Three-dimensional corrective osteotomy for cubitus varus deformity using patient-matched instruments

Background

Various methods of two or three-dimensional (3D) corrective osteotomy for cubitus varus deformity have been reported. However, whether 3D correction of cubitus varus deformity is necessary is controversial because of technical difficulties and surgical complications. This study introduced 3D simulations and printing technology for corrective osteotomy against cubitus varus deformities. Moreover, recent studies on the application of these technologies were reviewed.

Methods

The amount of 3D deformity was calculated based on the difference in 3D shape between the affected side and the contralateral normal side. Patient-matched instruments were created to perform the actual surgery as simulated. Further, a 3D corrective osteotomy was performed using patient-matched instruments for cubitus varus deformity in pediatric and adolescent patients. The humerus-elbow-wrist angle, tilting angle, and elbow ranges of motion were evaluated.

Results

Humerus-elbow-wrist angle and tilting angle were corrected from -21° to 14° and from 30° to 43°, respectively, in the pediatric patient and from -18° to 10° and from 20° to 40°, respectively, in the adolescent patient. The elbow flexion and extension angles changed from 130° to 140° and from 20° to 10°, respectively, in the pediatric patient and from 120° to 130° and from 15° to 0°, respectively, in the adolescent patient.

Conclusion

The 3D computer simulations and the use of patient-matched instruments for cubitus varus deformity are reliable and can facilitate an accurate and safe correction. These technologies can simplify the complexity of 3D surgical procedures and contribute to the standardization of treatment for cubitus varus deformity.

Reproduction of forearm rotation dynamic using intensity-based biplane 2D-3D registration matching method

This study aimed to reproduce and analyse the in vivo dynamic rotational motion of the forearm and to clarify forearm motion involvement and the anatomical function of the interosseous membrane (IOM). The dynamic forearm rotational motion of the radius and ulna was analysed in vivo using a novel image-matching method based on fluoroscopic and computed tomography images for intensity-based biplane two-dimensional-three-dimensional registration. Twenty upper limbs from 10 healthy volunteers were included in this study. The mean range of forearm rotation was 150 ± 26° for dominant hands and 151 ± 18° for non-dominant hands, with no significant difference observed between the two. The radius was most proximal to the maximum pronation relative to the ulna, moved distally toward 60% of the rotation range from maximum pronation, and again proximally toward supination. The mean axial translation of the radius relative to the ulna during forearm rotation was 1.8 ± 0.8 and 1.8 ± 0.9 mm for dominant and non-dominant hands, respectively. The lengths of the IOM components, excluding the central band (CB), changed rotation. The transverse CB length was maximal at approximately 50% of the rotation range from maximum pronation. Summarily, this study describes a detailed method for evaluating in vivo dynamic forearm motion and provides valuable insights into forearm kinematics and IOM function.

Neurotropin® accelerates peripheral nerve regeneration in a rat sciatic nerve crush injury model

BACKGROUND

Peripheral nerve injuries are common and serious conditions. The effect of Neurotropin® (NTP), a nonprotein extract derived from the inflamed skin of rabbits inoculated with vaccinia virus, on peripheral nerve regeneration has not been fully elucidated. However, it has analgesic properties via the activation of descending pain inhibitory systems. Therefore, the current study aimed to determine the effects of NTP on peripheral nerve regeneration.

METHODS

We examined axonal outgrowth of dorsal root ganglion (DRG) neurons using immunocytochemistry in vitro. In addition, nerve regeneration was evaluated functionally, electrophysiologically, and histologically in a rat sciatic nerve crush injury model in vivo. Furthermore, gene expression of neurotrophic factors in the injured sciatic nerves and DRGs was evaluated.

RESULTS

In the dorsal root ganglion neurons in vitro, NTP promoted axonal outgrowth at a concentration of 10 mNU/mL. Moreover, the systemic administration of NTP contributed to the recovery of motor and sensory function at 2 weeks, and of sensory function, nerve conduction velocity, terminal latency, and axon-remyelination 4 weeks after sciatic nerve injury. In the gene expression assessment, insulin-like growth factor 1 and vascular endothelial growth factor expressions were increased in the injured sciatic nerve 2 days postoperatively.

CONCLUSIONS

Therefore, NTP might be effective in not only treating chronic pain but also promoting peripheral nerve regeneration after injury.

Acceptable range of forearm deformity derived from relation to three-dimensional analysis and clinical impairments

This study aimed to investigate deformity patterns that cause clinical impairments and determine the acceptable range of deformity in the treatment of forearm diaphyseal fractures. A three-dimensional (3D) deformity analysis based on computed bone models was performed on 39 patients with malunited diaphyseal both-bone forearm fractures to investigate the 3D deformity patterns of the radius and ulna at the fracture location and the relationship between 3D deformity and clinical impairments. Clinical impairments were evaluated using forearm motion deficit. Cutoff values of forearm deformities were calculated by performing receiver operating characteristic analysis using the deformity angle and the limited forearm rotation range of motion (less than 50° of pronation or supination) resulting in activities of daily living (ADL) impairment as variables. The extension, varus, and pronation deformities most commonly occurred in the radius, whereas the extension deformity was commonly observed in the ulna. A positive correlation was observed between pronation deficit and extension deformity of the radius (R = 0.41) and between supination deficit and pronation deformity of the ulna (R = 0.44). In contrast, a negative correlation was observed between pronation deficit and pronation deformity of the radius (R = -0.44) and between pronation deficit and pronation deformity of the ulna (R = -0.51). To minimize ADL impairment, radial extension deformity should be <18.4°, radial rotation deformity <12.8°, and ulnar rotation deformity <16.6°. The deformities in the sagittal and axial planes of the radius and in the axial plane of the ulna were responsible for the limited forearm rotation.

Demographic Traits, Clinical Status, and Comorbidities of Patients With Thromboangiitis Obliterans in Japan

BACKGROUND

The latest demographics, clinical and living conditions, and comorbidities of patients with thromboangiitis obliterans (TAO) in Japan are unknown.Methods and Results: We conducted a retrospective cross-sectional survey using the annual database of the Japanese Ministry of Health, Labour and Welfare medical support system for patients with TAO between April 2013 and March 2014. This study included 3,220 patients (87.6% male), with current age ≥60 years in 2,155 patients (66.9%), including 306 (9.5%) patients aged ≥80 years. Overall, 546 (17.0%) had undergone extremity amputation. The median interval from onset to amputation was 3 years. Compared with never smokers (n=400), 2,715 patients with a smoking history had a higher amputation rate (17.7% vs. 13.0%, P=0.02, odds ratio [OR]=1.437, 95% confidence interval [CI]=1.058-1.953). A lower proportion of workers and students was seen among patients after amputation than among amputation-free patients (37.9% vs. 53.0%, P<0.0001, OR=0.542, 95% CI=0.449-0.654). Comorbidities, including arteriosclerosis-related diseases, were found even in patients in their 20-30 s.

CONCLUSIONS

This large survey confirmed that TAO is not a life-threatening but an extremity-threatening disease that threatens patients' professional lives. Smoking history worsens patients' condition and extremity prognosis. Long-term total health support is required, including care of extremities and arteriosclerosis-related diseases, social life support, and smoking cessation.

Impact of preoperative identification of the artery of Adamkiewicz on spinal cord injury after descending aortic and thoracoabdominal aortic repair

Background

Some recent reports have demonstrated that preoperative Adamkiewicz artery (AKA) identification and its targeted reconstruction has provided satisfactory outcomes with respect to spinal cord protection. This paper investigates the impact of preoperative identification of the AKA on reducing the incidence of spinal cord injury (SCI) in open repair (OR) and endovascular repair (EVR) of descending thoracic aortic (dTA) and thoracoabdominal aortic aneurysm (TAA) repair.

Methods

The clinical data of patients with dTA and TAA treated between 2011 and 2022 were investigated. A total of 256 patients comprising of 201 males and 55 females, with a mean age of 72.1±10.0 years, were included. OR was used in 102 patients and EVR in 154 patients whose distal landing zone was below T8, all of which needed preoperative identification of the AKA.

Results

The AKA was identified in 207 (80.9%) patients, and was located in the level between T8 and T12 in 81.2%. In OR, the responsible arteries, including the identified AKA, were promptly reconstructed in 66 (64.7%) patients. In EVR, 65 (42.2%) patients had the AKA covered by an endovascular prosthesis. Deaths prior to 30 days occurred in seven (2.7%, four in OR and three in EVR) patients. In OR, SCI occurred in six (5.9%) patients including three (2.9%) with paraplegia and three (2.9%) with paraparesis, whereas in EVR ten (6.5%) patients had SCI, including two (1.3%) with paraplegia and eight (5.2%) with paraparesis. The incidence of SCI was significantly higher in patients with the AKA covered than those without it covered [13.8% (9 of 65) vs. 1.1% (1 of 89); P=0.002], whereas no significant differences were found between patients with or without the AKA reconstructed.

Conclusions

Preoperative identification of the AKA was useful enough to determine treatment strategies with less likelihood of SCI in both OR and EVR for dTA and TAA pathologies.

Association of simple renal cysts to aneurysm sac shrinkage in true thoracic aortic aneurysms after thoracic endovascular aortic repair

BACKGROUND

An increased prevalence of thoracic aortic aneurysms (TAA) has been demonstrated in patients with simple renal cysts (SRC); patients with SRC have a less elastic aortic wall than those without SRC. The purpose of this study was to evaluate aneurysm sac shrinkage after thoracic endovascular aortic repair (TEVAR) for true TAA in patients with and without SRC.

METHODS

One hundred three patients with true aneurysms of the thoracic aorta who underwent TEVAR at our university hospital from November 2013 to December 2021 were included in this study. Aneurysm sac size was compared between that on baseline preoperative computed tomography and that on postoperative computed tomography scans at 1 year. A change in aneurysm sac size ≥5 mm was considered to be significant, whether due to expansion or shrinkage.

RESULTS

The patients were divided into two groups: those with SRC (46 patients [45%]) and those without SRC (57 patients [55%]). At 1 year, there was a significant difference in the proportion of aneurysm sac shrinkage between patients with SRC and those without SRC (23.9% vs 59.6%; P < .001). Patients with SRC showed significantly less aneurysm sac shrinkage than those without SRC (-1.8 ± 5.6 mm vs -5.1 ± 6.6 mm; P = .009). Univariable and multivariable analyses showed that the initial sac diameter (odds ratio, 1.08; 95% confidence interval, 1.03-1.14; P = .002) and the presence of SRC (odds ratio, 0.15; 95% confidence interval, 0.06-0.40; P < .001) were positively and negatively associated with aneurysm sac shrinkage after TEVAR, respectively.

CONCLUSIONS

The presence of a SRC was independently associated with failure of aneurysm sac shrinkage after TEVAR for true TAA. This suggests that the presence of a SRC may be a predictor for the failure of aneurysm sac shrinkage after TEVAR.

Endothelial mechanisms for inactivation of inflammation-induced hyperpermeability

BACKGROUND

Microvascular hyperpermeability is a hallmark of inflammation. Many negative effects of hyperpermeability are due to its persistence beyond what is required for preserving organ function. Therefore, we propose that targeted therapeutic approaches focusing on mechanisms that terminate hyperpermeability would avoid the negative effects of prolonged hyperpermeability while retaining its short-term beneficial effects.

METHODS

We tested the hypothesis that inflammatory agonist signaling leads to hyperpermeability and initiates a delayed cascade of cAMP-dependent pathways that causes inactivation of hyperpermeability. We applied platelet-activating factor (PAF) and vascular endothelial growth factor (VEGF) to induce hyperpermeability. We used an Epac1 agonist to selectively stimulate exchange protein activated by cAMP (Epac1) and promote inactivation of hyperpermeability.

RESULTS

Stimulation of Epac1 inactivated agonist-induced hyperpermeability in the mouse cremaster muscle and in human microvascular endothelial cells (HMVEC). PAF induced nitric oxide (NO) production and hyperpermeability within one minute, and NO-dependent increased cAMP concentration in about 15-20 minutes in HMVEC. PAF triggered phosphorylation of vasodilator-stimulated phosphoprotein (VASP) in a NO-dependent manner. Epac1 stimulation promoted cytosol-to-membrane eNOS translocation in HMVEC and in myocardial microvascular endothelial (MyEnd) cells from wild-type mice, but not in MyEnd cells from VASP knockout mice.

CONCLUSIONS

We demonstrate that PAF and VEGF cause hyperpermeability and stimulate the cAMP/Epac1 pathway to inactivate agonist-induced endothelial/microvascular hyperpermeability. Inactivation involves VASP-assisted translocation of eNOS from the cytosol to the endothelial cell membrane. We demonstrate that hyperpermeability is a self-limiting process, whose timed inactivation is an intrinsic property of the microvascular endothelium that maintains vascular homeostasis in response to inflammation.

Type IIIb endoleak due to stent suture line fabric breakage in the Endurant stent graft: a case report

Background

Early type IIIb endoleak is a very rare complication of endovascular aneurysm repair (EVAR).

Case presentation

An 87-year-old man was diagnosed with infrarenal abdominal aortic aneurysm. The patient underwent EVAR using the Endurant stent graft. Postoperative color duplex ultrasound revealed a regular row of pulsatile blood flow from the main body and left leg. The blood flow appeared to be bleeding from the stent suture lines because of its regularity. Type IIIb endoleak was suspected due to stent suture line fabric breakage but was not treated surgically or endovascularly because of the patient’s poor general health status. Six months later, contrast-enhanced CT demonstrated a deformation and enlargement of the aneurysm sac as well as an oozing of the contrast medium on the main body and left limb. Thereafter, he died of a subdural hematoma due to a fall. Autopsy showed no visible abnormal erosion or holes on the graft fabric, suggesting that suture line fabric breakage may have existed during the manufacturing process.

Conclusions

Although rare, type IIIb endoleaks can occur even in the perioperative period after EVAR. Early type IIIb endoleaks may not resolve spontaneously and should be treated promptly, if possible.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40792-022-01415-8.

Association of neutrophils, lymphocytes, and neutrophil-lymphocyte ratio to overall mortality after endovascular abdominal aortic aneurysm repair

BACKGROUND

The purpose of this study was to determine the predictive ability of neutrophilia, lymphocytopenia, and neutrophil-lymphocyte ratio (NLR) for overall mortality after EVAR for AAA.

METHODS

Data on patients with AAA treated by EVAR between March 2012 and December 2016 were obtained from a prospectively maintained EVAR database at Tokyo Medical University Hospital. The NLR was calculated by dividing the absolute neutrophil count by the absolute lymphocyte count. A cut-off value of total WBC count, neutrophil count, lymphocyte count, and NLR was determined according to a receiver operating characteristic (ROC) curve. Univariate and multivariate analyses were performed using the Cox proportional hazard analyses to account for the time at risk.

RESULTS

178 patients were included in this study after selection based on the exclusion criteria. The subjects consisted of 150 men and 28 women with a mean age of 77.5 years (range, 51-89 years). A ROC curve analysis determined the optimal cut-off values of preoperative total WBC, neutrophils, lymphocytes, and NLR for predicting overall mortality with 7,050 /μL, 4,012 /μL, 1,312 /μL, and 3.19, respectively. On univariate analysis and multivariate analyses, octogenarian, obesity, COPD, active cancer, and lymphocytopenia or NLR were detected as independent predictors for overall mortality.

CONCLUSIONS

Specific leukocyte populations, such as lymphocyte count and NLR, are useful biomarkers to predict overall mortality in patients undergoing EVAR for AAA, suggesting that WBC count and its subsets, which are easy to perform a test, may be used to stratify patients at risk for poor prognosis following EVAR.

Association of High-Sensitivity C-Reactive Protein With Aneurysm Sac Shrinkage in Patients Undergoing Endovascular Abdominal Aneurysm Repair

PURPOSE

The factors associated with aneurysm sac shrinkage after endovascular aneurysm repair (EVAR) are not well established. As inflammation is implicated in aneurysm pathophysiology, we hypothesized that high-sensitivity C-reactive protein (hsCRP) was associated with aneurysm sac shrinkage after EVAR and compared the preoperative level of hsCRP between patients with and without postoperative aneurysm sac shrinkage after EVAR.

METHODS

From November 2013 to April 2019, 143 patients undergoing EVAR using Gore C3 Excluder (W. L. Gore & Associates, Inc, Flagstaff, Arizona) at our university hospital were included in this study. Aneurysm sac size was compared between that on baseline preoperative computed tomography (CT) and that on postoperative CT scans. A change in aneurysm sac size ≥5 mm was considered to be significant, whether due to enlargement or shrinkage.

RESULTS

Aneurysm sac size showed a significant decrease from 50.6 ± 9.8 mm to 47.1 ± 10.3 mm at 1 year. At 1 year postoperatively, aneurysm sac shrinkage (≥5 mm) was observed in 48 patients (34%), a stable aneurysm sac was noted in 93 patients (65%), and aneurysm sac enlargement was noted in 2 patients (1.4%). The mean preoperative hsCRP was 0.33 ± 0.54 mg/dL. Univariable analysis showed that preoperative hsCRP (p=0.029) and the presence of a renal cyst (p=0.002) were associated with aneurysm sac shrinkage. Multivariable analysis showed that preoperative hsCRP [>0.19mg/dL] (odds ratio [OR] = 0.22; 95% confidence interval [CI] = 0.05-0.96; p=0.042), and the presence of a renal cyst (OR = 0.31; 95% CI = 0.15-0.67; p=0.002) were independent risk factors for aneurysm sac shrinkage after EVAR.

CONCLUSIONS

The level of preoperative hsCRP was independently associated with aneurysm sac shrinkage after EVAR in patients with abdominal aortic aneurysms. These data suggest that the high level of hsCRP can be a negative predictor for aneurysm sac shrinkage after EVAR.

Artificial intelligence to diagnosis distal radius fracture using biplane plain X-rays

Background

Although the automatic diagnosis of fractures using artificial intelligence (AI) has recently been reported to be more accurate than those by orthopedics specialists, big data with at least 1000 images or more are required for deep learning of the convolutional neural network (CNN) to improve diagnostic accuracy. The aim of this study was to develop an AI system capable of diagnosing distal radius fractures with high accuracy even when learning with relatively small data by learning to use bi-planar X-rays images.

Methods

VGG16, a learned image recognition model, was used as the CNN. It was modified into a network with two output layers to identify the fractures in plain X-ray images. We augmented 369 plain X-ray anteroposterior images and 360 lateral images of distal radius fractures, as well as 129 anteroposterior images and 125 lateral images of normal wrists to conduct training and diagnostic tests. Similarly, diagnostic tests for fractures of the styloid process of the ulna were conducted using 189 plain X-ray anteroposterior images of fractures and 302 images of the normal styloid process. The distal radius fracture is determined by entering an anteroposterior image of the wrist for testing into the trained AI. If it identifies a fracture, it is diagnosed as the same. However, if the anteroposterior image is determined as normal, the lateral image of the same patient is entered. If a fracture is identified, the final diagnosis is fracture; if the lateral image is identified as normal, the final diagnosis is normal.

Results

The diagnostic accuracy of distal radius fractures and fractures of the styloid process of the ulna were 98.0 ± 1.6% and 91.1 ± 2.5%, respectively. The areas under the receiver operating characteristic curve were 0.991 {n = 540; 95% confidence interval (CI), 0.984–0.999} and 0.956 (n = 450; 95% CI 0.938–0.973).

Conclusions

Our method resulted in a good diagnostic rate, even when using a relatively small amount of data.

Spinal Cord Ischemia in the Setting of Acute Type B Aortic Dissection: Successful Rescue with Thoracic Endovascular Aortic Repair

We report 2 cases of successful thoracic endovascular aortic repair (TEVAR) for acute type B aortic dissection (ABAD) complicated with spinal cord ischemia (SCI). Case 1. A 70-year-old gentleman found with an uncomplicated ABAD with false lumen occluded, developed SCI shortly after admission during the initial medical management. Cerebrospinal fluid drainage (CSFD) was initiated followed by emergent TEVAR. SCI improved, and the patient was discharged. Case 2. A 52-year-old gentleman developed uncomplicated ABAD with patent false lumen. 5 hours after admission, he developed SCI during the initial medical management. Emergent TEVAR was performed followed by CSFD, and the SCI improved before discharge. These cases prompted us to address prompt TEVAR for primary entry closure and true lumen dilatation with postoperative hypertensive management to relieve the dynamic obstruction of the segmental arteries responsible for the compromised spinal cord circulation in complicated ABAD.

Surgical treatment for secondary aortoesophageal fistula

Background

Aortoesophageal fistula (AEF) is a relatively rare condition that is often life-threatening. Secondary AEF is a complication of previous surgery, which can be more critical and challenging than primary AEF. The number of secondary AEF is increasing due to increase in the number of thoracic endovascular aortic repair (TEVAR). Although TEVAR has become a successful alternative surgical strategy for thoracic aortic aneurysms, secondary AEF after TEVAR might be critical than other secondary AEF because of severe adhesion between the esophagus and residual thoracic aortic wall.

Methods

This study analyzed six patients with secondary AEF who were treated at Tokyo Medical University Hospital between 2011 and 2016. These participants included four patients who had undergone TEVAR and two who had undergone total arch replacement.

Results

Although they were subsequently hospitalized for a long period, open surgical repair was completed in two patients who had undergone total arch replacement. TEVAR alone was performed in two patients who had undergone TEVAR and they were discharged without major complications shortly. Combined repair of TEVAR as a bridge to open surgery was planned for two patients who had undergone TEVAR. However, reconstruction of the aorta and esophagus could not be completed in these patients due to severe adhesions, and they died during hospitalization.

Conclusions

Definitive open repair was successfully performed in patients with secondary AEF after total arch replacement. However, in the patients with secondary AEF after TEVAR, severe adhesion between the aorta and esophagus led to difficulty in performing a successful definitive open repair. The strategy for secondary AEF should, therefore, be decided considering the etiology of secondary AEF. In secondary AEF after TEVAR, definitive open repair is difficult to complete because of catastrophic complication, and palliative treatment using TEVAR without reconstruction of aorta and esophagus can be an alternative.

Successful Treatment of Bronchial Artery Aneurysms Associated With Racemose Hemangioma by Combined Therapy of Transcatheter Bronchial Artery Embolization and Thoracic Endovascular Aortic Repair

A 70-year-old man was referred to our hospital for an abnormal chest shadow. Enhanced computed tomography (CT) revealed 2-humped bronchial artery aneurysms (BAAs) associated with racemose hemangioma. The combined therapy of transcatheter bronchial artery embolization and thoracic endovascular aortic repair was performed. Postoperative CT confirmed the complete exclusion of the aneurysms with no evidence of an endoleak. Our result suggests that this combined therapy is a safe and effective treatment for BAA.

Type IIIb Endoleak After Endovascular Aneurysm Repair Using the Zenith Stent Graft

We present 3 cases of type IIIb endoleak after endovascular aneurysm repair (EVAR) using the Zenith stent graft system. Type III endoleak, like type I endoleak, is a high-pressure, high-risk leak that increases sac pressure up to or even above arterial pressure, and is associated with an increased frequency of open conversions or risk of aneurysm rupture. Type IIIb endoleak is rare but there is much concern that the incidence of type IIIb endoleak is likely to increase hereafter; the mechanism of type IIIb endoleak is deterioration of graft fabric in conjunction with stent sutures. Type IIIb endoleak is difficult to diagnose before rupture. The possibility of type IIIb endoleak should be highly suspected when the continued growth of an excluded aneurysm sac without direct radiologic evidence is observed during follow-up. Type IIIb endoleak can be repaired by relining of the stent graft with additional stent grafts.

Impact of preservation of the latissimus dorsi muscle through a left anteroaxillary thoracotomy on spinal cord protection in descending thoracic and thoraco-abdominal aortic operations†

OBJECTIVES

The presence of collateral network circulation to the spinal cord, which is reflected in the repair of a descending thoracic aortic aneurysm (dAo) and a thoraco-abdominal aortic aneurysm (TAAo), has been demonstrated in clinical and animal experimental data. The latissimus dorsi muscle (LDM) including the thoracodorsal artery might be one of the major sources of this collateral network. The objective of this study was to evaluate the impact on spinal cord safety of a left anteroaxillary thoracotomy with minimal muscle division including preservation of the LDM in surgery for dAo and TAAo.

METHODS

Sixty-nine patients [64 (23-85) years old; 56 men] who underwent surgical repair for dAo and TAAo were divided into 2 groups: 29 [65 (23-84) years old] with an anteroaxillary thoracotomy with LDM preservation (PL group) and 40 [61 (28-85) years old] with a lateral thoracotomy without LDM preservation (NL group).

RESULTS

Aortic repairs were performed at the dAo in 30 patients including 14 in the PL group vs 16 in the NL group and at the TAAo in 39 patients including 15 in the PL group vs 24 in the NL group. There were 2 (2.9%) 30-day deaths; 2 (7.9%) in the PL group vs none in the NL group (P = 0.173). No strokes occurred. In patients with a femoro-femoral partial cardiopulmonary bypass with mild hypothermia, the incidence of loss of signal of motor-evoked potentials (>50%) was significantly lower in the PL group; 5.6% vs 31.8% (P = 0.039). The frequency of signal reduction of the remaining motor-evoked potential after surgery was also significantly lower in the PL group: 3.7% vs 25% (P = 0.040). Subsequently, the rate of spinal cord complications were lower in the PL group: 3.4% vs 12.5% (P = 0.188).

CONCLUSIONS

The left anteroaxillary thoracotomy with minimal incision of the muscles including the LDM might have potential advantages for spinal cord protection via preserved intramuscular collateral circulations to the spinal cord in dAo/TAAo open repairs.

Impact of switching oral bisphosphonates to denosumab or daily teriparatide on the progression of radiographic joint destruction in patients with biologic-naïve rheumatoid arthritis

In biologic-naïve female RA patients, switching oral BPs to DMAb significantly reduced radiographic joint destruction compared to continuing oral BPs or switching to TPTD at 12 months, which were significantly associated with a decrease of a bone resorption marker at 6 months.

INTRODUCTION

The aim of this study was to clarify the effects of switching oral bisphosphonates (BPs) to denosumab (DMAb) or daily teriparatide (TPTD) on the progression of radiographic joint destruction in patients with biologic-naïve rheumatoid arthritis (RA).

METHODS

A retrospective, case-controlled study involving 90 female RA patients (mean age 68.2 years, 96.7% postmenopausal, disease activity score assessing 28 joints with CRP (DAS28-CRP) 2.4, methotrexate treatment 81.1%, prednisolone treatment 68.9%, and prior BP treatment 44.8 months), who were allocated depending on each patient's and physician's wishes, to (1) the BP-continue group (n = 30), (2) the switch-to-DMAb group (n = 30), or (3) the switch-to-TPTD group (n = 30), was conducted. Patients were retrospectively selected to minimize the difference of possible clinical backgrounds that may affect the joint destruction of RA. The primary endpoint was to clarify the change of the modified total Sharp score (mTSS) from baseline to 12 months.

RESULTS

After 12 months, the mean changes of the modified Sharp erosion score were significantly lower in the switch-to-DMAb group (0.2 ± 0.1; mean ± standard error) than in the switch-to-TPTD group (1.3 ± 0.5; P < 0.05), and mTSS was significantly lower in the switch-to-DMAb group (0.3 ± 0.2) than in the BP-continue group (1.0 ± 0.3; P < 0.05) and the switch-to-TPTD group (1.7 ± 0.6; P < 0.05). The logistic regression analysis showed that mTSS changes were significantly associated with the percent changes of TRACP-5b at 6 months (β = 0.30, 95% CI = 0.002-0.016; P < 0.01).

CONCLUSIONS

Changes of systemic bone turnover induced by switching BPs to DMAb or TPTD may affect not only systemic bone mass, but also local joint destruction, and its clinical relevance should be considered comprehensively.

Assessment of the effects of switching oral bisphosphonates to denosumab or daily teriparatide in patients with rheumatoid arthritis

The aim of this observational, non-randomized study was to clarify the unknown effects of switching oral bisphosphonates (BPs) to denosumab (DMAb) or daily teriparatide (TPTD) in patients with rheumatoid arthritis (RA). The characteristics of the 194 female patients included in the study were 183 postmenopausal, age 65.9 years, lumbar spine (LS) T score -1.8, femoral neck (FN) T score -2.3, dose and rate of taking oral prednisolone (3.6 mg/day) 75.8%, and prior BP treatment duration 40.0 months. The patients were allocated to (1) the BP-continue group (n = 80), (2) the switch-to-DMAb group (n = 74), or (3) the switch-to-TPTD group (n = 40). After 18 months, the increase in bone mineral density (BMD) was significantly greater in the switch-to-DMAb group than in the BP-continue group (LS 5.2 vs 2.3%, P < 0.01; FN 3.8 vs 0.0%, P < 0.01) and in the switch-to-TPTD group than in the BP-continue group (LS 9.0 vs 2.3%, P < 0.001; FN 4.9 vs 0.0%, P < 0.01). Moreover, the switch-to-TPTD group showed a higher LS BMD (P < 0.05) and trabecular bone score (TBS) (2.1 vs -0.7%; P < 0.05) increase than the switch-to-DMAb group. Clinical fracture incidence during this period was 8.8% in the BP-continue group, 4.1% in the switch-to-DMAb group, and 2.5% in the switch-to-TPTD group. Both the switch-to-DMAb group and the switch-to-TPTD group showed significant increases in LS and FN BMD, and the switch-to-TPTD group showed a higher increase in TBS compared to the BP-continue group at 18 months. Switching BPs to DMAb or TPTD in female RA may provide some useful osteoporosis treatment options.

Administration of Oxygen Ultra-Fine Bubbles Improves Nerve Dysfunction in a Rat Sciatic Nerve Crush Injury Model

Ultra-fine bubbles (<200 nm in diameter) have several unique properties and have been tested in various medical fields. The purpose of this study was to investigate the effects of oxygen ultra-fine bubbles (OUBs) on a sciatic nerve crush injury (SNC) model rats. Rats were intraperitoneally injected with 1.5 mL saline, OUBs diluted in saline, or nitrogen ultra-fine bubbles (NUBs) diluted in saline three times per week for 4 weeks in four groups: (1) control, (sham operation + saline); (2) SNC, (crush + saline); (3) SNC+OUB, (crush + OUB-saline); (4) SNC+NUB, (crush + NUB-saline). The effects of the OUBs on dorsal root ganglion (DRG) neurons and Schwann cells (SCs) were examined by serial dilution of OUB medium in vitro. Sciatic functional index, paw withdrawal thresholds, nerve conduction velocity, and myelinated axons were significantly decreased in the SNC group compared to the control group; these parameters were significantly improved in the SNC+OUB group, although NUB treatment did not affect these parameters. In vitro, OUBs significantly promoted neurite outgrowth in DRG neurons by activating AKT signaling and SC proliferation by activating ERK1/2 and JNK/c-JUN signaling. OUBs may improve nerve dysfunction in SNC rats by promoting neurite outgrowth in DRG neurons and SC proliferation.

Neurotropin® Accelerates the Differentiation of Schwann Cells and Remyelination in a Rat Lysophosphatidylcholine-Induced Demyelination Model

Neurotropin^® (NTP), a non-protein extract of inflamed rabbit skin inoculated with vaccinia virus, is clinically used for the treatment of neuropathic pain in Japan and China, although its effect on peripheral nerve regeneration remains to be elucidated. The purpose of this study was to investigate the effects of NTP on Schwann cells (SCs) in vitro and in vivo, which play an important role in peripheral nerve regeneration. In SCs, NTP upregulated protein kinase B (AKT) activity and Krox20 and downregulated extracellular signal-regulated kinase1/2 activity under both growth and differentiation conditions, enhanced the expression of myelin basic protein and protein zero under the differentiation condition. In a co-culture of dorsal root ganglion neurons and SCs, NTP accelerated myelination of SCs. To further investigate the influence of NTP on SCs in vivo, lysophosphatidylcholine was injected into the rat sciatic nerve, leading to the focal demyelination. After demyelination, NTP was administered systemically with an osmotic pump for one week. NTP improved the ratio of myelinated axons and motor, sensory, and electrophysiological function. These findings reveal novel effects of NTP on SCs differentiation in vitro and in vivo, and indicate NTP as a promising treatment option for peripheral nerve injuries and demyelinating diseases.

Impact of dexamethasone concentration on cartilage tissue formation from human synovial derived stem cells in vitro

Human synovial mesenchymal stem cells (hSMSCs) are a promising cell source for cartilage regeneration because of their superior chondrogenic potential in vitro. This study aimed to further optimize the conditions for inducing chondrogenesis of hSMSCs, focusing on the dose of dexamethasone in combination with transforming growth factor-β3 (TGFβ3) and/or bone morphogenetic protein-2 (BMP2). When hSMSCs-derived aggregates were cultured with TGFβ3, dexamethasone up to 10 nM promoted chondrogenesis, but attenuated it with heterogeneous tissue formation when used at concentrations over than 100 nM. On the other hands, BMP2-induced chondrogenesis was remarkably disturbed in the presence of more than 10 nM dexamethasone along with unexpected adipogenic differentiation. In the presence of both TGFβ3 and BMP2, dexamethasone dose dependently promoted cartilaginous tissue formation as judged by tissue volume, proteoglycan content, and type 2 collagen expression, whereas few adipocytes were detected in the formed tissue when cultures were supplemented with over 100 nM dexamethasone. Even in chondrogenic conditions, dexamethasone thus affected hSMSCs differentiation not only toward chondrocytes, but also towards adipocytes dependent on the dose and combined growth factor. These findings have important implications regarding the use of glucocorticoids in in vitro tissue engineering for cartilage regeneration using hSMSCs.

Comparison of the effects of denosumab between a native vitamin D combination and an active vitamin D combination in patients with postmenopausal osteoporosis

The aim of this 12-month, retrospective study was to compare the effects of denosumab (DMAb; 60 mg subcutaneously every 6 months) plus native vitamin D (VD) (cholecalciferol) combination therapy with DMAb plus active VD analog (alfacalcidol) combination therapy in patients with postmenopausal osteoporosis. Patients [N = 127; mean age 75.6 years (range 58-93 years); 28 treatment-naïve patients, 59 patients treated with oral bisphosphonate therapy, 40 patients treated with teriparatide daily] were allocated to either (1) the DMAb plus native VD group (n = 60; cholecalciferol, 10 μg, plus calcium, 610 mg/day; 13 treatment-naïve patients, 28 patients treated with oral bisphosphonate therapy, and 19 patients treated with teriparatide daily) or (2) the DMAb plus active VD group [n = 67; alfacalcidol, 0.8 ± 0.0 μg, plus calcium, 99.2 ± 8.5 mg/day; 15 treatment-naïve patients, 31 patients treated with oral bisphosphonate therapy, and 21 patients treated with teriparatide daily) on the basis of each physician's decision. Changes in bone mineral density (BMD), serum bone turnover marker levels, and fracture incidence were monitored every 6 months. There were no significant differences in baseline age, BMD, bone turnover marker levels, and prior treatments between the two groups. After 12 months, compared with the DMAb plus native VD group, the DMAb plus active VD group showed similar increases in the BMD of the lumbar spine (6.4% vs 6.5%) and total hip (3.3% vs 3.4%), but significantly greater increases in the BMD of the femoral neck (1.0% vs 4.9%, P < 0.001) and the distal part of the forearm (third of radius) (-0.8% vs 3.9%, P < 0.01). These tendencies were similar regardless of the differences in the prior treatments. The rates of decrease of bone turnover marker levels were similar for tartrate-resistant acid phosphatase isoform 5b (-49.0% vs -49.0%), procollagen type I N-terminal propeptide (-45.9% vs -49.3%), and undercarboxylated osteocalcin (-56.0  vs -66.5%), whereas serum intact parathyroid hormone levels were significantly lower in the DMAb plus active VD group (47.6 pg/mL vs 30.4 pg/mL, P < 0.001). The rate of hypocalcemia was 1.7% in the DMAb plus native VD group and 1.5% in the DMAb plus active VD group, and the rate of clinical fracture incidence was 8.3% in the DMAb plus native VD group and 4.5% in the DMAb plus active VD group, with no significant difference between the groups. DMAb with active VD combination therapy may be a more effective treatment option than DMAb with native VD combination therapy in terms of increasing BMD of the femoral neck and distal part of the forearm and also maintaining serum intact parathyroid hormone at lower levels.

Comparison of the effects of forefoot joint-preserving arthroplasty and resection-replacement arthroplasty on walking plantar pressure distribution and patient-based outcomes in patients with rheumatoid arthritis

Purpose

The purpose of this retrospective study is to clarify the difference in plantar pressure distribution during walking and related patient-based outcomes between forefoot joint-preserving arthroplasty and resection-replacement arthroplasty in patients with rheumatoid arthritis (RA).

Methods

Four groups of patients were recruited. Group1 included 22 feet of 11 healthy controls (age 48.6 years), Group2 included 36 feet of 28 RA patients with deformed non-operated feet (age 64.8 years, Disease activity score assessing 28 joints with CRP [DAS28-CRP] 2.3), Group3 included 27 feet of 20 RA patients with metatarsal head resection-replacement arthroplasty (age 60.7 years, post-operative duration 5.6 years, DAS28-CRP 2.4), and Group4 included 34 feet of 29 RA patients with metatarsophalangeal (MTP) joint-preserving arthroplasty (age 64.6 years, post-operative duration 3.2 years, DAS28-CRP 2.3). Patients were cross-sectionally examined by F-SCAN II to evaluate walking plantar pressure, and the self-administered foot evaluation questionnaire (SAFE-Q). Twenty joint-preserving arthroplasty feet were longitudinally examined at both pre- and post-operation.

Results

In the 1^st MTP joint, Group4 showed higher pressure distribution (13.7%) than Group2 (8.0%) and Group3 (6.7%) (P<0.001). In the 2^nd-3^rd MTP joint, Group4 showed lower pressure distribution (9.0%) than Group2 (14.5%) (P<0.001) and Group3 (11.5%) (P<0.05). On longitudinal analysis, Group4 showed increased 1^st MTP joint pressure (8.5% vs. 14.7%; P<0.001) and decreased 2^nd-3^rd MTP joint pressure (15.2% vs. 10.7%; P<0.01) distribution. In the SAFE-Q subscale scores, Group4 showed higher scores than Group3 in pain and pain-related scores (84.1 vs. 71.7; P<0.01) and in shoe-related scores (62.5 vs. 43.1; P<0.01).

Conclusions

Joint-preserving arthroplasty resulted in higher 1^st MTP joint and lower 2^nd-3^rd MTP joint pressures than resection-replacement arthroplasty, which were associated with better patient-based outcomes.

Oxygen ultra-fine bubbles water administration prevents bone loss of glucocorticoid-induced osteoporosis in mice by suppressing osteoclast differentiation

Oxygen ultra-fine bubbles (OUB) saline injection prevents bone loss of glucocorti\coid-induced osteoporosis in mice, and OUB inhibit osteoclastogenesis via RANK-TRAF6-c-Fos-NFATc1 signaling and RANK-p38 MAPK signaling in vitro.

INTRODUCTION

Ultra-fine bubbles (<200 nm in diameter) have several unique properties, and they are tested in various medical fields. The purpose of this study was to investigate the effects of oxygen ultra-fine bubbles (OUB) on glucocorticoid-induced osteoporosis (GIO) model mice.

METHODS

Prednisolone (PSL, 5 mg) was subcutaneously inserted in 6-month-old male C57BL/6J mice, and 200 μl of saline, OUB-diluted saline, or nitrogen ultra-fine bubbles (NUB)-diluted saline was intraperitoneally injected three times per week for 8 weeks the day after operations. Mice were divided into four groups; (1) control, sham-operation + saline; (2) GIO, PSL + saline; (3) GIO + OUB, PSL + OUB saline; (4) GIO + NUB, PSL + NUB saline. The effects of OUB on osteoblasts and osteoclasts were examined by serially diluted OUB medium in vitro.

RESULTS

Bone mass was significantly decreased in GIO [bone volume/total volume (%): control vs. GIO 12.6 vs. 7.9; p < 0.01] while significantly preserved in GIO + OUB (GIO vs. GIO + OUB 7.9 vs. 12.9; p < 0.05). In addition, tartrate-resistant acid phosphatase (TRAP)-positive cells in the distal femur [mean osteoclasts number/bone surface (mm^-1)] was significantly increased in GIO (control vs. GIO 6.8 vs. 11.6; p < 0.01) while suppressed in GIO + OUB (GIO vs. GIO + OUB 11.6 vs. 7.5; p < 0.01). NUB did not affect these parameters. In vitro experiments revealed that OUB significantly inhibited osteoclastogenesis by inhibiting RANK-TRAF6-c-Fos-NFATc1 signaling, RANK-p38 MAPK signaling, and TRAP/Cathepsin K/DC-STAMP mRNA expression in a concentration-dependent manner. OUB did not affect osteoblastogenesis in vitro.

CONCLUSIONS

OUB prevent bone loss in GIO mice by inhibiting osteoclastogenesis.

Two-year outcome of the Endurant stent graft for endovascular abdominal aortic repair in Japanese patients: incidence of endoleak and aneurysm sac shrinkage

BACKGROUND

We aimed to review 50 consecutive Japanese abdominal aortic aneurysm (AAA) and common iliac aneurysm (CIAA) patients to evaluate the 2-year outcomes, particularly endoleak and aneurysm sac shrinkage, of the Endurant stent graft.

METHODS

Between June 2012 and January 2014, 50 consecutive Japanese AAA and CIAA patients underwent EVAR with the Endurant stent graft. Clinical outcomes of overall survival, aneurysm-related survival, and secondary intervention-free survival were analyzed; endoleaks and aneurysm sac changes were also evaluated.

RESULTS

The 2-year Kaplan-Meier estimates for overall survival, aneurysm-related survival, and secondary intervention-free survival were 85.4%, 97.7% with one device-related death, and 84.9%, respectively. Type I, II, and III endoleaks at any one point (all comers) after EVAR were detected in 2 (4%), 6 (12%), and 3 (6%) patients, respectively, whereas type IV endoleak was detected in 19 (38%) patients. The percentage of patients with significant sac shrinkage was only 19% (7/37) of the patients at 2 years. Multivariate analysis detected hypertension as a significant factor affecting aneurysm sac shrinkage (OR: 0.09, 95% CI: 0.001-0.99, P=0.049).

CONCLUSIONS

The Endurant stent graft has demonstrated consistently successful clinical performance in Japanese patients for 2 years. However, the incidence of type IV endoleak was high, while the percentage of significant sac shrinkage was low. Careful and longer follow-up is required to determine the durability of the Endurant stent graft in Japanese patients.

Venous hemodynamic improvement after endovenous radiofrequency ablation of saphenous varicose veins

BACKGROUND

Endovenous radiofrequency ablation (RFA) has been a viable treatment option for patients with saphenous varicose veins. The purpose of our study was to assess venous hemodynamic change before and after RFA by using air plethysmography (APG).

METHODS

We prospectively analyzed the data of consecutive 91 patients with 124 limbs who underwent RFA for primary varicose veins. Overall venous hemodynamics of the limb was assessed using APG. The Venous Filling Index (VFI) was determined as a measure of reflux (normal range, <2 mL). Duplex scanning were performed to evaluate saphenous vein occlusion, deep venous thrombus and endovenous heat-induced thrombosis (EHIT).

RESULTS

The VFI were significantly reduced from 4.1±3.1 preoperatively to 1.4±1.0, 1.3±0.8 and 1.4±1.2 at 1 week, 1 month and 4 month postoperatively, respectively. The percentage of the VFI >2 mL/s was 77% preoperatively, while it significantly decreased to 17%, 16%, and 18% at 1 week, 1 month, and 4 month postoperatively, respectively. Duplex scanning showed 100% of saphenous vein occlusion and no significant EHIT II-IV.

CONCLUSIONS

Correction or significant improvement of venous reflux was achieved by RFA. Together with duplex scanning findings, RFA is a safe and hemodynamically effective treatment for varicose veins.

A Rare Case of Dacron Graft Rupture due to Friction against a Rib

A 54-year-old man underwent aortic repair for the infected thoracoabdominal aneurysm with a woven Dacron graft (Vascutek, Renfrewshire, Scotland) treated with gentian violet. Four months later, he complained of sudden back pain, resulting in preshock status. Computed tomographic scans showed massive hematoma around the Dacron graft, suggesting graft rupture. Initially, emergency thoracic endovascular aortic repair was performed, which was subsequently followed by open repair. The Dacron graft had a small hole, which was completely compatible with the site contacting with the rib. The graft rupture was considered due to its friction against the rib. We report on a rare event of mechanical Dacron graft rupture after the thoracoabdominal aortic replacement.

Successful treatment using percutaneous drainage for aortic arch prosthetic graft infection

Prosthetic graft infection in the ascending aorta or aortic arch is a life-threatening complication. Redo graft replacement is also associated with high mortality and morbidity rates. Conservative treatments without graft removal recently developed as alternatives to conventional surgical approach have been reported with successful outcomes. We report a case of successful treatment of prosthetic graft infection in the aortic arch, for which percutaneous catheter drainage was initially performed prior to open surgery, followed by graft coverage with an omental flap. <Learning objective: Redo graft replacement for the prosthetic graft infection in the ascending aorta or aortic arch is associated with high mortality and morbidity rates. Conservative treatments without graft removal have recently been developed as alternatives to surgical approaches. Less invasive percutaneous drainage and irrigation would be a useful alternative second-line treatment before radical open repairs for the treatment of aortic graft infection.>.

Endovascular stent graft repair for thoracic aortic aneurysms: the history and the present in Japan

Stent-grafts for endovascular repair of thoracic aortic aneurysms have been commercially available for more than ten years in the West, whereas, in Japan, a manufactured stent-graft was not approved for the use until March 2008. Nevertheless, endovascular thoracic intervention began to be performed in Japan in the early 1990s, with homemade devices used in most cases. Many researchers have continued to develop their homemade devices. We have participated in joint design and assessment efforts with a stent-graft manufacturer, focusing primarily on fenestrated stent-grafts used in repairs at the distal arch, a site especially prone to aneurysm. In March 2008, TAG (W.L. Gore & Associates, Inc., Flagstaff, Arizona, USA) was approved as a stent graft for the thoracic area first in Japan, which was major turning point in treatment for thoracic aortic aneurysms. Subsequently, TALENT (Medtronic, Inc., Minneapolis, Minnesota, USA) was approved in May 2009, and TX2 (COOK MEDICAL Inc., Bloomington, Indiana, USA) in March 2011. Valiant as an improved version of TALENT was approved in November 2011, and TX2 Proform as an improved version of TX2 began to be supplied in October 2012. These stent grafts are excellent devices that showed good results in Western countries, and marked effectiveness can be expected by making the most of the characteristics of each device. A clinical trial in Japan on Najuta (tentative name) (Kawasumi Labo., Inc., Tokyo, Japan) as a line-up of fenestrated stent grafts that can be applied to distal arch aneurysms showing a high incidence, and allow maintenance of blood flow to the arch vessel was initiated. This trial was completed, and Najuta has just been approved in January of 2013 in Japan, and further development is expected. In the U.S., great efforts have recently been made to develop and manufacture excellent stent grafts for thoracic aneurysms, and rapid progress has been achieved. In particular, in the area of the aortic arch, in which we often experience aneurysmal change, but there are no commercially available devices which are urgently needed. Companies are competing keenly to develop devices. To our knowledge, more than 4 manufacturers are involved in the development of functionally new stent grafts in this area. The introduction of branched stent grafts may not be faraway.

Difficulty in the management of anticoagulation with argatroban during off-pump coronary artery bypass grafting

Heparin-induced thrombocytopenia (HIT) can often result in devastating thromboembolic outcomes. Argatroban is frequently administered as an alternative anticoagulant to heparin. We present a complicated case of HIT in which off-pump coronary artery bypass grafting was performed using anticoagulation with argatroban. Although the active clotting time was maintained between 220 and 270 s using argatroban, intraoperative thrombotic complications and postoperative prolonged coagulopathy were encountered. <Learning objective: The use of argatroban involves a potential risk of inadequate anticoagulation or life-threatening postoperative bleeding depending on the dose. We recommend that the target ACT during off-pump coronary artery bypass grafting with argatroban should be strictly maintained over 250 s, although an ACT exceeding 300 s may cause prolonged coagulopathy>.

Apicoaortic valved conduit bypass for progressing aortic graft stenosis due to malformation of repeated thoracic endovascular aortic repairs

Since the first report by Cooley and colleagues in 1975 [Cooley DA, Norman JC, Mullins CE, Grace R. Left ventricle to abdominal aorta conduit for relief of aortic stenosis. Cardiovasc Dis 1975;2:376-83], an apicoaortic valved conduit bypass has been usually administrated to selected patients presenting with certain clinical conditions or complications such as aortic stenosis associated with porcelain aorta, unclampable atherosclerotic aorta, resternotomy, or previous coronary bypass surgery. On the other hand, thoracic endovascular aortic repair for various aortic lesions has become a promising and less invasive therapy. We encountered a critical case of a patient suffering from aortic graft stenosis due to malformation of a previous thoracic endovascular aortic repair procedure originally performed for acute type A aortic dissection. Because of a deep sternal wound infection, apicoaortic valved conduit bypass from the left ventricular apex to the abdominal aorta was successfully performed.

A potential risk of myocardial ischemia during thoracoabdominal aortic repair after coronary artery bypass grafting using the right gastroepiploic artery

In-situ right gastroepiploic artery (RGEA) has been used as one of the reliable conduits for coronary artery bypass grafting (CABG). We report a case of thoracoabdominal aortic aneurysm (TAAA) repair in a patient who had previous CABG using the RGEA graft. There is a great potential risk for critical myocardial ischemia when performing open repair for TAAA in those patients.

Growth rates of abdominal aortic aneurysms in Japanese patients observed in one institute

AIM

The aim of this paper was to investigate the growth rate of abdominal aortic aneurysms (AAA) in Japanese patients.

METHODS

We retrospectively studied patients conservatively followed with infrarenal AAA in terms of AAA diameter measured using computed tomography (CT) in our hospital between 1999 and 2009. The AAA surgery criterion in our institute was a diameter ≥ 5.0 cm or a growth rate ≥5 mm/year. We estimated operation-free ratios by initial AAA diameter and changes in AAA growth rates. Patients with an initial AAA diameter < 5.0 cm were divided into 2 groups. Patients with AAA that met the criteria for surgery were classified into the expansion group, and those remaining into the non-expansion group. Their AAA growth rates were compared.

RESULTS

The group consisted of 124 patients (average age, 73.7±8.6 years (range 54-92)) who had at least 2 recorded AAA measurements. The average follow-up period was 3.0±2.2 years (range 0.3-10.2). There were no cases of rupture during follow-up. Twenty-six patients (21.0%) underwent surgery (open replacement [N.=20]; endovascular abdominal aneurysm repair [N.=6]). The growth rate determined from the initially measured diameter was significantly faster in AAAs measuring 5.0-5.4 cm than in AAAs measuring 4.5-4.9 cm (P=0.01). More than 90% of patients with an initial AAA diameter <5.0 cm were observed conservatively for 2 years or more. However, more than half of the patients with an initial AAA diameter ≥4.0 cm needed surgery within 5 years. The growth rates of AAAs for each size during growth were significantly faster when the AAA diameter was 4.5-4.9 cm than when it was 4.0-4.4 cm (P=0.006), and when the AAA diameter was 5.0-5.4 cm than when it was 4.5-4.9 cm (P = 0.009). The expansion and non-expansion groups consisted of 38 (34.2%) and 73 (75.8%) patients, respectively. The AAA growth rate in the expansion group was significantly faster than that in the non-expansion group (3.4±2.2 mm/year vs. 1.4±1.3 mm/year, P=0.0001).

CONCLUSION

It may be considered that the appropriate indication for AAA repair is defined by a diameter of 5.0 cm for Japanese patients. Patients with AAA that is growing continuously by ≥3 mm/year and who have low operative risk may undergo surgery even if their AAA is <5.0 cm.

Functional significance of cytosolic endothelial nitric-oxide synthase (eNOS): regulation of hyperpermeability

Endothelial NOS (eNOS)-derived NO is a key factor in regulating microvascular permeability. We demonstrated previously that eNOS translocation from the plasma membrane to the cytosol is required for hyperpermeability. Herein, we tested the hypothesis that eNOS activation in the cytosol is necessary for agonist-induced hyperpermeability. To study the fundamental properties of endothelial cell monolayer permeability, we generated ECV-304 cells that stably express cDNA constructs targeting eNOS to the cytosol or plasma membrane. eNOS-transfected ECV-304 cells recapitulate the eNOS translocation and permeability properties of postcapillary venular endothelial cells (Sánchez, F. A., Rana, R., Kim, D. D., Iwahashi, T., Zheng, R., Lal, B. K., Gordon, D. M., Meininger, C. J., and Durán, W. N. (2009) Proc. Natl. Acad. Sci. U.S.A. 106, 6849-6853). We used platelet-activating factor (PAF) as a proinflammatory agonist. PAF activated eNOS by increasing phosphorylation of Ser-1177 and inducing dephosphorylation of Thr-495, increasing NO production, and elevating permeability to FITC-dextran 70 in monolayers of cells expressing wild-type and cytosolic eNOS. PAF failed to increase permeability to FITC-dextran 70 in monolayers of cells transfected with eNOS targeted to the plasma membrane. Interestingly, this occurred despite eNOS Ser-1177 phosphorylation and production of comparable amounts of NO. Our results demonstrate that the presence of eNOS in the cytosol is necessary for PAF-induced hyperpermeability. Our data provide new insights into the dynamics of eNOS and eNOS-derived NO in the process of inflammation.

Intraoperative evaluation of blood perfusion by laser-assisted indocyanine green angiography after ex vivo vascular reconstruction of intrahilar renal artery aneurysm

The surgical reconstruction of intrahilar renal artery aneurysms (RAAs) is a difficult surgery because of complex anatomy. We present a case of right intrahilar RAA diagnosed in a 67-year-old man. We performed ex vivo reconstruction using an organ preservation solution to prevent postoperative renal failure. We assessed graft patency and blood perfusion was assessed by laser-assisted indocyanine green angiography using the SPY system after autotransplantation. Postoperative renal insufficiency was not observed. The results demonstrate that ex vivo reconstruction of intrahilar RAAs using an organ preservation solution, and graft patency and blood perfusion evaluation using the SPY system are effective methods for preserving renal function.

Conservative therapy for surgically untreatable extensive arteriovenous malformation from the lower extremity to the pelvis with secondary consumptive coagulopathy

We present a woman with surgically untreatable extended arteriovenous malformations (AVM) and consumptive coagulopathy, which had been controlled by conservative compression and anticoagulation therapies for 17 years. At age 13, she was diagnosed with extended AVM in the entire left leg and pelvis. At age 16, limited surgical resection of the enlarged superficial vein in the left calf was performed for persistent leg pain. One year later, anticoagulation therapy was performed for massive bleeding from hemorrhoids due to AVM and coagulopathy. Despite its intractability, her condition has been favorably controlled with conservative methods, including compression and anticoagulation therapies.

Surgical repair for aortic dissection accompanying a right-sided aortic arch

Aortic anomaly in which a right-sided aortic arch associated with Kommerell's diverticulum and aberrant left subclavian artery is rare. The present report describes a patient with type-B aortic dissection accompanying aortic anomalies consisting of right-sided aortic arch and the left common carotid and left subclavian artery arising from Kommerell's diverticulum. As dissecting aortic aneurysm diameter increased rapidly, Single-stage surgical repair of extensive thoracic aorta was performed through median sternotomy and right posterolateral fifth intercostal thoracotomy, yielding favorable results. Our surgical procedures are discussed.

Alterations in PNA binding of keratinocytes in oral keratosis

Changes in the expression of peanut lectin (PNA) were examined in keratinocytes of oral keratosis showing a mixture of hyperortho- and hyperparakeratinized epithelium. In the hyperorthokeratinized epithelium, which was reacted with anti-filaggrin antibody in both granular and cornified cells, PNA bound to the surface of keratinocytes from the spinous layer to the granular layer. Neither anti-filaggrin nor PNA reactions were detected in keratinocytes of the hyperparakeratinized epithelium. After neuraminidase pretreatment, however, PNA staining appeared in all cells, except cornified cells, of both hyperortho- and hyperparakeratinized epithelia. These findings suggest that PNA-binding epitopes in keratinocytes were modified by sialic acid during the hyperparakeratotic process of oral keratosis.

Clinical comparison of two different types of bifurcated graft for postoperative baPWV and ABI

AIM

A newly-designed bifurcated graft with the distal end larger than the conventional type has been developed. The purpose of this study was to evaluate the early results of graft replacement using this new graft, and to compare whether the new graft is more advantageous than the conventional graft in terms of peripheral blood flow and arterial stiffness.

METHODS

Records of 36 patients who underwent bifurcated graft replacement for infrarenal abdominal aortic aneurysm (AAA), from May 2003 to September 2006 were reviewed after excluding peripheral arterial disease (ABI > 0.9). Subjects were divided into two groups: group C (N.=20), with implantation of the conventional type and group N (N.=16), with implantation of the new type. We investigated changes in brachial-ankle pulse wave velocity (baPWV) and ankle-brachial pressure index (ABI), measurements being performed preoperatively and postoperatively.

RESULTS

baPWV in the postoperative group as a whole was significantly higher than in the preoperative group (P<0.05), while ABI in the postoperative group was lower than in the preoperative group (P<0.05). In group C, baPWV increased (P<0.05) and ABI decreased (P<0.05) after bifurcated graft replacement, whereas in group N, there were no significant differences in changes of baPWV and ABI.

CONCLUSIONS

This study shows that the new graft reduces the development of arterial stiffness postoperatively compared with the conventional type. These results may predict the new type graft decrease in the risk of morbidity and mortality caused by atherosclerotic disease.

Nitroglycerin-induced S-nitrosylation and desensitization of soluble guanylyl cyclase contribute to nitrate tolerance

Nitrates such as nitroglycerin (GTN) and nitric oxide donors such as S-nitrosothiols are clinically vasoactive through stimulation of soluble guanylyl cyclase (sGC), which produces the second messenger cGMP. Development of nitrate tolerance, after exposure to GTN for several hours, is a major drawback to a widely used cardiovascular therapy. We recently showed that exposure to nitric oxide and to S-nitrosothiols causes S-nitrosylation of sGC, which directly desensitizes sGC to stimulation by nitric oxide. We tested the hypothesis that desensitization of sGC by S-nitrosylation is a mechanism of nitrate tolerance. Our results established that vascular tolerance to nitrates can be recapitulated in vivo by S-nitrosylation through exposure to cell membrane-permeable S-nitrosothiols and that sGC is S-nitrosylated and desensitized in the tolerant, treated tissues. We next determined that (1) GTN treatment of primary aortic smooth muscle cells induces S-nitrosylation of sGC and its desensitization as a function of GTN concentration; (2) S-nitrosylation and desensitization are prevented by treatment with N-acetyl-cysteine, a precursor of glutathione, used clinically to prevent development of nitrate tolerance; and (3) S-nitrosylation and desensitization are reversed by cessation of GTN treatment. Finally, we demonstrated that in vivo development of nitrate tolerance and crosstolerance by 3-day chronic GTN treatment correlates with S-nitrosylation and desensitization of sGC in tolerant tissues. These results suggest that in vivo nitrate tolerance is mediated, in part, by desensitization of sGC through GTN-dependent S-nitrosylation.

[Adequate size of elephant trunk in the procedure of total arch replacement for acute aortic dissection]

Total aortic arch replacement using the 'elephant trunk (ET)' procedure has commonly been applied to acute aortic dissection, but enlargement of a residual false lumen of the descending thoracic aorta sometimes occurs. We performed endovascular stent-grafting to close the entry as the second operation and obtained successful outcomes. From April 1997 to January 2004, we performed the modified ET procedure for acute aortic dissection in 29 patients and evaluated postoperative changes of the false lumen. In many cases of the residual false lumen, kinks and wrinkles were observed at the site of the ET grafts in the descending aorta. An adequate length of ET would be about 8 cm long to prevent kinking, and a diameter about 20 mm to prevent wrinkles.