研究者詳細 - 杉本　昌之

論文 - 杉本　昌之

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Midterm Outcomes of Zone 0 Antegrade Endograft Implantation During Type I Hybrid Aortic Arch Repair

Banno H., Mutsuga M., Sugimoto M., Tokuda Y., Kodama A., Usui A., Komori K.

European Journal of Vascular and Endovascular Surgery 61 巻 ( 6 ) 頁： 938 - 944 2021年6月

記述言語：英語出版者・発行元：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

Low-density vulnerable thrombus/plaque volume on preoperative computed tomography predicts for spinal cord ischemia after endovascular repair for thoracic aortic aneurysm

Banno H., Kawai Y., Sato T., Tsuruoka T., Sugimoto M., Kodama A., Komori K.

Journal of Vascular Surgery 73 巻 ( 5 ) 頁： 1557 - 1565.e1 2021年5月

記述言語：日本語出版者・発行元：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

Long-Term Effectiveness of a Drug-Eluting Stent for Femoropopliteal In-Stent Restenosis: Subanalysis of the Zilver PTX Japan Post-Market Surveillance Study

Sugimoto, M; Komori, K; Yokoi, H; Ohki, T; Kichikawa, K; Nakamura, M; Nanto, S; O'Leary, EE; Lottes, AE; Saunders, AT; Dake, MD

JOURNAL OF ENDOVASCULAR THERAPY 28 巻 ( 2 ) 頁： 229 - 235 2021年4月

記述言語：英語出版者・発行元：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

The association between perioperative embolization of hypogastric arteries and type II endoleaks after endovascular aortic aneurysm repair

Meshii K., Sugimoto M., Niimi K., Kodama A., Banno H., Komori K.

Journal of Vascular Surgery 73 巻 ( 1 ) 頁： 99 - 107 2021年1月

記述言語：日本語出版者・発行元：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

Early and midterm outcomes of celiac artery coverage during thoracic endovascular aortic repair

Banno, H; Ikeda, S; Kawai, Y; Meshii, K; Takahashi, N; Sugimoto, M; Kodama, A; Komori, K

JOURNAL OF VASCULAR SURGERY 72 巻 ( 5 ) 頁： 1552 - 1557 2020年11月

記述言語：英語出版者・発行元：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

Clinical Comparison Between Early and Late Spontaneous Sac Shrinkage After Endovascular Aortic Aneurysm Repair

Sugimoto, M; Ikeda, S; Kawai, Y; Tsuruoka, T; Niimi, K; Kodama, A; Banno, H; Komori, K

JOURNAL OF VASCULAR SURGERY 72 巻 ( 1 ) 頁： E188 - E189 2020年7月

Endovenous Laser Ablation with and Without Concomitant Phlebectomy for the Treatment of Varicose Veins: A Retrospective Analysis of 954 Limbs

Kawai Y., Sugimoto M., Aikawa K., Komori K.

Annals of Vascular Surgery 66 巻頁： 344 - 350 2020年7月

記述言語：英語出版者・発行元：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

Influence of Preoperative Sarcopenia and Nutritional Status on Midterm and Long-term Mortality of Abdominal Aortic Aneurysm After Endovascular Aneurysm Repair

Ikeda, S; Kodama, A; Komori, K; Banno, H; Sugimoto, M; Niimi, K; Kawai, Y; Tsuruoka, T

JOURNAL OF VASCULAR SURGERY 72 巻 ( 1 ) 頁： E88 - E88 2020年7月

Aneurysm Sac Thrombus Volume Predicts Aneurysm Expansion with Type II Endoleak After Endovascular Aneurysm Repair

Fujii, T; Banno, H; Kodama, A; Sugimoto, M; Akita, N; Tsuruoka, T; Sakakibara, M; Komori, K

ANNALS OF VASCULAR SURGERY 66 巻頁： 85 - + 2020年7月

記述言語：英語出版者・発行元：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

Zinc Deficiency and Clinical Outcome After Infrainguinal Bypass Grafting for Critical Limb Ischemia.

Koyama A, Kodama A, Tsuruoka T, Fujii T, Sugimoto M, Banno H, Komori K

Circulation reports 2 巻 ( 3 ) 頁： 167 - 173 2020年2月

Suprarenal fixation is associated with worse midterm renal function after endovascular abdominal aortic aneurysm repair compared with infrarenal fixation

Banno H., Ikeda S., Kawai Y., Fujii T., Akita N., Takahashi N., Sugimoto M., Kodama A., Komori K.

Journal of Vascular Surgery 71 巻 ( 2 ) 頁： 450 - 456 2020年2月

記述言語：日本語出版者・発行元：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

Associations of nutritional status and muscle size with mortality after open aortic aneurysm repair

Kodama, A; Takahashi, N; Sugimoto, M; Niimi, K; Banno, H; Komori, K

JOURNAL OF VASCULAR SURGERY 70 巻 ( 5 ) 頁： 1585 - 1593 2019年11月

記述言語：英語出版者・発行元：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

Effect of Intraoperative Division of the Left Renal Vein on the Fate of Renal Function and Left Renal Volume After Open Repair of Para- and Juxtarenal Aortic Aneurysm

Sugimoto, M; Takahashi, N; Niimi, K; Kodama, A; Banno, H; Komori, K

CIRCULATION JOURNAL 83 巻 ( 9 ) 頁： 1844 - 1850 2019年9月

記述言語：英語出版者・発行元：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

Proximal Bare Stent May Reduce Bird-Beak Configuration, Which is Associated with Distal Migration of Stent Graft in the Aortic Arch

Banno H., Akita N., Fujii T., Tsuruoka T., Takahashi N., Sugimoto M., Niimi K., Komori K.

Annals of Vascular Surgery 56 巻頁： 108 - 113 2019年4月

記述言語：日本語出版者・発行元：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

Three cases of dorsal metatarsal artery bypass in patients with Buerger disease

Kodama A., Takahashi N., Sugimoto M., Niimi K., Banno H., Komori K.

Journal of Vascular Surgery Cases and Innovative Techniques 4 巻 ( 3 ) 頁： 185 - 188 2018年9月

記述言語：日本語出版者・発行元：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

Anatomical Suitability of the GORE EXCLUDER Iliac Branch Endoprosthesis in Japanese Patients with Common Iliac Aneurysms Treated by Standard EXCLUDER Endografts

Sugimoto, M; Takahashi, N; Niimi, K; Kodama, A; Banno, H; Komori, K

ANNALS OF VASCULAR SURGERY 50 巻頁： 179 - 185 2018年7月

記述言語：英語掲載種別：研究論文（学術雑誌）出版者・発行元：Annals of Vascular Surgery

Background: The EXCLUDER iliac branch endoprosthesis (IBE) is designed to exclude a common iliac artery (CIA) aneurysm (CIAA), preserving the internal iliac artery (IIA) during endovascular aneurysm repair (EVAR). We assessed the anatomical suitability of the IBE in patients whose aortoiliac aneurysms (AIAs) had already been treated with a standard EXCLUDER endograft, compromising their IIAs. Methods: From June 2007 to January 2017, 202 patients underwent elective EVAR for AIAs with the EXCLUDER endograft at our institute. Among them, patients whose IIAs were embolized for the external iliac artery (EIA) landing were included in this study. Patients with solitary or small CIAAs of <25 mm in diameter were excluded. Preoperative computed tomography scans were analyzed using a 3D workstation to evaluate the suitability of the IBE when following its instructions for use. Results: Twelve patients with bilateral CIAAs and 24 patients with unilateral CIAAs were enrolled in this study. Among the 48 iliac segments, 15 (31.3%) were eligible for unilateral IBE implantation. A total of 40% of the CIAAs did not have a large enough luminal diameter, which was the most common barrier to the use of the unilateral IBE in our patients. Among the iliac segments of the 12 patients with bilateral CIAAs, 2 (16.7%) were suitable for bilateral implantation. An insufficient length between the renal artery (RA) and the IIA was the major barrier to the use of bilateral IBE. Conclusions: A total of 31.3% of the compromised IIAs could have been preserved if the IBE was used. Bilateral implantation seemed possible in a limited number of cases. In addition to a small CIA lumen, an insufficient length between the RA and the IIA was also a predominant anatomical limitation, especially when bilateral implantation was planned.

DOI： 10.1016/j.avsg.2017.11.071

Long-term fate of renal function after open surgery for juxtarenal and pararenal aortic aneurysm

Sugimoto M., Takahashi N., Niimi K., Kodama A., Banno H., Komori K.

Journal of Vascular Surgery 67 巻 ( 4 ) 頁： 1042 - 1050 2018年4月

記述言語：英語掲載種別：研究論文（学術雑誌）出版者・発行元：Journal of Vascular Surgery

Background: Although the indications for endovascular aneurysm repair for abdominal aortic aneurysm have been expanding, our primary strategy for pararenal and juxtarenal abdominal aortic aneurysm (P/JRAA) is open surgery (OS). One consequence of OS for P/JRAA is transient renal ischemia owing to renal artery clamping, which can be followed by acute kidney injury (AKI). Prior studies referred to the impact of renal ischemia on AKI, but they have rarely evaluated longer-term renal function. This study focused on a chronic renal decline (CRD) during follow-up. Methods: A retrospective review of our series of P/JRAA treated with OS from 2007 to 2015. Patients on hemodialysis at the time of surgery were excluded. Preoperative renal function was estimated using the chronic kidney disease (CKD) staging system. Postoperative AKI was defined by the RIFLE criteria (Risk, Injury, Failure, Loss of function, End-stage renal disease). CRD was defined as progression in CKD stage or estimated glomerular filtration rate (eGFR) decline of >20%. Results: Among 451 elective OS, 111 underwent repair for P/JRAA. Three patients were excluded because of preoperative hemodialysis. Consequently, 108 patients were enrolled. Preoperatively, 41 patients (38.0%) had CKD stage 3 (eGFR < 60 mL/min/1.73 m2). Eight patients (7.2%) were in stage 4 (eGFR < 30 mL/min/1.73 m2). Proximal clamping was supraceliac (6 patients), suprarenal (34 patients), and inter-renal (68 patients). The median renal ischemic time was 33 minutes. The left renal vein was divided in 24 patients. Fourteen renal arteries in 14 patients were revascularized. Cold renal perfusion was applied in 11 patients. One in-hospital death was excluded from these analyses. AKI was observed in 20 patients (18.7%). One patient required temporary hemodialysis. During a median renal function follow-up for 24.5 months (interquartile range, 3.34-48.4), 17 patients (15.9%) had CRD. One patient required hemodialysis 5 years after surgery. In univariate analysis, CKD stages 3 and 4 were significant predictors for CRD (P =.014 and P <.001, respectively). Cold renal perfusion was associated with a higher risk of CRD (P =.047). On multivariate analysis, preoperative CKD stage 3 (hazard ratio, 4.22; 95% confidence interval, 1.10-16.3; P =.036) and stage 4 (hazard ratio, 59.72; 95% confidence interval, 10.13-352.0; P <.001) were identified as risk factors. In patients with CKD stage ≤2, the estimated freedom from CRD at 5 years was 96.6 ± 3.4%. Conclusions: CKD stage ≥3 was a significant risk for CRD after OS for P/JRAA. Renal artery clamping seemed innocuous for patients with a preoperative eGFR of ≥60 mL/min/1.73 m2 in terms of CRD. No significant impact of left renal vein division on CRD was confirmed.

DOI： 10.1016/j.jvs.2017.07.121

Association Between Preoperative Frailty and Mortality in Patients With Critical Limb Ischemia Following Infrainguinal Bypass Surgery - Usefulness of the Barthel Index -

Kodama, A; Koyama, A; Sugimoto, M; Niimi, K; Banno, H; Komori, K

CIRCULATION JOURNAL 82 巻 ( 1 ) 頁： 267 - 274 2018年1月

記述言語：英語出版者・発行元：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

Impact of renal arterial morphology on fluoroscopy time in chimney endovascular aneurysm repair

Sugimoto M., Torsello G., Donas K.

Vascular 25 巻 ( 5 ) 頁： 514 - 519 2017年10月

記述言語：英語掲載種別：研究論文（学術雑誌）出版者・発行元：Vascular

Objectives: To evaluate the impact of renal artery morphology on fluoroscopy time in chimney endovascular aneurysm repair. Methods: Morphology of renal artery was retrospectively quantified in the preoperative CT angiography. Renal artery angulation, ostial diameter, severity of ostial stenosis, main renal artery length, and tortuosity were analyzed with a 3D workstation. The main measure outcome was fluoroscopic time as an indicator of complexity. Uni- and multivariate logistic regression analyses were performed to determine predictors of longer fluoroscopy. Secondary endpoints were amount of contrast medium, patency of renal artery, and type Ia endoleak. Results: The enrolled 38 patients (mean age 75.0 years; 34 males) were stratified at the median of fluoroscopic time of 35.2 min (interquartile range, 21.5) and classified in group A (n = 19) and group B (n = 19) having a fluoroscopic time of 24.5 (interquartile range, 5.9) and 46.4 (interquartile range, 16.0) min, respectively. The severity of ostial stenosis (OsSte) was significantly different between group A and B of 26.3 ± 13.4% and 41.6 ± 18.0%, respectively; P <.01. ROC curve analysis revealed that 35.5% was an optimal cut-off for OsSte. The difference of renal angulation (RAng) (−22.5° and −2.0°; interquartile ranges 49 and 35; P =.13), and main renal artery length (33.4 ± 11.8 mm and 33.7 ± 14.3 mm; P =.94) were not significantly different. In multivariate analysis after dichotomizing OsSte and RAng, OsSte > 35.5% was identified as the only significant predictor for the longer fluoroscopy (HR: 4.33; 95% CI: 1.02–18.4, P =.04). As for the secondary endpoints, no significant differences were observed between the groups. No correlation between longer fluoroscopy and renal patency or type Ia endoleak was observed. Conclusion: Severity of ostial stenosis seems to be a significant predictor for longer fluoroscopic time.

DOI： 10.1177/1708538117700765

Long-term Comparison of Endovascular and Open Repair of Abdominal Aortic Aneurysms: Retrospective Analysis of Matched Cohorts with Propensity Score

Sugimoto, M; Koyama, A; Niimi, K; Kodama, A; Banno, H; Komori, K

ANNALS OF VASCULAR SURGERY 43 巻頁： 96 - 103 2017年8月

記述言語：英語掲載種別：研究論文（学術雑誌）出版者・発行元：Annals of Vascular Surgery

Background Although recent guidelines recommend endovascular aneurysm repair (EVAR) for robust younger patients, we have been limiting our indication to older patients or those who are physically frail. This study compares long-term outcomes of our series of abdominal aortic aneurysms (AAAs) treated with endovascular repair (ER) and open surgery (OS), using propensity score matching. Methods Between June 2007 and October 2014, 819 patients with infrarenal AAA underwent elective repair at our institution. Among them, 737 patients (386 ERs and 351 OSs) with over 1-year follow-up or any events (reintervention or mortality) were enrolled. Covariates for matching included age, sex, hypertension, coronary arterial disease, obstructive pulmonary disease, diabetes, stroke, malignancy, hemodialysis, ejection fraction, serum creatinine, and respiratory function. Results After propensity score matching, 157 pairs were selected. In the original cohort, overall survival at 5 years was 84.1% in ER and 89.3% in OS; the difference was significant (P = 0.019). The freedom-from-reintervention rates at 5 years were also significantly different, 81.8% in ER and 92.8% in OS (P = 0.007). In the matched cohort, age and comorbidities were similar both in ER and OS. The overall survival at 5 years was 85.4% and 90.1% in ER and OS, respectively; the difference was not significant (P = 0.242). The freedom-from-reintervention rates at 5 years were 81.1% in ER and 89.1% in OS; these were also not significantly different (P = 0.178). Conclusions Risk-adjusted comparisons revealed that long-term outcomes of ER and OS were comparable among our relatively frail patients in their age 70s. Our results failed to show the long-term advantage of EVAR in rather high-risk patients and provided no supportive evidence for our selection criteria.

DOI： 10.1016/j.avsg.2017.01.011

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