Five-year follow-up of randomized clinical trial for pre-emptive inferior mesenteric artery embolization during endovascular aneurysm repair

INTRODUCTION

Type II endoleak (T2EL) is the most common type of endoleak after endovascular aneurysm repair (EVAR) and a common indication for reintervention due to late sac enlargement. Although pre-emptive embolization of the inferior mesenteric artery (IMA) has been proposed to prevent this, no studies have prospectively demonstrated its efficacy. This study aimed to prove the validity of IMA embolization during EVAR in selective cases by analyzing the mid-term outcomes of a randomized clinical trial (RCT).

METHODS

This single-center, parallel-group, non-blinded RCT included participants at high risk of T2EL, characterized by a patent IMA in conjunction with one or more following risk factors: a patent IMA ≥3 mm in diameter, lumbar arteries ≥2 mm in diameter, or an aortoiliac-type aneurysm. The participants were randomly assigned to two groups in a 1:1 ratio: one undergoing EVAR with IMA embolization and the other without. The primary endpoint was T2EL occurrence. The secondary endpoints included aneurysm sac changes and reintervention. In addition to RCT participants, outcomes of patients with low-risk of T2EL were also analyzed.

RESULTS

The embolization and non-embolization groups each contained 53 patients. Five-year follow-up after the last patient enrolment revealed that T2ELs occurred in 28.3% and 54.7% of patients in the IMA embolization and non-embolization groups, respectively (P=.006). Both freedom from T2EL-related sac enlargement ≥5 mm and cumulative incidence of sac shrinkage ≥5 mm were significantly higher in the IMA embolization group than in the non-embolization group (95.5% vs. 73.6% at 5 years; P=.021, 54.2% vs. 33.6% at 5 years; P=.039). The freedom from T2EL-related sac enlargement ≥10 mm, an alternative indicator for T2EL-related reintervention, showed similar results (100% vs. 90.4% at 5 years; P=.019). Outcomes in the low-risk group were preferable than those in the non-embolization group and comparable to those in the IMA embolization group.

CONCLUSION

A lower threshold for pre-emptive IMA embolization when implementing EVAR would be more appropriate if limited to patients at high risk of T2ELs.

Time-Dependent Changes of Extremity Volume and Tissue Alterations in Swollen Arms Caused by Taxanes

Background: We aimed to determine the course of arm swelling caused by the use of taxanes and to identify valid predictors of persistent swelling. Methods and Results: A total of 15 patients with unilateral arm swelling that developed during the course, or within 3 months after termination, of postoperative taxane-based chemotherapy were included in the present study. The patients attended follow-up appointments every 3-6 months for 24 months after their initial visit. Their arm circumference was measured at each follow-up appointment, while ultrasonography of the skin and subcutaneous tissues was performed at the 0-, 6-, 12-, and 24-month follow-ups. Of the 15 patients, 12 (80%) saw their taxane-induced arm swelling resolved within a median of 12 months (range, 3-29 months) after their final taxane administration. Of the 12 patients whose swelling resolved, 9 did not use compression sleeves; however, their course of resolution did not differ from the other 3 patients who regularly used compression sleeves. In the three patients with persistent swelling, the excess subcutaneous thickness in the medial upper arm (median, 283%) was significantly greater than that in the patients whose swelling resolved (120%; p < 0.05) during their initial visits. Conclusions: Of the 15 patients included in the present study, 80% saw their taxane-induced arm swelling resolve within a median of 12 months after their final taxane administration, independent of the use of compression therapy. Persistent swelling may be predicted during the initial visit based on subcutaneous thickening of the medial upper arm.

Efficacy of Airbo·Wave in Nighttime Compression for Leg Lymphedema

Objectives: This study aimed to clarify the efficacy of Airbo·Wave EV1 in nighttime compression therapy as part of complex decongestive therapy (CDT) for leg lymphedema. Patients and Methods: We retrospectively reviewed 33 patients with leg lymphedema who used Airbo·Wave EV1 between April 2021 and September 2022. In these patients, the changes in leg volume and skin hardness were assessed using a scale ranging from 1 (softest) to 7 (hardest), and dermal thickness before and after the use of Airbo·Wave EV1 was evaluated. Results: Twenty-two patients used Airbo·Wave EV1 for nighttime compression in CDT. Their skin hardness in the lower calf decreased mildly (mean scale: before, 3.9; after, 3.6 [p <0.05]), but the leg volume and skin thickness were unchanged. Eleven patients who were nonadherent could restart compression therapy by using Airbo·Wave EV1. Their skin hardness in the medial lower calf (before, 5.1; after, 4.3 [p <0.05]), leg volume (before, 8412 mL; after, 8191 mL [p <0.01]), and skin thickness in the medial and lateral lower leg were reduced. Conclusion: Airbo·Wave EV1 could improve skin hardness in the calf area. Moreover, it is a safe procedure for the nonadherent while reducing leg volume reasonably.

Dependent Leg Edema in Older Patients with or without Skin Lesion

Objective: This study aimed to clarify the features and causes of dependent edema (DE) in the legs of patients in geriatrics. Patients and Methods: We retrospectively reviewed 224 patients with DE, aged ≥65 years, who visited our clinic from April 2009-March 2022. DE was defined as bilateral leg edema in patients without known systemic edemagenic conditions, venous insufficiency confirmed by duplex venous scanning, or a cancer treatment history in the pelvic/inguinal lesions. Results: The median patient age was 77 years (range: 65-94 years), where 74% were female. Overall, 198 patients (88%) had gait disturbances caused mainly by musculoskeletal disorders, but 58 (26%) walked without aid. Compared with patients with DE only (N=129), patients with DE and venous stasis-related skin lesions (N=95) included a larger number of those with obesity than did those with DE only (26% vs. 14%, p=0.02). Conclusion: The primary cause of DE in older patients was the sedentary lifestyle secondary to aging and gait disturbance, not solely because of reduced leg function. The complications of obesity are associated with increased venous stasis-related skin lesions.

Leg volume reduction during tiptoe movement is caused by venous ejection and calf muscle contraction

OBJECTIVES

To clarify the cause of leg volume reduction during tiptoe movement in the standing position.

METHODS

The right legs of 20 participants were assessed. The participants performed tiptoe movement in the supine position, and then stood up and performed the tiptoe movement and ankle dorsiflexion. Leg volume changes were recorded continuously using air plethysmography.

RESULTS

Differences between leg volume changes due to tiptoe movement and the refilling volumes were not significantly different between the supine (59 mL) and standing (49 mL) positions, indicating that this amount of motion artifact was included in the downward trace recorded by tiptoe movement in the standing position.

CONCLUSIONS

Leg volume reduction during tiptoe movement in the standing position included a significant amount of motion artifacts. Therefore, it may be difficult to accurately measure the ejection volume using tiptoe movement in the standing position.

Post-treatment course of acute lipodermatosclerosis

OBJECTIVES

We aimed to clarify whether acute lipodermatosclerosis (LDS) progress to chronic LDS without continued compression therapy.

METHODS

Between April 2015 and November 2021, 30 patients with acute/subacute LDS, which was diagnosed clinically by presence of isolated, poorly demarcated, tender erythema, and induration limited to the lower leg(s), visited our clinic and were able to be followed up for longer than a year. We reviewed their treatment results and the post-treatment courses.

RESULTS

In all cases, the symptoms in the acute phase subsided with compression bandages. After the discontinuation of compression therapy, 18 legs (56%) progressed to chronic LDS, and 14 legs (44%) did not. In the legs without progression, subcutaneous tissue in the affected leg was thicker compared with that in the contralateral leg (median 19.1 mm vs. 13.4 mm, p < 0.05) on the initial visit. In the legs with progression, the difference in subcutaneous tissue thickness between the affected and unaffected legs was not significant (10.0 mm vs. 7.6 mm).

CONCLUSIONS

Our findings suggest that in legs which later progress to chronic LDS, subcutaneous tissue contraction due to panniculitis is already present during the acute phase; therefore, long-term compression therapy is unlikely to improve the prognosis.

Cryopreserved allogenic fibroblast sheets: development of a promising treatment for refractory skin ulcers

The purpose of this study was to investigate the therapeutic effect of cryopreserved allogenic fibroblast cell sheets in a mouse model of skin ulcers. It is necessary to reduce the cost of regenerative medicine for it to be widely used. We consider that cell sheets could be applied to various diseases if cryopreservation of allogenic cell sheets was possible. In this study, fibroblasts were frozen using a three-dimensional freezer. Freeze-thawed fibroblasts had ~80% cell viability, secreted ≥ 50% vascular endothelial growth factor, hepatocyte growth factor, and stromal derived factor-1α compared with non-frozen fibroblast sheets, and secreted approximately the same amount of transforming growth factor-β1. There was no difference in wound-healing rates in the skin ulcer model between non-frozen and freeze-thawed fibroblast sheets regardless of autologous and allogenic cells. The degree of angiogenesis was comparable between autologous and allogenic cells. The number of CD3-positive cells in healed tissues was larger for allogenic fibroblast sheets compared with autologous fibroblast sheets. However, histopathological images showed that the fibrosis, microvascular density, and healing phase of the wound in allogenic freeze-thawed fibroblast sheets were more similar to autologous freeze-thawed fibroblast sheets than to allogenic non-frozen fibroblast sheets. These results suggest that allogenic freeze-thawed fibroblast sheets may be a promising therapeutic option for refractory skin ulcers.

Perivascular Adipose Tissue Is a Major Source of Nitric Oxide in Saphenous Vein Grafts Harvested via the No-Touch Technique

Background

Saphenous vein grafts (SVGs) are broadly used in coronary artery bypass grafting despite their inferior patency compared with arterial grafts. Recently, the no‐touch technique (NT), in which an SVG is harvested with a pedicle of perivascular adipose tissue (PVAT) without conduit distension, was shown to improve long‐term patency compared with conventional preparation (CV), wherein outer tissue is removed with distension. The NT was also reportedly associated with reduced atherosclerosis. Although endothelial damage provoked by conventional distension may underlie poor patency when CV is performed, the precise mechanisms underlying the salutary effects of the NT have been unclear.

Methods and Results

Residual SVGs prepared with CV (CV‐SVGs) or NT (NT‐SVGs) were obtained during coronary artery bypass grafting. Nitric oxide (NO₂⁻/NO₃⁻ (NO_x)) levels after 24 hours of tissue culture were quantified. The protein expression and localization were analyzed. The isometric force of SVG strips was measured. NT‐SVGs showed superior NO_x production to CV‐SVGs. PVAT generated the majority of NO_x in NT‐SVGs. PVAT highly expressed arginosuccinate synthase 1, a rate‐limiting enzyme in the molecular circuit for NO synthesis, thereby continuously providing the substrate for NO. A substantial level of endothelial NO synthase was also expressed in PVAT. Pharmacological inhibition of arginosuccinate synthase 1 or endothelial NO synthase significantly suppressed the NO_x production in NT‐SVGs. PVAT induced vasorelaxation through NO production, even in the endothelium‐denuded SVG strips.

Conclusions

Preserving PVAT was predominantly involved in the superior NO_x production in NT‐SVGs. Since NO plays crucial roles in suppressing atherosclerosis, this mechanism may greatly contribute to the excellent patency in NT‐SVGs.

Hardness Sensed by Skin Palpation in Legs with Lymphedema Is Predominantly Correlated with Dermal Thickening

Background: We aimed to clarify whether pathological changes in skin and subcutaneous tissue with lymphedema affected the skin hardness sensed by palpation. Methods and Results: In 50 patients with unilateral legs with lymphedema (LE), the skin hardness of the lower inner thigh and lower inner calf was determined using a scale ranging from 1 (softest) to 7 (hardest) based on palpation. Then, the skin hardness was correlated with the measurements of skin/subcutaneous tissue ultrasonography images obtained from the palpated parts. Multivariate logistic regression analysis demonstrated that dermal thickness was a significant factor that affected the difference in skin hardness between the LE and the contralateral asymptomatic leg for both thigh (p < 0.05) and calf (p < 0.01). When the thigh and calf in the LE were individually studied, subcutaneous echogenicity (p < 0.05), indicating subcutaneous inflammation/fibrosis, and subcutaneous thickness (p < 0.01) also seemed to affect skin hardness, respectively. Conclusions: The skin hardness sensed in the LE seemed to be affected predominantly by dermal thickening. In addition, the pathological changes in the subcutaneous tissue caused by LE seemed to have an impact on skin hardness. Clinical Trial Registration number 2020-150.

Hyperbaric Oxygen Therapy Is an Effective Adjunctive Therapy to Manage Treatment-Resistant Venous Leg Ulcers

We report five cases of venous leg ulcers (VLU) that were resistant to conservative therapy for 22–119 months and were eventually healed via hyperbaric oxygen therapy (HBOT). In one patient, VLU recurred four times and was managed using HBOT, each time. The VLU sizes ranged from 18 to 68 cm² before HBOT. HBOT was administered at 2.0 atmospheres absolute with 100% oxygen for 60 min per session, five sessions a week during hospitalization. All VLUs healed after 17–66 sessions of HBOT.

A pilot study using cell-mixed sheets of autologous fibroblast cells and peripheral blood mononuclear cells to treat refractory cutaneous ulcers

BACKGROUND/AIMS

We invented a cell-mixed sheet consisting of autologous fibroblast cells and peripheral blood mononuclear cells (PBMNCs) to treat refractory cutaneous ulcers. These sheets secrete the growth factors needed throughout the wound healing process in animal models.

METHODS

We performed this study as a pilot phase I clinical trial (UMIN-CTR: UMIN000031645). Fibroblast cells were isolated and cultured from the oral tissue, and PBMNCs were collected by apheresis. A cell-mixed sheet was prepared by co-culturing these collected cells for 3 days. The primary observation index was safety, including all adverse events. Additional observation indices were wound healing over 1, 3, and 6 months; wound healing rate at 7 days and 1, 3, and 6 months.

RESULTS

Six patients with venous leg ulcers (VLUs) were enrolled in the study, including three patients who were treated with the cell-mixed sheet transplantation. One patient was excluded because no fibroblast cells grew from the oral tissue culture, and other two were excluded because the growth factor secreted from mixed-cell sheets did not reach the reference value. The VLUs of two patients who received the cell-mixed sheet transplantation healed, and the VLU in one patient decreased in size.

CONCLUSIONS

This pilot study demonstrated that cell-mixed sheets might be a new topical intervention to treat VLUs. However, it was also suggested that this treatment might be limited when using autologous cells collected from patients with VLUs. Therefore, it may be necessary to use high-quality allogeneic cells instead of autologous cells to improve the feasibility of this treatment.

Interface Pressures Derived from a Tubular Elastic Bandage

Objective: We sought to clarify the interface pressure (IP) when using a tubular elastic bandage (TEB) and examine the possibility for TEBs to provide IPs comparable to those provided by anti-thrombotic stockings.

Materials and Methods: In 40 healthy patients, IPs were measured at the level of calf at its maximum diameter (C) and transition of the medial gastrocnemius muscle into the Achilles tendon (B1) while a single or double layer of TEBs (17.5 cm in circumference) were applied with the patient in a supine position.

Results: Including both the C and B1 levels, circumferences and IPs showed a good correlation (single layer; r=0.72, double layer; r=0.75). The IP obtained with a single layer of TEB at the C level (median, 17 mmHg [range, 12–23 mmHg]) was higher than that at the B1 level (14 mmHg [11–18 mmHg], p<0.001). When double-layer TEB was used, the IP at B1 level increased to 18 (14–23) mmHg (p<0.001 vs. single layer).

Conclusion: Considering the characteristics of TEBs and using a single or double layer appropriately, creating a pressure profile mimicking that of an anti-thrombotic stocking seemed to be feasible when using a TEB.

Treatment Results of Endovascular Aneurysm Repair Using the Parallel Stent-Graft Double D Technique for Distal Saccular Abdominal Aortic Aneurysms and Common Iliac Aneurysms

BACKGROUND

Endovascular aneurysm repair (EVAR) using a bifurcated stent graft may involve technical challenges when aortic disease (aneurysm or dissection) consists of a length <70 mm between the inferior renal artery and aortic bifurcation or narrow aortic bifurcation that is common in asymmetric distal abdominal aortic aneurysms (AAAs) or iliac artery aneurysms (IAAs). We use EVAR with the double D technique (DDT-EVAR) for such cases, which involves straight type of stent grafts with same diameter in left and right that are deployed parallel to an aortic cuff that has been previously placed. In addition, DDT-EVAR can preserve the inferior mesenteric artery (IMA) for IAA.

METHODS

DDT-EVAR was performed for 21 of 910 (2%) cases from April 2007 to April 2019 at our institution. The median patient age was 74 years (range, 52-85). Nineteen patients (90%) were men. Six patients (all saccular; 1 rupture) had AAAs, 12 had IAAs, and 3 had chronic type B aortic dissociation (TBAD) for re-entry closure. AAA and IAA had diameters of 45 mm (range, 34-71) and 34 mm (range, 25-58), respectively. An aortic cuff was used for 19 (90%) cases. Endurant II (Medtronic, Santa Rosa, CA) was used for 12 cases. The Excluder (W.L. Gore & Associates, Inc, Flagstaff, AZ) was used for 7 cases. Endurant II was used for 20 cases, and the VBX (W.L. Gore & Associates, Inc) was used for 1 case as stent-graft limbs.

RESULTS

The procedural success rate was 100%. The median operative time was 146 min (range, 88-324). IMA planned for preservation was successful for all 12 cases. Type I and type III endoleaks were not observed. With TBAD, flow to the false lumen decreased or disappeared, and no complications during the hospital stay were associated with the procedure. For 2 patients whose procedure involved Endurant II stent-graft limb, limb occlusions were observed postoperatively, and reintervention was required. No other patients required additional treatment at a median follow-up of 18 months (range, 4-50).

CONCLUSIONS

DDT-EVAR is a safe and straightforward technique for the treatment of distal AAA, common iliac artery aneurysm, and TBAD. It may help preserve the IMA and internal iliac artery, even when it is impossible to preserve them with a bifurcated stent graft.

Extracellular Fluid Content in the Legs of Patients with Chronic Venous Disease

BACKGROUND

This study aimed to determine the factors that affect the extracellular fluid (ECF) content in the legs of patients with chronic venous disease (CVD).

METHODS

Bioimpedance analysis and air plethysmography (APG) were performed in 79 patients with CVD who visited our clinic between September 2016 and March 2019. The normal right legs (N) of 14 healthy volunteers were also reviewed for comparison. The ratio of ECF resistance (Re) of the leg to that of the arm (ReL/ReA) was used to express the ECF content in the tested leg. The severity of CVD was expressed using the clinical, etiological, anatomical, and pathophysiological (CEAP) classification.

RESULTS

The ReL/ReA decreased as the CEAP class increased (N: median; 0.81 [range 0.66-0.95], C0-1: 0.79 [0.60-0.98], C2: 0.77 [0.56-1.08], C3: 0.67 [0.57-0.85], C4: 0.64 [0.44-0.89]). Older age, female sex, and CEAP class affected the ReL/ReA, but body mass index did not. The ReL/ReA did not correlate with the parameters that were derived from APG, including the venous filling index.

CONCLUSIONS

We found that the ECF content in legs of patients with CVD might be primarily affected by patient-related factors and CEAP class, as opposed to venous hemodynamics.

Allogeneic fibroblast sheets accelerate cutaneous wound healing equivalent to autologous fibroblast sheets in mice

BACKGROUND/AIMS

This study sought to confirm the difference of the wound-healing effect, cell survival, and immune response between autologous fibroblast sheets and allogeneic fibroblast sheets.

METHODS

Regarding wound healing, autologous or allogeneic fibroblast sheets were transplanted onto a mouse cutaneous wound healing model and the wound contraction rate was evaluated. The luciferase-expressing fibroblast sheet was prepared and the survival of the cell sheet was evaluated by IVIS^® after autologous or allogeneic transplantation. Histological evaluation was performed at five and 14 days after transplantation.

RESULTS

Allogeneic fibroblast-sheet transplantation showed significant wound contraction at the early phase of wound healing, which was equivalent to that seen with the autologous fibroblast sheets. Luminescence of the autologous and allogeneic luciferase-expressing fibroblast sheets peaked on Day 5, and no luminescence was observed on Day 13. In the allogeneic fibroblast-sheet transplant group, a significant accumulation of immune cells was observed in the healed tissue but not in the early stage of wound healing.

CONCLUSION

The allogeneic fibroblast sheets showed comparable rates of cell survival and wound-healing effects to those of the autologous fibroblast sheets, despite the subsequent immunogenic response. This result supports the potential practical clinical application of scaffold-free allogeneic fibroblast sheets based on the paracrine effect.

Endovascular Aneurysm Repair With Re-entry Closure in a Patient With Abdominal Aortic Aneurysm Concomitant With Acute Type B Aortic Dissection

Introduction

Abdominal aortic aneurysm (AAA) concomitant with acute aortic dissection is rare.

Case report

An acute type B aortic dissection involving AAA in a 58 year old woman is described. Computed tomography angiography demonstrated that the false lumen of the abdominal aorta including the aneurysm remained patent, secondary to entry sites in the abdominal aorta, bilateral external iliac arteries, and a membrane tear of the left renal artery (LRA). The aneurysm was isolated by endovascular aneurysm repair and LRA stenting; all entry sites were occluded by endovascular treatment that included covered stenting of the LRA. Imaging performed three months after the procedure confirmed complete thrombosis of the false lumen and AAA sac shrinkage.

Discussion

Endovascular treatment with covered stents is reported as an alternative strategy for treatment of AAA concomitant with acute aortic dissection involving a visceral artery.

•

A 58 year old woman developed acute type B aortic dissection involving an AAA.

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AAA concomitant with acute aortic dissection is rare.

•

Endovascular treatment using a covered stent of the visceral artery can be effective.

Perioperative variations in indices derived from noninvasive assessments to detect postmastectomy lymphedema

OBJECTIVE

This study aimed to clarify the variations in indices derived from noninvasive assessments for the early detection of postmastectomy lymphedema (LE) from 1 month preoperatively until 2 years postoperatively.

METHODS

In total, 120 patients who underwent surgery for breast cancer in our institution were prospectively followed up with a questionnaire for arm swelling as well as with tape measurements, bioimpedance analysis (BIA), and skin and subcutaneous tissue ultrasound at 1 month before and 3, 6, 12, 18, and 24 months after surgery.

RESULTS

Ninety-seven patients completed the study. Among 93 patients who did not present with LE, 9% complained of arm swelling even before surgery, and the incidence peaked at 17% at 6 months after surgery. There were no differences in the circumferences of the upper arm, forearm, and hand between sides throughout the study period. However, the postoperative circumference values of the upper arm only on the operation side were slightly increased compared with the preoperative values. The mean excess fluid in the arm on the operation side compared with the contralateral side, as assessed by BIA, was nearly zero throughout the study period. There were no differences in subcutaneous echogenicity or skin and subcutaneous thicknesses between the sides throughout the study period. However, time-dependent increases in subcutaneous thicknesses were noticed on both sides. Four patients (4.1%) developed LE. In three of these patients, abnormality in the BIA was recorded 6 to 12 months before presentation. Immediately after presentation, the common findings included BIA abnormality and increased subcutaneous echogenicity and skin thickness in the medial forearm.

CONCLUSIONS

In this study, a complaint of arm swelling was not sensitive enough for detection of the early onset of LE because a certain number of patients constantly complained of this symptom. Measurements of circumference might help in the diagnosis of LE onset, but this method is not specific enough because these measurements are also affected by various factors. However, BIA and skin and subcutaneous ultrasound were identified as potential tools for the early detection of LE.

Compression Therapy Using Bandages Successfully Manages Acute or Subacute Lipodermatosclerosis

We report nine cases with acute or subacute lipodermatosclerosis treated successfully using multilayer bandages. All patients were women aged 52-90 years. Before presenting to our clinic, all patients had been treated for a tentative diagnosis of cellulitis caused by bacterial infection or inflammation of unknown cause for 3-19 weeks without improvement. Initially, we instructed all patients or their caregivers regarding the bandaging technique to achieve an interface pressure of >40 mmHg. Subsequently, this technique was continued by patients/caregivers. Symptoms subsided within 2-7 weeks in all patients except one who had been noncompliant with the compression therapy.

Chimney Endovascular Aneurysm Repair Using Endurant Stent-Grafts With Bare Balloon-Expandable Stents for Patients With Juxtarenal Aortic Aneurysms

PURPOSE

To evaluate the advantages of chimney endovascular aneurysm repair (chEVAR) using an Endurant stent-graft with uncovered balloon-expandable stents (BES) for patients with juxtarenal aortic aneurysms.

MATERIALS AND METHODS

Twenty-two patients (mean age 78.5±9.0 years; 13 men) who underwent chEVAR using Endurant and uncovered BES between January 2014 and December 2017 were analyzed retrospectively. The maximum aneurysm diameter was 59.1±11.9 mm, and the proximal neck length was 5.2±2.9 mm. Of the 22 cases, 9 (40%) involved proximal neck angulation and 9 (40%) had a conical neck. Single and double chimneys were performed using BES in 19 and 3 cases, respectively. In 2 cases, an additional self-expanding covered stent was used inside the uncovered BES.

RESULTS

The technical success was 91% (20/22) as 2 (9%) cases showed minor type Ia endoleak. No postoperative systemic complications or acute renal dysfunction (Acute Kidney Injury Network classification stage 2 or higher) were observed. The mean radiologic observation period was 16.1±9.6 months, and no aneurysm expansion (>5 mm) was observed during this time. The mean maximum aneurysm diameter decreased to 52.9±10.2 mm (p<0.001 vs preoperative), with an individual mean sac regression of 6.2±5.9 mm. Overall primary chimney stent patency was 100%. One of the 2 cases of intraoperative type Ia endoleak resolved at the 6-month imaging, and no new type Ia endoleaks developed in any cases at follow-up. No additional treatment- or aneurysm-related events were observed.

CONCLUSION

Short-term outcomes of chEVAR using Endurant with uncovered BES have been favorable when covered stents were unavailable, and it can be useful for high-risk patients with juxtarenal aortic aneurysms.

Using bifurcated endoprosthesis after iliac artery recanalization for concomitant abdominal aortic aneurysm and chronic total occlusions of access routes

OBJECTIVE

Concurrent abdominal aortic aneurysm (AAA) and unilateral iliac occlusion is a challenge in the implantation of bifurcated stent grafts (BFGs). The endovascular approach is less invasive than open surgery; the aortouni-iliac (AUI) graft with crossover femorofemoral bypass (CFFB) has many problems associated with extra-anatomic reconstruction. We attempted endovascular aneurysm repair (EVAR) using BFGs in such cases and evaluated the outcomes.

METHODS

This was a retrospective study. Between October 2012 and December 2017, there were 649 patients who underwent surgery for AAA, of whom 32 patients underwent open reconstruction and 617 patients underwent endovascular aneurysm repair; 15 patients with unilateral occluded iliac arteries and AAA were included. The analysis included patients with unilateral iliac chronic total occlusion (CTO). The intraoperative, postoperative, and follow-up variables were reviewed.

RESULTS

The occluded lesions were the common iliac artery in 5 patients, the common iliac artery-external iliac artery (EIA) in 2 patients, the EIA in 7 patients, and the EIA-common femoral artery in 1 patient. The mean occlusive length was 89.7 ± 43.6 mm, and the mean AAA size was 54.6 ± 5.6 mm. Technical success was achieved in 13 patients (87%). All patients underwent recanalization through the true lumen and stent placement. The only procedure-related complication was distal embolism, which was treated with intraoperative thrombectomy. Recanalization of CTO lesions was not possible in two patients (13%), who underwent AUI graft placement with CFFB. The 30-day mortality and morbidity rates were 0%. The mean follow-up periods were 12 and 32 months for patients who underwent BFG placement and AUI graft placement with CFFB, respectively. During follow-up, the primary patency rate of successfully recanalized arteries was 100%. Aneurysm size decreased in four patients who underwent BFG placement; no change was seen in the other 11 patients. Freedom from aneurysm-related events was 100%; no patient needed secondary interventions. All patients with claudication pain preoperatively reported improvement in their symptoms during follow-up. In addition, the ankle-brachial index improved significantly from 0.51 ± 0.25 preoperatively to 0.88 ± 0.20 postoperatively (P < .001) in patients who underwent BFG placement.

CONCLUSIONS

Recanalization of unilateral iliac CTO lesions and placement of BFG in cases with concomitant aneurysmal disease and unilateral iliac occlusive disease demonstrated a significant primary patency rate with improvements in claudication and ankle-brachial index.

Effectiveness of Embolization of Inferior Mesenteric Artery to Prevent Type II Endoleak Following Endovascular Aneurysm Repair: A Review of the Literature

Type II endoleak is a common complication that develops after endovascular aneurysm repair. Patients with type II endoleak, which has persisted for 6 months, have a significantly higher rate of aneurysmal sac enlargement, reintervention, and rupture. To date, several studies have examined the effectiveness of preoperative embolization of branch vessels for the prevention of type II endoleak. Particularly, the embolization of the large inferior mesenteric artery (IMA) seems to be a precise, safe, and effective method. IMA is a significant risk factor for type II endoleak. However, there is currently no strong evidence to prove which patients would benefit from preventive IMA embolization. In addition, considering the incidence of type II endoleak and the adverse event rate, routine embolization seems to be unreliable and time-consuming. Moreover, previous reports of preoperative IMA embolization were retrospective. Thus, prospective and randomized studies are necessary so that the usefulness of IMA embolization can be proved and the potential benefits can be assessed. To establish preventive IMA embolization as one of the effective therapeutic strategies to prevent type II endoleak and to maximize its therapeutic effect, we should provide a wide range of therapeutic strategies to suit the state of the patient.

Aggressive Decongestion in Limbs with Lymphedema without Subcutaneous Echo-Free Space

BACKGROUND

To study the impact of aggressive decongestion in limbs with lymphedema without subcutaneous echo-free space (SEFS) in subcutaneous tissue ultrasonography.

METHODS

In 13 patients with arm lymphedema (ALE) (13 arms) and 16 patients with leg lymphedema (LLE) (18 legs) without SEFS, an aggressive decongestion was performed as the first phase of complex decongestive therapy. Measurements of circumference and calculation of limb volume were performed before and after the treatment.

RESULTS

In ALE, no significant reduction in arm volume (median -63 [range -251 to 176] mL) or edema ratio (-4 [-15 to 12]%) was confirmed. On the other hand, a small but significant reduction in leg volume (-207 [-834 to 131] mL, P < 0.001) and edema ratio (-4 [-14 to 2]%, P < 0.01) was confirmed in LLE.

CONCLUSION

In limbs with lymphedema without SEFS, the impact of aggressive decongestion seemed limited.

Venous hemodynamics assessed with air plethysmography in legs with lymphedema

This study was conducted to identify specific abnormalities using the results from air plethysmography in legs with lymphedema. A routine air plethysmography exercise protocol was performed in 31 patients with unilateral leg lymphedema, and the results were compared with those of 53 patients with unilateral great saphenous vein reflux and 15 normal subjects. The venous filling index in legs with lymphedema (2.1 ± 1.2 mL/sec) was smaller than in legs with great saphenous vein reflux (6.4 ± 4.1 mL/sec, p < 0.05), but was not different from that in normal legs (1.9 ± 1.2 mL/sec). The ejection fraction was similar in all groups. The residual volume fraction in legs with lymphedema (35 ± 32%) was larger than that in normal subjects (13 ± 23%, p < 0.05), but was not significantly different from that in the contralateral leg of the lymphedema patients (32 ± 27%). In conclusion, we found no specific air plethysmography findings in uncomplicated lymphedema.

Peculiar clinical features of cellulitis in peripheral lymphedema

Although the occurrence of cellulitis in lymphedema (LE) is believed to be an infection-related event, many findings in its clinical course seem to suggest that it is unlikely to be an infection. Therefore, we tried to clarify the specific features of cellulitis in LE. In-hospital courses of cellulitis obtained from medical charts were reviewed in the patients with leg LE (LE; 24 patients, 72admissions), chronic venous insufficiency (CVI; 28 patients, 29 admissions), and leg cellulitis secondary to wound infection without underlying disease (N; 42 patients, 42 admissions). The patients with LE complained of less local pain (peak numerical scale; LE: 1.4 ± 1.7, CVI: 4.1 ± 2.5, N: 3.2 ±2.0, p < 0.0001), showed an abnormally higher peak procalcitonin level (LE: 33.8 ± 34.8 (N = 7), CVI: 2.9 ± 5.8 (N = 8), N: 0.4 ± 0.6(N = 10), p < 0.05), and required fewer antibiotics (LE: 1.1 ± 0.3, CVI: 1.8 ± 0.9, N: 1.5 ± 0.9, p < 0.0001). These findings suggested that the occurrence of cellulitis in LE seems unlikely to be an infection-related type of cellulitis similar to that found in CVI.

Pleth variability index can predict spinal anaesthesia-induced hypotension in patients undergoing caesarean delivery

BACKGROUND

Spinal anaesthesia carries a risk of hypotension. We hypothesized that pleth variability index and perfusion index would assess maternal volume status, and thus, allow identification of patients at higher risk of developing hypotension after spinal anaesthesia for caesarean delivery.

METHODS

Fifty patients undergoing elective caesarean delivery were enrolled. All patients received spinal anaesthesia with 0.5% hyperbaric bupivacaine (10 mg) and fentanyl (10 mcg). Blood pressure was measured every minute. Pleth variability index and perfusion index were automatically measured throughout the procedure using pulse oximetry on the index finger. In case of hypotension (systolic blood pressure below 90 mmHg or 80% of the baseline value), ephedrine 5 mg was administered. Receiver-operating characteristic and multivariate logistic regression analyses for spinal anaesthesia-induced hypotension were performed.

RESULTS

Hypotension occurred in 32 patients (64%). The areas under the receiver-operating characteristic curve were 0.751 (95% confidence interval: 0.597-0.904) for pleth variability index before anaesthesia, 0.793 (95% confidence interval: 0.655-0.930) for pleth variability index after anaesthesia and 0.731 (95% confidence interval: 0.570-0.892) for perfusion index change (percent change in perfusion index induced by spinal anaesthesia). The optimal threshold value of pleth variability index (after anaesthesia) for predicting hypotension was 18% (sensitivity: 78.1%, specificity: 83.3%). Pleth variability index after spinal anaesthesia was an independent factor for hypotension (odds ratio: 1.21, P = 0.041).

CONCLUSIONS

Pleth variability index after spinal anaesthesia was a good predictor of spinal anaesthesia-induced hypotension in patients undergoing caesarean delivery. In addition, perfusion index change after spinal anaesthesia has the potential to predict hypotension.

Local Echo-Free Space in a Limb with Lymphedema Represents Extracellular Fluid in the Entire Limb

BACKGROUND

We previously reported that local subcutaneous echo-free space (SEFS) in the leg was stirringly correlated with extracellular fluid (ECF) status in the same part of the leg when assessed using bioelectrical impedance analysis (BIA). In this study, we examined whether local SEFS represents the ECF status in the entire limb.

METHODS AND RESULTS

In 51 legs and 40 arms with lymphedema (LE), subcutaneous tissue ultrasonography was performed to determine SEFS severity (range, 0-2). BIA was also performed to calculate the L-Dex^® score (LDS), which is a BIA-derived parameter to represent ECF status, for the arm and modified LDS (mLDS) for the leg (the right arm was used as a reference instead of the contralateral leg). SEFS severity in any part of the leg showed good correlation with mLDS, but that in the lateral lower calf showed the strongest correlation (ρ = 0.86). In contrast, only SEFS severity in the medial forearm showed good correlation with LDS (ρ = 0.74).

CONCLUSIONS

Local SEFS may represent ECF status in the entire limb in both the leg and arm LE.

Correlation Between the Severity of Subcutaneous Echo-Free Space and the Amount of Extracellular Fluid Determined by Bioelectrical Impedance Analysis of Leg Edema

BACKGROUND

Both subcutaneous echo-free space (SEFS) observed by ultrasonography and the ratio of intracellular fluid resistance to extracellular fluid resistance (R_i/R_e) calculated from bioelectrical impedance analysis (BIA) represent extracellular edema status in the extremities. We tried to correlate these parameters.

METHODS AND RESULTS

In 70 legs with venous edema (VE) and 68 legs with lymphedema (LE), subcutaneous tissue ultrasonography to determine SEFS severity (range, 0-2) and BIA to calculate R_i/R_e were performed. In the calf, SEFS severity showed good linear correlation with R_i/R_e, particularly in the lower lateral calf where the mean R_i/R_e for LE (SEFS grade 0: 3.2 ± 0.8; SEFS grade 1: 4.0 ± 0.9; SEFS grade 2: 6.3 ± 3.6) and VE (SEFS grade 0: 3.6 ± 0.6; SEFS grade 1: 4.4 ± 1.6; SEFS grade 2: 5.3 ± 2.0) was similar. In the thigh, a mild correlation was confirmed only in LE.

CONCLUSIONS

It may be concluded that SEFS in the lower calf area well represents the local fluid status regardless of the type of edema, but not so in the thigh.

Self-Care-Based Treatment Using Ordinary Elastic Bandages for Venous Leg Ulcers

Objective: We aimed to study venous leg ulcer (VLU) healing and recurrence rates of VLU using a self-care-based treatment strategy. Methods: The study included 36 patients (43 legs) who visited our clinic between April 2009 and June 2015 because of non-healing VLUs and who had been treated by us for more than a year (until June 2016). Patients or their caregivers were first provided instructions for performing the "no-intentional-stretch" bandaging technique using ordinary elastic bandages. Wounds were cleansed with tepid water daily, and bandages were re-applied by patients or their caregivers; this was continued until VLUs were healed. Compression was discontinued after healing, but was restarted if persistent swelling and/or dermatitis was noticed on their legs. Results: The median ulcer size was 6.5 cm² (range, 1-105 cm²). The median number of clinic visits until healing was six (range, 3-35). The 6- and 12-month healing rates were 67% and 86%, respectively. Twenty (44%) legs required compression therapy after VLU healing. The cumulative recurrence-free rate at 60 months was 86%. Conclusion: Reasonable healing and recurrence rates were achieved by applying a self-care-based VLU treatment strategy.

Skin and Subcutaneous Tissue Ultrasonography Features in Breast Cancer-Related Lymphedema

Objective: To investigate skin, subepidermal low echogenic band (SELEB), and subcutaneous tissue (SCT) thickness as well as the degree of increase in subcutaneous echogenicity (SEG) and subcutaneous echo-free space (SEFS) in arms with lymphedema (LE). Materials and Methods: The skin and SCT of both arms of 30 patients with unilateral stage II breast cancer-related LE were scanned at five points (medial/lateral upper arm/forearm and dorsum of the hand). SEG and SEFS grades were determined according to severity (range: 0-2). Results: All measured parameters, except the SEFS in the medial upper arm, were significantly higher on the LE side than on the normal (N) side. The parameters differed most remarkably in the medial forearm (MFA; skin: LE 1.7 ± 0.8 mm vs. N 0.8 ± 0.2 mm; SELEB: LE 1.0 ± 0.6 mm vs. N 0.3 ± 0.1 mm; SCT: LE 8.7 ± 3.4 mm vs. N 3.8 ± 2.0 mm; SEG: LE 0.9 ± 0.5 vs. N 0.1 ± 0.3; and SEFS: LE 0.5 ± 0.7 vs. N 0). Conclusion: The differences in the thickness of the skin, SELEB, and SCT and the SEG and SEFS grades between the LE and N arms seemed most evident in the MFA.

Distribution of Extracellular Fluid in Legs with Venous Edema and Lymphedema

BACKGROUND

This study aimed to determine the specific fluid distribution pattern in legs with lymphedema (LE) in comparison to normal legs and legs with venous edema (VE) using bioelectrical impedance analysis (BIA).

METHODS AND RESULTS

BIA was performed in 47 patients with lymphedema (LE; 63 legs), 33 patients with venous edema (VE; 60 legs), and 33 normal subjects (N; 66 legs). The ratio of intracellular fluid (ICF) resistance (Ri) to extracellular fluid (ECF) resistance (Re) of a whole leg normalized to the right arm (Ri/Re leg), a surrogate parameter for ECF/ICF, and the Ri/Re of the thigh and calf without normalization (Ri/Re thigh, Ri/Re calf, respectively) were obtained. Increases in Ri/Re leg (N 2.5 ± 0.7, VE 3.9 ± 3.7, LE 3.7 ± 1.5), Ri/Re thigh (N 1.8 ± 0.5, VE 3.2 ± 3.8, LE 3.8 ± 1.9), and Ri/Re calf (N 2.6 ± 0.6, VE 4.6 ± 1.7, LE 4.4 ± 2.2) were confirmed in VE and LE compared to normal subjects. However, the ratios of Ri/Re calf to Ri/Re thigh in normal subjects and those with untreated VE/LE were all ∼1.5 (N 1.5 ± 0.3, VE 1.5 ± 0.7, LE 1.6 ± 0.7).

CONCLUSIONS

Fluid content was increased in legs with VE and LE compared to normal subjects, while the mode of gravitational fluid distribution was similar among all legs. Thus, no specific finding for LE was confirmed.

Risk Factors in Patients with Venous Stasis-Related Skin Lesions without Major Abnormalities on Duplex Ultrasonography

Purpose: To clarify the risk factors for venous stasis-related skin lesions in the legs in patients without major abnormalities on duplex ultrasonography (DUS). Methods: Fifty patients (nine males and 41 females, age 27-93 years) with symptoms of C4 or greater according to the Clinical, Etiological, Anatomical, Pathological (CEAP) classification, but having no abnormalities on DUS were reviewed for known risk factors for chronic venous insufficiency (CVI) such as older age (>70 years), obesity (body mass index [BMI] >30 kg/m²), short walking distance (<200 m/day), reduced ankle range of motion (<20°), and occupation requiring prolonged standing (>8h per day). Results: The risk factor was different between male and female patients; although all patients had at least one of the above risk factors, the most commonly found risk factor in male patients was occupation requiring prolonged standing (63%), while advanced age (78%) and limited walking distance (83%) were risk factors in female patients. Conclusions: Although male and female patients had different risk factors, insufficient walking seemed to be closely related to the development of venous stasis-related skin lesions.

Adherence to and efficacy of different compression methods for treating chronic venous insufficiency in the elderly

Objectives To investigate the adherence to and efficacy of different compression methods in elderly patients. Methods A retrospective review of compression therapy in 120 elderly patients (≥65 years) with chronic venous insufficiency was performed to study the initially preferred compression method, adherence to each method, and its efficacy. Results Initially, an oversize strong stocking (24%), an appropriate size moderate stocking (19%), and bandages (37%) were equally preferred. Adherence at 1 month was 69%, 96%, and 91%, respectively, and they reduced ankle circumferences in C3 patients by 1.8 ± 1.9 cm, 0.3 ± 1.7 cm, and 2.9 ± 1.7 cm, respectively. The improvement rates of C4 symptoms were 79%, 60%, and 91%, respectively. Only three patients (2%) preferred an appropriate size strong stocking. Conclusions In elderly patients, an appropriate size strong stocking was not preferred. The best adherence was achieved by using a moderate stocking, while the best efficacy was achieved by using bandages.

Immediate Changes to Skin and Subcutaneous Tissue Strains Following Manual Lymph Drainage in Legs with Lymphedema

OBJECTIVES

To study the immediate impact of manual lymph drainage (MLD) on skin and subcutaneous tissue strains in legs with lymphedema using free-hand real-time tissue elastography (RTE).

METHODS

Skin and subcutaneous tissue strain measurements were taken at the middle of the inner thigh and calf by RTE in 20 legs with lymphedema of 18 patients (stage II: 11, late stage II: 7, stage III: 2) and in 70 legs of 35 normal subjects. In patients with lymphedema, the same measurements were repeated immediately following MLD.

RESULTS

Significant negative correlations were found between pre-MLD strains and the MLD-induced changes in thigh and calf skin strains (thigh skin: p <0.01, calf skin: p = 0.05), but not in subcutaneous tissue strains. Pre-MLD intercepts of these regression lines were closer to normal values as compared to mean pre-MLD values (normal thigh skin: 0.54% ± 0.30%, calf skin: 0.25% ± 0.18%, Pre-MLD thigh skin: 0.39% ± 0.20%, calf skin: 0.17% ± 0.12%, Pre-MLD intercept of thigh skin: 0.48%, Pre-MLD intercept of calf skin: 0.31%).

CONCLUSIONS

It appears that MLD did not simply soften the skin, but rather normalized it in terms of strain. However, this was not confirmed in the subcutaneous tissue.

Combinatorial Treatment with Apelin-13 Enhances the Therapeutic Efficacy of a Preconditioned Cell-Based Therapy for Peripheral Ischemia

Hypoxic pretreatment of peripheral blood mononuclear cells (PBMNCs) enhances therapeutic angiogenesis in ischemic tissues after cell transplantation. However, newly formed vessels generated using this approach are immature and insufficient for promoting functional recovery from severe ischemia. In this study, we examined whether apelin-13, a regulator of vessel maturation, could be an effective promoter of therapeutic angiogenesis, following severe limb ischemia. Combinatorial treatment of hypoxic preconditioned PBMNCs with apelin-13 resulted in increased blood perfusion and vascular reactivity in ischemic mouse hindlimbs compared with a monotherapy comprising each factor. Apelin-13 upregulated expression of PDGF-BB and TGF-β1 in hypoxic PBMNCs, as well as that of PDGFR-β in vascular smooth muscle cells (VSMCs). Proliferation and migration of VSMCs treated with apelin-13 was accelerated in the presence of PDGF-BB. Interestingly, expression of an apelin receptor, APJ, in PBMNC was increased under hypoxia but not under normoxia. In addition, an in vitro angiogenesis assay using a co-culture model comprising mouse thoracic aorta, hypoxic PBMNCs, and apelin-13 demonstrated that combinatorial treatment recruited mural cells to sprouted vessel outgrowths from the aortic ring, thereby promoting neovessel maturation. Thus, combinatorial injection of hypoxic PBMNCs and apelin-13 could be an effective therapeutic strategy for patients with severe ischemic diseases.

Differentiation of High and Low Output Lymphatic Failure Using Qualitative Lymphangioscintigraphy

PURPOSE

To use qualitative lymphangioscintigraphy (LAS) findings to differentiate leg edema caused by high and low output lymphatic failure.

METHODS

LAS was performed in legs with secondary lymphedema (LE), i.e., low output failure (N = 79), and functional venous insufficiency (FVI), i.e., high output failure (N = 56), and normal legs (N = 26). Whole body images were obtained, 15, 60, and 180 min after technetium-99m injection. The rate and timing of visualization of lymphatic structures, washout out of tracer, and presence of dermal backflow were assessed.

RESULTS

The most significant finding for differentiating LE from other conditions was not the visualization of lymphatic structures, but the washout of the tracer from the leg trunk (LE 27%, FVI 100%, normal leg 100%, P <.0001). On the other hand, the most significant finding for differentiating FVI from other legs was the visualization of inguinal lymph nodes at 15 min (LE 11%, FVI 82%, normal leg 8%, P <.0001).

CONCLUSIONS

We found that the lack of washout from the leg trunk was most suggestive of a low output status of the lymphatic system, while earlier visualization of inguinal lymph nodes was suggestive of a high output status.

Skin and subcutaneous tissue strain in legs with lymphedema and lipodermatosclerosis

We compared skin and subcutaneous tissue strains in legs with lymphedema (LE) of varying severity and legs with lipodermatosclerosis (LDS) using real-time tissue elastography. Strain was assessed at the inner thigh and calf in 62 legs with LE (International Society of Lymphology [ISL] stage 0: 16, stage I: 5, stage II: 28, late stage II: 7, stage III: 6) and 15 legs with LDS. In thighs and calves with LE, skin strain and subcutaneous tissue strain did not significantly differ between ISL stage 0, that is, asymptomatic legs, and other stages. However, strain values in calves with LDS were lower than values in calves with stage 0, II and late II LE. These results indicate that skin and subcutaneous tissue strains were not lower in legs with symptomatic LE than in asymptomatic legs until an advanced stage.

Effect of three-size too large strong stocking on venous hemodynamics in normal subjects

OBJECTIVES

To study the differences in impact on venous hemodynamics between larger size strong graduated elastic compression stockings (GECS) and appropriate size strong/moderate GECS.

METHOD

In healthy legs fitted for a small (Group S; n = 8) and large (Group L; n = 8) GECS, air plethysmography was performed without GECS, with an appropriate size strong GECS (GECS1), with a three-size too large strong GECS (GECS2), and with an appropriate size moderate GECS (GECS3) in this order.

RESULTS

In Group S, interface pressure with GECS2 was equal to or higher than that with GECS3. Decreased venous volume, unchanged ejection volume, and decreased residual volume were achieved by GECS, but differences in these parameters among GECS were not observed. Although insignificant, a similar tendency was found in Group L.

CONCLUSIONS

A larger size strong GECS seemed to have equivalent interface pressure and impact on venous hemodynamics compared to an appropriate size moderate or strong GECS.

Goal-Directed fluid therapy with closed-loop assistance during moderate risk surgery using noninvasive cardiac output monitoring: A pilot study

BACKGROUND

Goal directed fluid therapy (GDFT) has been shown to improve outcomes in moderate to high-risk surgery. However, most of the present GDFT protocols based on cardiac output optimization use invasive devices and the protocols may require significant practitioner attention and intervention to apply them accurately. The aim of this prospective pilot study was to evaluate the clinical feasibility of GDFT using a closed-loop fluid administration system with a non-invasive cardiac output monitoring device (Nexfin™, BMEYE, Amsterdam, Netherlands).

METHODS

Patients scheduled for elective moderate risk surgery under general anaesthesia were enrolled. The primary anaesthesia team managing the case selected GDFT targets using the controller interface and all patients received a baseline 3 ml kg(-1) h(-1) crystalloid infusion. Colloid solutions were delivered by the closed-loop system for intravascular volume expansion using data from the Nexfin™ monitor. Compliance with GDFT management was defined as acceptable when a patient spent more than 85% of the surgery time in a preload independent state (defined as pulse pressure variation <13%) or when average cardiac index during surgery was >2.5 litre min(-1) m(-2).

RESULTS

A total of 13 patients were included in the study group. All patients met the established criteria for delivery of GDFT for greater than 85% of case time. The median length of stay in the hospital was 5 [3-6] days.

CONCLUSION

In this pilot study, GDFT management using the closed-loop fluid administration system with a non-invasive CO monitoring device was feasible and maintained a high rate of protocol compliance.

CLINICAL TRIAL REGISTRATION

NCT02020863.