extent of renal coverage were not. By avoiding highly tortuous renal branch paths, good outcomes are expected even in upwardly directed renal arteries. Longer paths are acceptable.

DOI： 10.1016/j.ejvs.2015.09.013

Web of Science

Scopus

PubMed

Language：English   Publisher：Surgery Today  

Background and purpose: Endovascular aneurysm repair (EVAR) is the main treatment for patients with abdominal aortic aneurysms. This study examines the relationship between the migration of the distal landing zone and the length of the landing zone. Materials and methods: The subjects of this study were 36 patients who underwent contrast-enhanced computed tomography 1 year after EVAR. We constructed curved multi-planar reconstruction imaging and measured the length of migration, the angle of the common iliac artery, and the diameter of the distal landing zone. Results: The mean length of migration was 1.2 ± 1.7 mm. Fifty-four legs had a distal landing zone of over 15 mm and 18 legs had a distal landing zone of less than 15 mm. Four (7.4 %) of the 54 legs with a landing zone of over 15 mm and 3 (16.7 %) of the 18 legs with a landing zone of less than 15 mm had migration of over 3 mm. This difference was significant (P = 0.05). Conclusion: The rate of migration on the distal landing zone 1 year after EVAR was reasonable when the length of the landing zone was about 15 mm. It is possible that significant migration can occur in patients with distal landing zones less than 10 mm in length.

DOI： 10.1007/s00595-014-1100-4

Web of Science

Scopus

PubMed

Language：Japanese   Publisher：Circulation Journal  

Background: To validate the criteria for endovascular aneurysm repair (EVAR) or open repair of abdominal aortic aneurysm (AAA) at Nagoya University Hospital, the results of both treatments were retrospectively compared. Methods and Results: Patient selection for EVAR was primarily based on suitable anatomy, minimum age 75 years, and significant comorbidity. From June 2007 to April 2014, 426 patients were treated via EVAR (EVAR group) and 346 patients were treated with open surgery (OS group). The mortality rates of the EVAR and OS groups were not significantly different (0.2% vs. 1.1%; P=0.33). Patient age, operation time, amount of bleeding, and duration of hospital stay were significantly lower in the EVAR group compared with the OS group. The incidence of comorbidity was higher in the EVAR group compared with the OS group. The incidence of early postoperative complications was significantly higher in the OS group, whereas the incidence of late complications for both groups was similar. The cumulative aneurysm-related survival rates were similar (98.9% vs. 98.5%; P=0.767). The cumulative survival rates and reintervention-free rates at 5 years were lower for the EVAR group (76% vs. 89%, P=0.019; 81% vs. 89%, P=0.046). Conclusions: Patient selection practices and criteria for EVAR and open repair at Nagoya University Hospital are generally acceptable.

DOI： 10.1253/circj.CJ-14-1160

Web of Science

Scopus

PubMed

Language：English   Publisher：Journal of Vascular Surgery  

Objective The introduction of fenestrated and multibranched endografting transformed the treatment paradigm of patients with thoracoabdominal aortic aneurysms (TAAAs). However, despite the minimally invasive character of the procedure, spinal cord ischemia (SCI) remains a devastating complication. The aim of this study was to address the SCI rates after endovascular TAAA repair and to analyze potential risk factors leading to this complication. Methods A consecutive cohort of patients with nonruptured TAAAs treated by means of fenestrated and multibranched endografting between January 2010 and September 2014 was analyzed. Neurologic examination was routinely performed by an independent neurologist before operation and at discharge. The main outcome measure was the onset of SCI (paraplegia or paraparesis). Secondary outcomes were neurologic complications associated with cerebrospinal fluid drainage (CSFD) and 30-day mortality. Finally, a multivariate regression analysis identified risk factors for SCI. Results A consecutive 142 patients with TAAAs (Crawford type II, n = 54 [38%]; type III, n = 76 [54%]; type IV, n = 12 [8%]) were included in this study. The majority of patients (n = 129 [91%]) were treated for an atherosclerotic aneurysm, whereas 13 patients (9%) were treated for a postdissection aneurysm. The mean maximal aortic diameter was 65 ± 13 mm. SCI developed in 23 patients (16%; paraplegia in 12 [8%] and paraparesis in 11 [8%]). Of these 23 patients, 10 patients (43%) showed the neurologic deficit directly after the procedure, 11 patients (48%) in the first 24 hours, and 2 patients (9%) after 24 hours. There was an improvement of the neurologic status in the majority of patients, with only three patients (2%) showing irreversible paraplegia at discharge. There was no difference in the 30-day mortality between patients with and without SCI (no SCI, n = 3 [3%] vs SCI, n = 1 [4%]; P =.511). Prophylactic use of CSFD before the procedure was performed in 64 patients (45%), and among them, 4 patients (6%) developed a CSFD-associated complication. No clinical benefit for patients receiving prophylactic placement of CSFD was found (P =.498). The multivariate analysis revealed the percentage of thoracic aortic coverage as the only significant risk factor for SCI (odds ratio, 1.03; 95% confidence interval, 1.01-1.05; P =.001). Conclusions The SCI rate after endovascular repair of TAAA was 16%, with 8% of those patients suffering from paraplegia. Prophylactic use of CSFD could not reduce the SCI rate and was associated with 6% adverse events. The percentage of thoracic aortic coverage was the most powerful determinant of SCI in these series.

DOI： 10.1016/j.jvs.2015.01.044

Web of Science

Scopus

PubMed

Language：Japanese   Publisher：Surgery Today  

Purpose: We herein review the long-term results of our series of critical ischemic limbs caused by Buerger’s disease.

DOI： 10.1007/s00595-014-0904-6

Web of Science

Scopus

PubMed

Language：English   Publisher：Journal of Vascular Surgery  

Objective As first-line treatment for type 2 diabetes, metformin has gained a strong position. In addition, type 2 diabetics benefit from the fact that metformin is associated with a reduction in cardiovascular events. Nevertheless, there is a dearth of information concerning the functional role of metformin in regulating angiogenesis. Our present study explores whether metformin is involved in the modulation of the revascularization processes in vivo by employing a hindlimb mice model of ischemia-induced angiogenesis. Methods For comparative purposes, randomly selected wild-type (WT) mice or endothelial nitric oxide synthase (eNOS) deficient mice were assigned to one of two groups. One group was orally administered a daily dose of metformin through a gastric tube whereas the other group served as a control with no metformin administered. Both groups were subjected to unilateral hindlimb ischemia. Laser Doppler analysis coupled with capillary density staining with CD31was the method employed to determine revascularization. Adenosine monophosphate-activated protein kinase (AMPK) and eNOS phosphorylation levels were assessed using Western blot analysis. Results Subsequent to hindlimb ischemic surgery, in comparison to the nontreated mice, metformin-treated WT mice showed accelerated limb perfusion, which was substantiated by laser Doppler blood-flow measurements and the presence of increased capillary density in the ischemic adductor muscle. Treatment with metformin significantly enhanced the increase in AMPK and eNOS phosphorylation levels of muscle tissues in WT mice induced by ischemia. In eNOS- deficient knockout mice, there was a significant increase in ischemic tissue AMPK phosphorylation induced by metformin; however, blood flow recovery in ischemic limb after surgery was unaffected. Conclusions Metformin promoted revascularization in the presence of tissue ischemia through an AMPK/eNOS-related mechanism. Our study indicates that, in addition to its glucose-lowering effect, metformin fosters improved revascularization, which is responsible for its positive effect on patients with critical limb ischemia.

DOI： 10.1016/j.jvs.2013.09.061

Web of Science

Scopus

PubMed

Language：English  

DOI： 10.3400/avd.oa.15-00054

PubMed

Language：Japanese   Publisher：European Journal of Vascular and Endovascular Surgery  

Objective To assess and risk-stratify the medium-term clinical outcomes after infrainguinal bypass grafting (IBG) to treat critical limb ischaemia (CLI) in patients with end-stage renal disease.

DOI： 10.1016/j.ejvs.2014.08.022

Web of Science

Scopus

Language：English  

DOI： 10.1007/s00595-013-0512-x

PubMed

Language：English   Publisher：Circulation Journal  

Buerger’s disease (thromboangiitis obliterans) is considered to be a nonatherosclerotic, inflammatory, and vasoocclusive disease, although the details of the mechanisms of pathogenesis remain unknown. The occurrence of the disease is strongly related to tobacco abuse and its progression is closely linked to continued smoking. The purpose of this review article is to demonstrate the pathological characteristics of arteries affected with Buerger’s disease from a possible immunoreactive point of view. In addition, we present the mechanisms for preserving the architecture of the arterial wall in affected vasculatures. Thereafter, we discuss the possibility that the pathogenesis of Buerger’s disease is a type of endarteritis obliterans, deeply connected to the Notch pathway, distinct from arteriosclerosis obliterans and other vasculitides.

DOI： 10.1253/circj.CJ-14-0656

Web of Science

Scopus

PubMed

Language：Japanese   Publisher：Surgery Today  

Purpose: To investigate the quality of life and venous function of the lower limbs after right external iliac vein (REIV) grafting for digestive surgery. Method: The study subjects included 66 patients treated surgically for hepatopancreatobiliary malignancy who underwent concomitant resection with REIV for use as autologous grafts. Fifteen patients completed the Chronic Lower Limb Venous Insufficiency Questionnaire (CIVIQ), and the venous function was assessed using air plethysmography (APG) and duplex ultrasound in 10 patients. The outcomes of the 15 patients were analyzed statistically. Results: Postoperative morbidity related to graft harvest occurred in three of the 66 patients (5 %). The right legs of the follow-up patients were 6 ± 3 % larger than the left legs. The mean CIVIQ score was acceptably low at 27; however, moderate symptoms (e.g., pain upon long-time standing or walking) occurred in seven of the 15 patients. APG revealed moderate to severe outflow obstructions that did not improve during long-term observation. The blood flow depicted on duplex ultrasonography was significantly associated with the patients' symptoms. No deep venous reflux was encountered, and no right leg skin changes or venous claudication developed. Conclusions: The symptoms occurring after REIV resection can be unexpectedly prolonged. These unfavorable effects must be kept in mind and the possible sequelae should be carefully explained to patients preoperatively. © 2012 Springer Japan.

DOI： 10.1007/s00595-012-0406-3

Web of Science

Scopus

PubMed

Language：English   Publisher：Surgery Today  

Mycotic aneurysms located in the tibioperoneal trunk are extremely rare, with only a few cases reported in the literature. Because of their infrequency and clinical presentations mimicking other etiologies, clinicians generally do not arrive at the diagnosis until the diameter becomes large enough to detect pulsation. We herein report a case of a 52-year-old male with an aneurysm of the tibioperoneal trunk resulting from infective endocarditis. His early clinical presentation was acute compartment syndrome of unknown cause, and a fasciotomy was performed by orthopedists who did not recognize the underlying aneurysm. Later, enhanced computed tomography revealed that an irregularly shaped aneurysm existed in his right tibioperoneal trunk. After the sepsis was controlled with the use of systemic antibiotics, resection of the aneurysm was performed in advance of cardiac surgery. No clinical symptoms due to ischemia were observed without any revascularization. Postoperative computed tomography demonstrated fine enhancement of the peroneal and posttibial arteries via collaterals. © Springer 2012.

DOI： 10.1007/s00595-012-0175-z

Web of Science

Scopus

PubMed

Language：Japanese   Publisher：Surgery  

Background: The surgical management of infected aneurysms remains challenging and controversial. We aimed to assess the results of our retrospective series of patients surgically treated for infected infrarenal aortoiliac aneurysms and to verify our strategy. Methods: Retrospective case review of a single center. Results: Between January 1994 and December 2008, 545 patients with infrarenal aortoiliac aneurysms underwent surgery at our institution. Among these cases, 13 (2.4%) were classified as primary infected aneurysms. Seven were located in the infrarenal aorta and 6 were located in the iliac artery. The identified pathogens were Salmonella species (n = 2), methicillin-resistant Staphylococcus aureus (n = 2), and others. Systemic antibiotics were administered preoperatively to control septic conditions. At the time of surgery, 4 (31%) aneurysms had ruptured already. All but 2 cases, which were treated with extra-anatomic bypass, were repaired in situ using a Dacron graft. Although no in-hospital deaths occurred among the 3 patients who underwent planned surgery after successful control of septic conditions, 4 of 8 patients who underwent emergency surgery under septic conditions died during the early postoperative period. No signs of persistent or recurrent infection have been observed in our surviving patients with a mean follow-up of 40 months. Conclusion: Timely surgical intervention after controlling sepsis provided excellent outcomes, whereas the mortality rate of patients with sepsis or rupture was still high. Debridement of periaortic-infected tissue and in situ prosthetic graft repair are feasible. © 2011 Mosby, Inc.

DOI： 10.1016/j.surg.2010.12.015

Web of Science

Scopus

PubMed

Language：English  

DOI： 10.1016/j.avsg.2010.11.014

PubMed

Language：Japanese   Publisher：General Thoracic and Cardiovascular Surgery  

We performed descending thoracic aortic repair via posterolateral thoracotomy using retrograde cerebral perfusion with direct cannulation into the left internal jugular vein. No postoperative neurological dysfunction was observed. This patient was discharged without any adverse events. © 2011 The Japanese Association for Thoracic Surgery.

DOI： 10.1007/s11748-010-0588-9

Scopus

PubMed

Language：Japanese   Publisher：Surgery Today  

Late graft failure of autologous vein grafts is associated with intimal hyperplasia resulting from the migration and proliferation of vascular smooth muscle cells (VSMCs). Endothelial nitric oxide synthase (eNOS) is an enzyme that synthesizes nitric oxide (NO). An impairment of NO-mediated vasorelaxation and increases in cell proliferation occurs in vein grafts after the surgery and these pathophysiological changes cause intimal thickening. The Rho/Rho-kinase pathway negatively regulates eNOS and is involved in intimal hyperplasia. Several studies have been conducted with the goal of controlling intimal hyperplasia targeting eNOS/NO and the Rho/Rho-kinase pathway. The oral administration of drugs, such as Rho-kinase inhibitor, l-arginine, beta-blocker and statins, significantly suppressed intimal thickening in animal models. This study revealed that statins upregulate eNOS through Rho-kinase inhibition to suppress intimal hyperplasia. The intraluminal gene transfer of eNOS inhibited intimal hyperplasia, thereby reducing the cell proliferation. These approaches are thus considered to be potentially promising therapeutic modalities for graft failure. © 2009 Springer.

DOI： 10.1007/s00595-008-3912-6

Web of Science

Scopus

PubMed

Language：English   Publisher：Developmental Cell  

A polarity complex of PAR-3, PAR-6, and atypical protein kinase C (aPKC) functions in various cell polarization events. PAR-3 directly interacts with Tiam1/Taim2 (STEF), Rac1-specific guanine nucleotide exchange factors, and forms a complex with aPKC-PAR-6-Cdc42•GTP, leading to Rac1 activation. RhoA antagonizes Rac1 in certain types of cells. However, the relationship between RhoA and the PAR complex remains elusive. We found here that Rho-kinase/ROCK/ROK, the effector of RhoA, phosphorylated PAR-3 at Thr833 and thereby disrupted its interaction with aPKC and PAR-6, but not with Tiam2. Phosphorylated PAR-3 was observed in the leading edge, and in central and rear portions of migrating cells having front-rear polarity. Knockdown of PAR-3 by small interfering RNA (siRNA) impaired cell migration, front-rear polarization, and PAR-3-mediated Rac1 activation, which were recovered with siRNA-resistant PAR-3, but not with the phospho-mimic PAR-3 mutant. We propose that RhoA/Rho-kinase inhibits PAR complex formation through PAR-3 phosphorylation, resulting in Rac1 inactivation. © 2008 Elsevier Inc. All rights reserved.

DOI： 10.1016/j.devcel.2007.11.021

Web of Science

Scopus

PubMed

Language：English   Publisher：Biochemical and Biophysical Research Communications  

Endothelial nitric oxide synthase (eNOS) produces nitric oxide (NO), which is involved in various physiological functions of the cardiovascular system. eNOS is activated by dephosphorylation at Thr495 and phosphorylation at Ser1177. Inhibition of Rho-kinase, an effector of the small GTPase RhoA, leads to activation of Akt/PKB, which phosphorylates eNOS at Ser1177 and thereby promotes NO production. However, little is known about the effects of Rho-kinase on phosphorylation of Thr495. We here found that the constitutively active form of Rho-kinase phosphorylated eNOS at Thr495 in vitro. Expression of the constitutively active form of RhoA or Rho-kinase increased this phosphorylation in COS-7 cells. Addition of thrombin to cultured human umbilical vein endothelial cells induced phosphorylation of eNOS at Thr495. Treatment with Y27632, a Rho-kinase inhibitor, suppressed thrombin-induced phosphorylation at Thr495. These results indicate that Rho-kinase can directly phosphorylate eNOS at Thr495 to suppress NO production in endothelium. © 2007 Elsevier Inc. All rights reserved.

DOI： 10.1016/j.bbrc.2007.07.030

Web of Science

Scopus

PubMed

Language：Japanese  

Web of Science

Web of Science

Language：Japanese  

Web of Science

Language：English   Publisher：Journal of Vascular Surgery  

Background: Recent studies suggest that statins can protect the vasculature in a manner that is independent of their lipid-lowering activity through inhibition of the small guanosine triphosphate-binding protein, Rho, and Rho-associated kinase. Little information is available on the inhibitory effect of statins on vein graft intimal hyperplasia, the main cause of late graft failure after bypass grafting. We therefore examined the effects of a hydrophilic statin on vein graft intimal hyperplasia in vivo and Rho-kinase activity in vitro. Methods: In the first experiment, rabbits were randomized to a control group (n = 7) that was fed regular rabbit chow or to a pravastatin group (n = 7) that was fed regular rabbit chow supplemented with 10 mg/kg pravastatin sodium. The branches of the jugular vein were ligated and an approximately 3-cm segment of the jugular vein was taken for an autologous reversed-vein graft. The carotid artery was cut and replaced with the harvested autologous jugular vein. At 2 and 4 weeks after the operation, vein grafts in both groups were harvested, and intimal hyperplasia of the vein grafts was assessed. In the second experiment, human umbilical vein endothelial cells and vascular smooth muscle cells were cultured and then treated with 1 μmol/L and 30 μmol/L pravastatin for 24 hours and harvested. Immunoblotting was performed on the resulting precipitates. Quantitative evaluation of phosphorylated myosin binding subunit and endothelial nitric oxide synthase was performed by densitometric analysis. Results: We demonstrated that oral administration of the hydrophilic statin pravastatin to normocholesterolemic rabbits inhibited intimal hyperplasia of carotid interposition-reversed jugular vein grafts 4 weeks after implantation (pravastatin group, 39.5 ± 3.5 μm vs control group, 64.0 ± 7.1 μm; n = 7; P < .05) and suppressed cell proliferation and apoptosis in the neointima 2 weeks after implantation. In addition, we found that pravastatin inhibited Rho-kinase activity and accelerated endothelial nitric oxide synthase expression in human umbilical vein endothelial cells but did not inhibit Rho-kinase activity in vascular smooth muscle cells. Conclusions: These novel findings clearly demonstrate that a hydrophilic statin can suppress intimal hyperplasia of the vein graft in vivo and also show endothelial cell-tropic inhibition of Rho-kinase in vitro. Furthermore, these results strongly support the clinical use of hydrophilic statins to prevent intimal hyperplasia of the vein graft after bypass grafting. Clinical Relevance: Late graft failure caused by neointimal hyperplasia limits the efficacy of vein grafting. Various treatments were examined to reduce neointimal hyperplasia, but a standard clinical treatment has not yet been established. We report here the inhibitory effect of pravastatin on the development of vein graft intimal hyperplasia. In addition, we demonstrate that pravastatin showed endothelial cell-tropic benefits through both the inhibition of Rho-kinase activity and acceleration of eNOS expression in vitro. Because the clinical benefits and safety of pravastatin have been established to a certain extent through long-term clinical usage, pravastatin may soon become standard treatment after vein bypass grafting. Copyright © 2005 by The Society for Vascular Surgery.

DOI： 10.1016/j.jvs.2005.05.041

Web of Science

Scopus

PubMed

Web of Science

Publisher：Systemic Vasculitides: Current Status and Perspectives  

DOI： 10.1007/978-3-319-40136-2_31

Scopus