Super-Elderly Case of Acute Lower Limb Ischemia Treated with Indigo Aspiration System in Japan

The Indigo Aspiration System (Penumbra Ltd., Alameda, CA, USA), a catheter-based device intended for the endovascular removal of clots from peripheral arteries and veins, was launched in Japan to treat acute limb ischemia after the cessation of urokinase sales. The initial application of this system in Japan was on a 96-year-old male patient. He was diagnosed with acute lower limb ischemia, which was caused by an embolism from a left common iliac artery aneurysm. The treatment significantly enhanced the perfusion to his left foot. This case report elaborates on the patient's treatment experience and discusses the indications for using the device.

One-Year Clinical Outcomes and Prognostic Factors Following Revascularization in Patients With Acute Limb Ischemia - Results From the RESCUE ALI Study

BACKGROUND

Acute limb ischemia (ALI) is a limb- and life-threatening condition and urgent treatment including revascularization should be offered to patients unless the limb is irreversibly ischemic. The aim of this study was to investigate 1-year clinical outcomes and prognostic factors following revascularization in patients with ALI.Methods and Results: A retrospective, multicenter, nonrandomized study examined 185 consecutive patients with ALI treated by surgical revascularization (SR), endovascular revascularization (ER), or hybrid revascularization (HR) in 6 Japanese medical centers from January 2015 to August 2021. The 1-year amputation-free survival (AFS) rate was estimated to be 69.2% (95% confidence interval [CI], 62.8-76.2%). There were no significant differences among SR, ER, and HR regarding both technical success and perioperative complications. Multivariate analysis revealed that Rutherford category IIb and III ischemia (hazard ratio [HR]: 1.86; 95% CI: 1.06-3.25), supra- to infrapopliteal lesion (HR: 2.06; 95% CI: 1.08-3.95), and technical failure (HR: 2.58; 95% CI: 1.49-4.46) were independent risk factors for 1-year AFS.

CONCLUSIONS

Rutherford category IIb and III ischemia, supra- to infrapopliteal lesions, and technical failures were identified as independent risk factors for 1-year AFS. Furthermore, patients with multiple risk factors had a lower AFS rate.

Venous Screening Activities at the Site of Hokkaido East Iburi Earthquake: Report from the Result of Venous Screening in Preventive Awareness Activities

After previous earthquakes, high prevalence of cardiovascular diseases including venous thromboembolism (VTE) has been reported. We performed venous screening at the site of Hokkaido East Iburi Earthquake which happened at 6th September 2018. VTE screening using ultrasound sonography was performed for total 7 days at Atsuma town, Mukawa town and Abira town (total 9 shelters). Deep vein thrombosis (DVT) was found in 19 of 195 evacuees (9.7%), including 8 fresh thrombus cases (4.1%). On multivariable analysis of evacuees and shelter environment factors, systolic blood pressure, use of cardboard bed and toilet environment were significant predictor of DVT. Introduction and setting-up of cardboard beds were found as an important shelter environment factor. (This is secondary publication from Jpn J Phlebol 2021; 32(1): 5-10.).

A case of lymphoma mimicking infected internal iliac artery aneurysm

BACKGROUND

Malignant lymphoma rarely mimics an infected arterial aneurysm and a ruptured arterial aneurysm because of similar imaging findings, leading to misdiagnosis. The hematomas of ruptured aneurysms are radiologically difficult to distinguish from those of malignant lymphoma in emergency settings. Hence, a definitive diagnosis is crucial to avoid unnecessary surgery.

CASE PRESENTATION

A man in his 80s with hematuria and shock vital had right internal iliac artery aneurysm (IIAA) and perianeurysmal fluid retention, which appeared to be a ruptured or an infected aneurysm. Treatment was initiated for infected IIAA instead of for ruptured IIAA. Systemic inflammatory response syndrome developed, and the infectious sources were assessed. Pacemaker lead and urinary tract infections were identified and treated; however, blood pressure was unstable. The aneurysm was treated with endovascular aortic aneurysm repair following antibiotic therapy; however, fluid retention increased, and inflammatory status and hematuria deteriorated. Open surgical conversion was performed to manage the infected lesions. Although an iliopsoas abscess was detected during surgery and nephrectomy and ureterectomy were performed to control the hematuria, analysis of the removed tissues led to the pathological diagnosis of diffuse large B-cell lymphoma (DLBCL).

CONCLUSIONS

We encountered a case of DLBCL with imaging findings mimicking an infected internal iliac artery aneurysm, and definitive diagnosis was made more than 2 months after the initial examination. Definitively diagnosing malignant lymphoma around an iliac artery aneurysm based merely on symptoms and imaging findings is extremely difficult. Thus, histological examination should be actively performed in atypical infected aneurysms.

Photoluminescence Properties of Single-Walled Carbon Nanotubes Influenced by the Tether Length of Reagents with Two Reactive Sites

The functionalization of single-walled carbon nanotubes (SWNTs) is an effective method for controlling a local band gap, resulting in photoluminescence (PL) in the near-infrared region. Herein, SWNTs were functionalized using a series of bromoalkanes and dibromoalkanes to evaluate the effects of their length on the nanotube PL properties. When bromoalkanes (CnH2n+1Br) or dibromoalkanes (CnH2nBr2) with tether lengths of six or more were utilized for six different semiconducting SWNTs, the obtained SWNT adducts exhibited two new PL peaks, whereas dibromoalkanes with tether lengths of 3-5 (CnH2nBr2: n = 3-5) produced single peaks. Combined with theoretical calculations, the results suggested that the tether length of reagents changes the formation mechanism of functionalized adducts, that is, CnH2nBr2 (n = 3-5) tends to result in kinetic products.

Case report: Unruptured small middle cerebral artery aneurysm with perianeurysmal edema

Background

Perianeurysmal edema (PAE) has a tendency to occur in embolized aneurysms but also in partially thrombosed, large, or giant aneurysms. However, there are only a few cases recorded in which PAE was detected in untreated or small aneurysms. We suspected that PAE might be an impending sign of aneurysm rupture in these cases. Herein, we presented a unique case of PAE that was related to an unruptured small middle cerebral artery aneurysm.

Case description

A 61-year-old woman was referred to our institute due to a newly formed abnormal fluid-attenuated inversion recovery (FLAIR) hyperintense lesion in the right medial temporal cortex. Upon admission, the patient did not present with any symptoms or complaints; however, FLAIR and CT angiography (CTA) suggested an increased risk of aneurysm rupture. Aneurysm clipping was conducted, and no evidence of subarachnoid hemorrhage and hemosiderin deposits around the aneurysm and brain parenchyma was noted. The patient was discharged home without any neurological symptoms. MRI taken at eight months post-clipping revealed complete regression of the FLAIR hyperintense lesion around the aneurysm.

Conclusion

PAE in unruptured, small aneurysm is thought to be an impending sign of aneurysm rupture. Early surgical intervention is critical even for small aneurysms with PAE.

Endovascular Coil Embolization for Recurrent Bow Hunter's Stroke

Bow hunter's stroke is a rare cause of vertebrobasilar infarction. There is no consensus regarding the optimal treatment. We herein report a case of bow hunter's stroke successfully treated by endovascular treatment. A 70-year-old man presented with central vertigo. Magnetic resonance imaging (MRI) showed posterior circulation infarcts. Dynamic angiography revealed thrombus formation and hypoperfusion of the right vertebral artery upon head rotation to the left. Endovascular parent artery occlusion of the right vertebral artery was performed, and there was no recurrence at follow-up MRI. Endovascular parent artery occlusion might be a useful treatment for bow hunter's stroke.

Subarachnoid hemorrhage due to a craniocervical junction arteriovenous fistula associated with thrombus formation in the internal jugular vein: illustrative case

BACKGROUND

A craniocervical junction arteriovenous fistula (CCJAVF) is a rare vascular malformation, and its etiology remains unclear. Here, to the best of the authors' knowledge, they present the first case of CCJAVF associated with thrombus formation in the ipsilateral internal jugular vein.

OBSERVATIONS

An 80-year-old man presented with a sudden occipital headache. Computed tomography revealed a subarachnoid hemorrhage surrounding the brainstem and upper cervical cord. Digital subtraction angiography showed a CCJAVF fed by the left C2 radiculomeningeal artery with ascending intracranial drainage and epidural plexus. After endovascular treatment, the authors retrospectively found that his ipsilateral internal jugular vein and innominate vein were occluded with a huge thrombus at admission.

LESSONS

This case suggested a restricted antegrade venous flow due to thrombus-induced progressive retrograde intracranial drainage causing hemorrhage. Venous hypertension should be considered one of the causes of hemorrhage due to CCJAVF as well as intracranial arteriovenous fistulas.

Lateral approach to distal peroneal artery without fibular resection

Bypass to the peroneal artery has sometimes been effective for pedal gangrene. However, the difficulty of approaching the terminal segment of the peroneal artery because of its anatomic features has been a clinical issue. Surgical access to this area can be achieved via a lateral approach with fibular resection. Although severe complications associated with fibular resection have rarely been reported, a less invasive surgical procedure would enable faster postoperative recovery and reduce the incidence of wound-related complications. We have described our experience with successful terminal peroneal artery bypass via a lateral approach without fibular resection in a 38-year-old male patient with chronic limb-threatening ischemia.

Traumatic Superficial Femoral Arteriovenous Fistula with Pulsatile Mass and Leg Pain 60 Years after Stabbing Injury

Post-traumatic arteriovenous fistula (AVF) is a vascular injury complication and can present with vessel dilation, forming pulsatile varices, venous hypertension, distal ischemia, and congestive heart failure. We present a case of only pulsatile mass and leg pain caused by a 60-year-old post-traumatic AVF. Computed tomography angiography showed an AVF between the superficial femoral artery and superficial femoral vein. Surgical repair with AVF ligation was successfully performed. Traumatic AVF caused vascular and heart failure in the future; therefore, post-traumatic AVF is better eliminated as soon as possible.

The Impact of Chronic Limb-Threatening Ischemia on Cardiac Surgery

Purpose

The effect of chronic limb threatening ischemia (CLTI) on advanced cardiac disease, which requires surgical treatment, has rarely been reported. The purpose of this study was to review the outcomes of cardiac surgery in patients with CLTI and determine the risk factors, with a particular focus on the severity of CLTI.

Patients

The baseline characteristics and outcomes of 33 patients who were treated for CLTI and underwent cardiac surgery were retrospectively analyzed. The states of CLTI were evaluated based on the Wound, Ischemia, and foot Infection (WIfI) classification system, and 33 patients were divided into the low-WIfI group (stages 1–2, n = 13) and high-WIfI group (stages 3–4, n = 20).

Results

The in-hospital mortality rate was 0% in low-WIfI group and 35% in high-WIfI group (p = 0.027). Postoperative complications, particularly severe infections, occurred more frequently among high-WIfI group than low-WIfI group (70.0% vs. 23.1%, p < 0.01). Multivariable analysis identified foot infection grade as a WIfI classification factor and lower albumin levels as factors significantly associated with postoperative complications. The 1-year and 2-year survival rates were 84.6% and 67.7% in low-WIfI group and 45% and 28.1% in high-WIfI group, respectively (p = 0.011).

Conclusions

Cardiac surgery in patients with high WIfI stage was an extremely high-risk procedure. In such patients, lowering the WIfI stage by lower extremity revascularization and/or debridement of diseased parts prior to cardiac surgery can be considered.

Successful endovascular therapy involving direct puncture for spontaneous internal iliac artery aneurysm rupture

Neurofibromatosis type 1 (NF-1) is associated with fatal vascular complications. A 40-year-old woman with NF-1 who had previously undergone left iliac artery ligation and femorofemoral bypass grafting for internal iliac artery (IIA) aneurysm rupture was transported to our hospital for the treatment of a newly developed IIA aneurysm. Although endovascular therapy was difficult owing to the previous surgery, we successfully performed embolization of the aneurysm and its feeding vessels via direct percutaneous puncture under ultrasound guidance. Aneurysm enhancement had completely disappeared at 2 months postoperatively. We have reported a novel approach of direct percutaneous puncture for IIA aneurysm embolization in a patient with NF-1.

Unruptured cerebral aneurysms with the segmental duplicated middle cerebral artery formed a fenestrated structure at origin

Background:

Middle cerebral artery (MCA) has a significantly lower incidence of anatomical variations than other intracranial arteries. We present an extremely rare case of unruptured aneurysms with the segmental duplicated MCA (d-MCA) formed a fenestrated structure at origin.

Case Description:

A 55-year-old female underwent direct surgery for the unruptured aneurysms at the top of the right internal cerebral artery with d-MCA. The d-MCA branches separated at the right internal cerebral artery top and had comparable with that of the main MCA trunk. Moreover, there was an anastomosis between the d-MCA branches. We diagnosed this anastomosis as segmental d-MCA. Two aneurysmal domes were identified during surgery at the origin of the d-MCA, which the main dome protruding backward was wide necked and another small one was collapsed or thrombosed protruding forward. We used a fenestrated clip for the posterior projecting dome, and the aneurysms were successfully obliterated.

Conclusion:

Although cerebral aneurysms associated with d-MCA are rare, there are technical difficulties in the surgical management. A fenestrated clip might be most reasonable to obtain patency of the parent arteries for the posterior projecting aneurysms if the perforators can be avoided.

Myeloperoxidase Antineutrophil Cytoplasmic Antibody-Associated Renal-Limited Vasculitis in a Young Adult Woman

Antineutrophil cytoplasmic antibody (ANCA)-associated renal-limited vasculitis (RLV) is a minor subtype of small vessel vasculitis characterized by the inflammation of blood vessels, tissue damage, and loss of renal function localized in the kidney without systemic involvements. Here, we report a case of myeloperoxidase (MPO) ANCA-associated RLV in a young adult woman in Japan presenting chronic hematuria and newly overt proteinuria. Percutaneous renal biopsy revealed focal fibro-cellular crescent glomerulonephritis and the absence of other small vasculitides, tubular atrophy, and interstitial fibrosis. Therapeutic intravenous methylprednisolone pulse followed by oral prednisolone was administered as a remission induction. The patient’s serum MPO-ANCA level gradually decreased, coinciding with dramatic changes in proteinuria and hematuria after therapeutic glucocorticoid administration. Renal function was maintained within the normal range, and disease activity was well-tolerated throughout the follow-up period for more than 14 weeks. While the incidence of RLV is rare among younger patients, it occurs with asymptomatic hematuria and proteinuria, which is important in differentiating RLV from typical glomerulonephritis. The overall prognosis of ANCA-associated RLV potentially depends on the severity of extrarenal involvements. Early diagnosis, appropriate treatment, and regular maintenance are essential for controlling and treating RLV. Due to the nontypical case presented here, further investigation is recommended to improve the diagnosis strategies and treatment options for this disease.

Wound Healing on the Cutting Plane of Ankle Bones after Incomplete Revascularization for Chronic Limb-Threatening Ischemia in an Elderly Patient: A Case Report

Chronic limb-threatening ischemia (CLTI) is an important issue for elderly patients with peripheral artery disease. Here, we present the case of a 91-year-old man with CLTI, residing in a rural district. The onset of CLTI rapidly deprived him of ambulation because of a foot infection. Given that he had difficulty with long-distance transportation, limb salvage for extensive tissue loss was performed at a district facility, based on his and his family’s request. Finally, skin grafting on the cutting plane of the right ankle bones resulted in wound healing in six months after incomplete revascularization and multiple minor amputations.

Stent-Graft Removal and Extra-Anatomical Bypass for the Treatment of Stent-Graft Infection after Endovascular Aneurysm Repair

Stent-graft infection is a rare but potentially life-threatening complication of endovascular aortic repair. There are currently no consensus guidelines for treating stent-graft infections, but surgical treatment is generally considered preferable due to the low overall survival rate of patients receiving conservative therapy; however, the revascularization method remains controversial. We report a case in which stent-graft infection after endovascular aneurysm repair was successfully treated by stent-graft removal and extra-anatomical bypass (EAB). EAB is an effective method of revascularization for stent-graft infection.

Collateral artery bypass in the infrapopliteal segment

A 74-year-old man with diabetes and end-stage renal failure on regular dialysis required revascularization for gangrene of multiple toes and a heel ulcer on the right foot with chronic limb-threatening ischemia. However, the anterior tibial artery, posterior tibial artery, and peroneal artery, which are the usual targets below the knee, showed obstruction or calcification and were considered inappropriate bypass targets. Instead, a collateral artery developed along the area of the posterior tibial artery, and bypass surgery was performed with this artery. This is a case report showing successful collateral artery bypass grafting in the distal infrapopliteal segment.

Limb-Based Patency After Surgical vs Endovascular Revascularization in Patients with Chronic Limb-Threatening Ischemia

PURPOSE

To determine whether limb-based patency (LBP) after infrainguinal revascularization for chronic limb-threatening ischemia (CLTI) is similar between bypass surgery and endovascular therapy (EVT).

MATERIALS AND METHODS

The database for the Surgical Reconstruction vs Peripheral Intervention in Patients With Critical Limb Ischemia (SPINACH) study was interrogated to identify 130 patients (mean age 73±8 years; 94 men) who underwent bypass surgery and 271 patients (mean age 74±10 years; 178 men) who underwent EVT alone. Skin perfusion pressure (SPP) and the ankle-brachial index (ABI) were measured before the procedure and at 0, 1, and 3 months after revascularization. The outcome measure was hemodynamically evaluated LBP (SPP ≥10 mm Hg or ABI ≥0.1) maintained over the first 3 months after treatment. Any reintervention or major amputation was regarded as loss of LBP. The associations between the revascularization strategy (bypass vs EVT) and between the preoperative characteristics and the study outcome (ie, SPP- or ABI-based LBP), were determined using generalized linear mixed models with a logit link function. Patency rates are presented with the 95% confidence interval (CI).

RESULTS

The bypass surgery group had a higher stage of limb severity (WIfI) and anatomic complexity (GLASS) than the EVT group, whereas the EVT group had a higher prevalence of heart failure. Both SPP- and ABI-based LBP rates were higher in the bypass group than in the EVT group. SPP-based LBP rates at 3 months were 73.8% (95% CI 63.4% to 84.2%) in the bypass group and 46.2% (95% CI 38.5% to 53.8%) in the EVT group; the corresponding ABI-based LBP rates were 71.5% (95% CI 61.8% to 81.2%) and 44.0% (95% CI 37.3% to 50.7%).

CONCLUSION

LBP is an important concept in the new global vascular guidelines for assessing the anatomic and hemodynamic status of CLTI patients. The present study found that LBP was significantly lower in the EVT group vs the bypass surgery group.

A Case of Chronic Limb-Threatening Ischemia with Heel Ulcers Cured by Revascularization and Partial Calcanectomy

Ischemic limbs with infected heel ulcers are often difficult to salvage. We present a case of an 82-year-old woman who had bilateral heel ulcers owing to chronic limb-threatening ischemia. She underwent right femoral-terminal posterior tibial artery bypass surgery, but right calcaneus osteomyelitis occurred and inhibited wound healing. She underwent partial calcanectomy (PC), and her right heel healed six months after the bypass surgery. The ulcer on her left foot also healed after distal bypass and PC. We describe our experience with a patient who needed PC to cure her heel ulcers.

A Clampless Aortoprosthetic End to Side Anastomotic Device with Large Diameter Aortic Puncher

Introduction

To facilitate safe anastomosis of a vascular prosthesis onto the proximal ascending aorta without side clamping, a clampless anastomotic device with large diameter aortic puncher was developed.

Report

First, a vascular prosthesis is anastomosed onto the aorta without making a hole, then the aortic wall within the prosthesis is punched out using the device.

Discussion

After further refinement of the present device, endovascular surgery with debranching could be performed more safely and quickly.

Distal Bypass Grafting Using the Basilic-Cephalic Loop Vein for Chronic Limb-Threatening Ischemia under Peripheral Nerve Blockades in a Patient with Severely-Reduced Heart Function and End-Stage Renal Disease

A 51-year-old man with severe comorbidities required redo revascularization due to left chronic limb-threatening ischemia caused by a previous vein graft occlusion. The saphenous veins were not available due to previous surgeries. Femoro-posterior tibial artery bypass surgery was successfully performed using the basilic–cephalic loop vein under peripheral nerve blockades. This anesthesia allowed a series of surgical revascularizations without general anesthesia, and the postoperative courses were uneventful. The patient survived for 4 years with ambulatory status. In conclusion, loop graft can be an alternative single vein material for distal bypass when no saphenous veins are available.

Additional seizure reduction by replacement with Vagus Nerve Stimulation Model 106 (AspireSR)

AspireSR is a novel vagus nerve stimulation (VNS) device which detects ictal heart rate changes and automatically apply additional stimulus. We investigated the difference of the efficacy between AspireSR and preceding VNS models in patients with device replacement. We retrospectively reviewed the clinical data of 17 patients whose VNS devices were changed because of battery discharge. The rates of seizure reduction, the number of antiepileptic drugs (AEDs) used and device parameters between the two devices were evaluated. AspireSR improved significantly the rates of seizure reduction of the patients. Four patients out of 11 patients with low response to the preceding VNS models (no change or <50 % reduction) achieved>50 % seizure reduction. The AEDs used were not different in the observed periods. The device parameters were low setting in AspireSR compared to preceding VNS models. AspireSR decrease significantly seizure frequencies compared to the preceding VNS models. Change of the devices to AspireSR at the time of battery empty could be recommendable.

Neuroendoscopic Surgery with a Combination of Image Detectable Sheath, Intraoperative Computed Tomography Scan, and Navigation System Improves Accuracy and Safety in Minimally Invasive Evacuation of Intracerebral Hematoma: Technical Note

BACKGROUND

Recent studies have confirmed the effectiveness of minimally invasive endoscopic surgery for intracerebral hematoma (ICH). However, improvements are needed because incomplete hematoma removal may offset the surgical benefits of the technique. We describe a technique of neuroendoscopic surgery using an image detectable sheath, intraoperative computed tomography (iCT) scan, and a navigation system.

METHODS

This is a retrospective study of 15 consecutive patients with spontaneous ICH who received neuroendoscopic surgery. During the surgery, a transparent sheath was fastened tightly to the scalp with 3.0 nylon. The patient's head was covered with a sterilized vinyl sheet and subsequent iCT scan visualized the orientation of the endoscopic sheath and the extent of residual hematoma, allowing the surgeon to decide to continue to remove the hematoma or to finish the treatment.

RESULTS

The median hematoma evacuation rate was 93% (interquartile range, 82.2%-95.9%). The Glasgow Coma Scale score of all patients significantly improved at 1 week after the operation (P < 0.05). No complications associated with the procedure were observed.

CONCLUSIONS

The combination of our techniques improves accuracy and safety of minimally invasive surgical evacuation of hematoma. Performing surgery with iCT scan also improves the spatial recognition of surgeons and therefore may be of educational value.

Unexpectedly Smaller Artifacts of 3.0-T Magnetic Resonance Imaging than 1.5 T: Recommendation of 3.0-T Scanners for Patients with Magnet-Resistant Adjustable Ventriculoperitoneal Shunt Devices

BACKGROUND

Magnetic resonance imaging (MRI) artifacts of adjustable shunt devices are thought to be similar to metal clip artifacts, in that they are larger with higher field strength scanners. We have published several reports about the artifacts of new MRI-resistant adjustable shunt devices, and we found a case in which a 3.0-T scanner showed smaller artifacts than the 1.5-T scanner. We aimed to clarify whether this claim is true or not.

METHODS

Under permission of our institutional Ethical Committee, 2 volunteers underwent imaging studies using 3.0-T and 1.5-T scanners from GE, Siemens, and Philips. Four MRI-resistant adjustable shunt devices-proGAV2.0 (Miethke), Codman Certas Plus (Johnson & Johnson), Polaris (Sophysa), and Strata MR valve (Medtronic)-were fixed on the left temporal scalp. Routine MRI images, including T1-and T2-weighted imaging, fluid-attenuated inversion recovery, diffusion-weighted imaging (DWI), and magnetic resonance angiography (MRA), were obtained. We also compared artifacts between a 3.0-T scanner and a-1.5 T scanner in 4 patients.

RESULTS

The 3.0 T-scanners showed smaller artifacts than the 1.5-T scanners on DWI and MRA images for all shunt devices and scanners. In the other sequences, the results depended on the MRI scanner manufacturer; however, the GE 3.0-T scanner showed smaller artifacts in every sequence. This was also true in the 4 clinical cases.

CONCLUSIONS

A 3.0-T scanner is recommended over a 1.5-T scanner for patients with MRI-resistant adjustable shunt devices in the diagnosis of acute ischemic condition or when using GE scanners.

Oral squamous cell carcinoma arising in a patient with Werner syndrome

Werner syndrome (WS) is an autosomal recessive disorder characterized by physical signs and symptoms, including premature aging and scleroderma-like skin changes. The gene responsible for WS is the WRN gene. A significant proportion of WS-related malignant tumours are non-epithelial types, and the incidence of oral squamous cell carcinoma (SCC) is rare. A case of oral SCC of the lower alveolus and gingiva arising in a 63-year-old woman with WS is reported here. Biopsy confirmed moderately differentiated SCC. Surgical resection was performed and there was no recurrence or metastasis at the 3-year follow-up. Mutation analysis using next-generation sequencing, detected no mutations in the genes encoding the molecules strongly involved in the development of oral SCC, such as TP53 or PIK3CA. No obvious mutations were detected. Based on the results of the study, the results of mutation analysis suggest that this case might be genetically different from the common mechanisms of SCC in the oral cavity.

Development of gene therapy with a cyclic adenosine monophosphate response element decoy oligodeoxynucleotide to prevent vascular intimal hyperplasia

OBJECTIVE

Intimal hyperplasia (IH) is the main cause of therapeutic failure after vascular and endovascular surgery. However, there is currently no targeted therapy for the treatment of IH. We recently reported that the inhibition of cyclic adenosine monophosphate response element (CRE) binding protein (CREB) activation is important in vein graft IH. We focused on a decoy oligodeoxynucleotide (ODN) therapeutic strategy for suppressing IH as a clinical application. The objective of this study was to confirm the therapeutic effect of a CRE decoy ODN in an animal model as a novel therapy for preventing intimal hyperplasia as the first step of the preclinical study of our strategy.

METHODS

We designed two phosphorothioate CREs and two scramble decoy ODNs and screened them using a CREB transcription assay to check their ability to bind to a CRE sequence. We chose a CRE decoy ODN with high first-binding ability and transfected it into vascular smooth muscle cells (VSMCs) in vitro. Proliferation and migration were assessed using MTS (3-(4,5-dimethylthiazol-2-yl)-5-(3-carboxymethoxyphenyl)-2-(4-sulfophenyl)-2H-tetrazolium) assays and modified Boyden chamber assays. We examined CRE activity using a luciferase reporter gene assay. We assessed the expression of messenger RNAs by quantitative real-time polymerase chain reaction. In a wire-injury mouse model (C57BL6, n = 6), CRE decoy ODN was transfected into the injured vessel wall using an ultrasound-sonoporation method in vivo. Mitogen-activated protein kinase-activated protein kinase 3 (MAPKAPK3) and four and a half LIM domains 5 (FHL5) expression of pregrafting vein remnants were assessed by immunohistologic analyses.

RESULTS

Compared with scramble decoy ODN, the selected CRE decoy ODN could significantly decrease CRE activity (mean ± standard error of the mean: 0.20 ± 0.03 vs 1.00 ± 0.16, n = 6; P < .05) as shown by a luciferase reporter gene assay, VSMC proliferation (0.73 ± 0.04 vs 0.89 ± 0.02, n = 6; P < .05) and migration (96.4 ± 6.1 vs 311.4 ± 19.1 migrated VSMCs/well, n = 6; P < .05) after 24-hour transfection. The CRE decoy ODN significantly suppressed the formation of IH at injured vessel walls in an animal model, as analyzed by pathologic staining (0.20 ± 0.02 vs 0.56 ± 0.08, area of the intima/area of the artery vs the control after 21 days' transfection, n = 6; P < .05). Furthermore, MAPKAPK3 and FHL5, which are CREB activators, were significantly expressed in pregrafting vein remnants in diabetes mellitus patients.

CONCLUSIONS

CREB-CRE signaling is an important mechanism of IH formation, and CRE decoy therapy can help preventing IH. This study is the first part of the preclinical study of our strategy.

Laser speckle flowgraphy can also be used to show dynamic changes in the blood flow of the skin of the foot after surgical revascularization

Objectives

Laser speckle flowgraphy is a new method that enables the rapid evaluation of foot blood flow without contact with the skin. We used laser speckle flowgraphy to evaluate foot blood flow in peripheral arterial disease patients before and after surgical revascularization.

Materials and methods

A prospective single-center study. Thirty-one patients with 33 limbs that underwent surgical revascularization for peripheral arterial disease were included. Pre- and postoperative foot blood flows were measured on the plantar surface via laser speckle flowgraphy and skin perfusion pressure. The laser speckle flowgraphy device was used to visualize the blood flow distribution of the target skin and processed the pulse wave velocity of synchronized heart beats. The mean blood flow, which was expressed as the area of the pulse wave as the beat strength of skin perfusion on laser speckle flowgraphy converted into a numerical value, was assessed as dynamic changes following surgery. Beat strength of skin perfusion was also investigated in non-peripheral arterial disease controls (23 patients/46 limbs).

Results

The suitability of beat strength of skin perfusion in non-peripheral arterial disease controls was achieved; the beat strength of skin perfusion value was significantly higher in every area of interest in non-peripheral arterial disease controls compared to that in peripheral arterial disease limbs at the preoperative stage (105.8 ± 8.2 vs. 26.3 ± 8.2; P < 0.01). Although the pulse wave before surgery was visually flat in peripheral arterial disease patients, the pulse wave was remarkably and immediately improved through surgical revascularization. Beat strength of skin perfusion showed a dynamic change in foot blood flow (26.3 ± 8.2 at preoperation, 98.5 ± 6.7 immediately after surgery, 107.6 ± 5.7 at seven days after surgery, P < 0.01 for each compared to preoperation) that correlated with an improvement in skin perfusion pressure.

Conclusions

Laser speckle flowgraphy is a noninvasive, contact-free modality that is easy to implement, and beat strength of skin perfusion is a useful indicator of foot circulation during the perioperative period. Further analysis with a larger number of cases is necessary to establish appropriate clinical use.

Fatal Vasospasm of the Coronary Arteries in a Patient Undergoing Distal Bypass Surgery and Endovascular Therapy for Threatened Lower Limbs Due to Acute Exacerbation of Peripheral Arterial Disease

A 79-year-old man with a heavy smoking history presented with threatened lower limbs due to acute exacerbation of peripheral artery disease (PAD). He underwent emergent distal bypass surgery for the right leg and external iliac stenting for the left leg. Fatal coronary artery spasm (CAS) with ST segment changes on electrocardiography was observed 28 h after the procedures, resulting in cardiac arrest. Coronary angiography showed widespread CAS with improvement after intra-arterial nitroglycerin infusion. We should keep in mind that CAS may occur more frequently than expected in PAD patients, especially those who have not stopped smoking prior to revascularization.

[Experience and Solution of Complications of Vagus Nerve Stimulation Therapy in 139 Implant Patients with Medically Refractory Epilepsy]

BACKGROUND

Vagus nerve stimulation(VNS)for patients with intractable epilepsy was approved by the Japan Ministry of Health, Labour and Welfare in 2010. More than 1,500 VNS systems were implanted by the end of August 2016. The aim of the present report is to describe complications we experienced at our department and consider the way to avoid them.

METHODS AND PATIENTS

We retrospectively reviewed 139 consecutive patients(122 new implantations and 17 reimplantations)between December 2010 and March 2016.

RESULTS

Seven patients demonstrated eight complications. Four patients experienced recurrent nerve paralysis with hoarseness and/or cough that did not require device removal. One patient experienced subsequent aspiration pneumonia. The device was removed in one case due to lead fracture and in three owing to surgical site infection(SSI).

CONCLUSION

All recurrent nerve paralysis occurred just after we started VNS implantations. It was presumed that the nerve paralysis was caused by retraction around the vagus nerve. Smaller skin incision and decreased retraction of the surgical field has eliminated this complication. The incidence of infections is reported as 2.2%. Allergic reaction to the VNS device might be one of the causes for SSI in our series. Fracture of the lead was caused by revolving of the pulse generator under the skin. Tight sutures around the pocket or subpectoral placement of a pulse generator is necessary to prevent rotation of the generator depending upon the activity of each patient. This paper provides insight into complications and successful strategies for better outcomes in VNS therapy.

Setting pressure can change the size and shape of MRI artifacts caused by adjustable shunt valves: a study of the 4 newest models

OBJECTIVEAdjustable shunt valves that have been developed for the management of hydrocephalus all rely on intrinsically magnetic components, and artifacts with these valves on MRI are thus inevitable. The authors have previously reported that the shapes of shunt artifacts differ under different valve pressures with the proGAV 2.0 valve. In the present study the authors compared the size and shape of artifacts at different pressure settings with 4 new-model shunt valves.METHODSThe authors attached 4 new models of MRI-resistant shunt valve to the temporal scalp of a healthy volunteer: the proGAV 2.0; Codman Certas Plus; Polaris; and Strata MR. They set 3 different scales of pressures for each valve, depending on magnet orientation to the body axis. Artifacts were evaluated and compared among all valves on a 3.0-T GE scanner and 2 valves were also evaluated on a Philips scanner and a Siemens scanner. In-plane artifact sizes were evaluated as the maximum distance of the artifact from the expected scalp.RESULTSThe sizes and shapes of artifacts changed depending on valve pressure for all valves on the 3 different MRI scanners. Artifacts were less prominent on spin echo sequences than on gradient echo sequences. For diffusion-weighted imaging and time-of-flight MR angiography, the authors matched image numbers within the same sequence and compared appearances of artifacts. For all valves, the number of images affected by artifacts and the image number showing the largest artifact differed among valve settings.CONCLUSIONSArtifacts of all adjustable shunt valves showed gross changes corresponding to pressure setting. Not only the maximum distance of artifacts but also the shape changed significantly. The authors suggest that changing pressure settings offers one of the easiest ways to minimize artifacts on MRI.

Abstract 692: Development of the Gene Therapy With CRE Decoy ODN to Prevent Vascular Intimal Hyperplasia

Background: Intimal hyperplasia (IH) is the main cause of vein graft stenosis or failure after bypass surgery. However, in the previous study, no therapeutic targets for the treatment of IH have been identified. Our recent research have been reported that the inhibition of Cyclic adenosine monophosphate response-element (CRE) binding protein (CREB) activation is a key role for vein graft IH.

Objective: In consideration of future clinical application, we focused on decoy oligodeoxynucleotide (ODN) transfection as gene therapy strategy for suppressing IH. The goal of the present study is to identify whether the CRE decoy ODN had the therapeutic efficacy for suppressing IH.

Methods: We developed phosphorothioate CRE decoy ODN and checked binding ability to a CRE sequence using CREB transcription assay . We chose a decoy ODN having high first-binding ability and transfected it to vascular smooth muscle cell(VSMC) in vitro. Proliferation was assessed using MTS assay and migration was assessed using a modified Boyden-chamber assay. We examined CRE activity using Luciferase reporter gene assay. We checked expression of mRNAs using qRT-PCR. In wire-injury mouse model(C57BL6,n=6), CRE decoy ODN was transfected to injured vessel wall using ultrasound-sonoporation method in vivo.

Results: CREB transcription factor assay showed CRE decoy had about 80 folds binding ability of control decoy in IC50 value (vs.control,n=5). Transfer of CRE decoy ODN resulted in significantly downregulated CRE activity(vs.control,P<.01,n=12) and inhibited VSMC proliferation (vs.control,P<.01,n=12) and migration (vs.control,P<.01,n=5). In a wire-injury mouse model, histopathological analysis revealed that transfer of the CRE decoy ODN significantly repressed IH whereas intensive IH was observed in the control group. In this vessel tissue, Levels of mRNA CCNA2 and Bcl2 were significantly lower in CRE decoy group than in control group(n=6,P<.01,respectively). CRE-activated gene expression was strongly repressed.

Conclusions: The present result suggested that CRE decoy ODN inhibiting CREB function provide an effective therapeutic approach to suppressing IH.

[A Case of Segmental Dysgenesis at the Terminal Portion(C1)of the Internal Carotid Artery with an Anomalous Collateral Vessel Containing Plexiform(Twig-like)Networks as a Possible Cause of Intracerebral Hemorrhage]

A 65-year-old woman was transferred to our hospital because of loss of consciousness along with a right hemiplegia due to an intracerebral hematoma(ICH)that extended from the left temporal lobe to the lateral part of the basal ganglia. CT angiograms(CTA)and 3D-rotational angiograms showed an absence of the distal C1 segment of the left internal carotid artery(ICA), and an anomalous collateral vessel arising from the proximal end of the left A2 with plexiform(twig-like)arterial networks, supplying antegrade blood flow to the left middle cerebral artery territory. The caliber of the left carotid arterial system decreased from the origin to the terminal end. The source images of CTA revealed that the plexiform arteries were very close to the ICH, suggesting that the vessels might have caused the bleeding. Because a hypoplastic left carotid canal was observed, the segmental dysgenesis of the C1 portion of the left ICA seemed to have occurred during the early embryonic period. T2-weighted DRIVE images of MRI demonstrated the presence of a cord-like rudimentary structure corresponding to the distal C1 and proximal M1 portions. The patient was managed conservatively and was transferred to another hospital for subsequent rehabilitation. Segmental dysgenesis of the C1 portion is extremely rare. To our knowledge, only a single report has been published. The present findings suggest that 1)an anomalous collateral vessel corresponding to Heubner's artery evolved with residual primitive plexiform(twig-like)arterial networks and 2)this anomalous structure has not been proposed as a type of collateral systems for ICA dysgenesis.

Seizure frequency can be reduced by changing intracranial pressure: A case report in drug-resistant epilepsy

A relationship between seizures and intracranial pressure (ICP) has been proposed, but not clearly identified. Whether changes in ICP can evoke seizures remains controversial. We report the case of a 23-year-old man who had undergone shunt surgery in childhood and later presented with focal impaired awareness seizures and behavior arrest. Seizures were uncontrolled despite 3 years of pharmacotherapy, but suddenly stopped after shunt removal. Our case supports the hypothesis that drug-resistant epilepsy can be influenced by changes in ICP. In particular, this case indicates that elevations in ICP may help reduce some seizures.

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A rare case indicating the relationship between drug-resistant epilepsy and ICP

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Drug-resistant epilepsy stopped just after a symptomatic increase in ICP.

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Seizures were controlled well by adjusting shunt valve pressure.

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This case suggests that elevations in ICP may help reduce seizures.