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Purpose: Revascularization of both endovascular therapy (EVT) and surgical reconstruction improve clinical outcomes of patients with critical limb ischemia (CLI); however, treatment of dialysis-dependent patients with CLI is still challenging. This study aimed to investigate the impact of dialysis-related parameters on the risk of mortality in dialysis-dependent patients undergoing revascularization for CLI. Materials and Methods: We retrospectively identified 274 dialysis-dependent patients with CLI (196 males; mean age 71 years), who underwent revascularization, from the clinical database of the surgical reconstruction vs peripheral intervention in patients with critical limb ischemia (SPINACH) study, which was a prospective, multicenter, observational study. Of these patients, 175 patients underwent EVT and 99 patients received surgical reconstruction. The current study evaluated the impact of dialysis vintage and renal biomarkers on the mortality rate of dialysis-dependent patients with CLI undergoing revascularization. Results: During a mean follow-up period of 1.7 ± 1.1 years, 147 deaths were observed. The 3-year overall survival rate and its standard error were estimated to be 40.5% ± 8.1% using the Kaplan-Meier method. A Cox proportional hazard analysis revealed that dialysis vintage ≥4 years, serum creatinine levels 2/dL2 were independent risk factors for mortality after adjustment for the detailed mortality risk score developed in the SPINACH study. Adding these parameters to the original mortality risk score slightly, but not significantly, increased the area under the time-dependent receiver operating characteristics curve from 0.74 (95% CI, 0.67 to 0.81) to 0.77 (0.71 to 0.84) (p=0.084), whereas continuous net reclassification improvement reached 0.75 (0.12 to 0.90) (p=0.027). Conclusion: We found that long dialysis vintage, low serum creatinine, high serum urea nitrogen, and high calcium-phosphate product were independently associated with the increased risk of mortality in dialysis-dependent patients with CLI undergoing revascularization.

The dynamic coronary roadmap (DCR) is a novel technology that creates a dynamic, motion-compensated, real-time overlay of the coronary arteries on a fluoroscopic image. Whether the DCR reduces contrast volume and enables safe and effective treatment was examined. A total of 146 patients undergoing percutaneous coronary intervention (PCI) from June 2017 to September 2017 in our hospital were retrospectively evaluated. Chronic total occlusion lesions, acute coronary syndrome, and hemodialysis patients were excluded. Patients were divided into the control group (PCI without DCR, 92 patients, 103 lesions) and the DCR group (38 patients, 43 lesions). The primary endpoint was contrast medium volume, and secondary endpoints were radiation dose, fluoroscopy time, and clinical success rate. There was no significant difference in the success rate (100% vs. 100%, P = 1.000) between the groups. Fluoroscopy time (16.3 ± 11.2 min. vs. 11.4 ± 5.5 min, P = 0.007) and contrast medium volume (152.1 ± 73.0 ml vs. 118.8 ± 49.7 ml, P = 0.006) were significantly lower in the DCR group than in the control group. DCR use during PCI was associated with a significant reduction in contrast volume and fluoroscopy time compared to a control group despite similar clinical, lesion, and procedural characteristics.

No scoring system for evaluating the bleeding risk of atrial fibrillation (AF) patients after drug-eluting stent (DES) implantation with triple antithrombotic therapy (TAT) is available. We aimed to develop a new scoring system for predicting bleeding complications in AF patients after DES implantation with TAT.Between April 2007 and April 2014, 227 AF patients undergoing DES implantation with TAT were enrolled. Bleeding incidence defined as Bleeding Academic Research Consortium criteria≥2 was investigated and predictors of bleeding complications were evaluated using multivariate analysis. Bleeding complications occurred in 58 patients (25.6%) during follow-up. Multivariate analysis revealed dual antiplatelet therapy (DAPT) continuation (OR 3.33, P=0.01), age75 (OR 2.14, P=0.037), international normalized ratio2.2 (OR 5.82, P0.001), gastrointestinal ulcer history (OR 3.06, P=0.037), and anemia (OR 2.15, P=0.042) as predictors of major bleeding complications. A score was created using the weighted points proportional to the beta regression coefficient of each variable. The DAIGA score showed better predictive ability for bleeding complications than the HAS-BLED score (AUC: 0.79 vs. 0.62, P=0.0003). Bleeding incidence was well stratified: 17.8% in low-risk (scores 0-1), 55.5% in moderate-risk (2-3), and 83.0% in high-risk (4-7) patients (P0.001).This scoring system is useful for predicting bleeding complications and risk stratification of AF patients after DES implantation with TAT.

Objectives This study sought to investigate the characteristics of in-stent restenosis (ISR) after drug-eluting stent (DES) implantation for femoropopliteal (FP) lesions, and to examine 1-year prognosis after repeat endovascular therapy (re-EVT) for these DES-ISR. Background The morphology of DES-ISR and its association with clinical outcomes after re-EVT have not been well examined. Methods This was a subanalysis of the ZEPHYR (Zilver PTX for the femoral artery and proximal popliteal artery) study. The current study included 210 cases with loss of patency confirmed 1 year after DES implantation. Morphology of DES-ISR was classified into the following subgroups: class I, focal lesions (≤50 mm in length), class II, diffuse lesions (>50 mm in length), and class III, totally occluded ISR. One-year prognosis after re-EVT for DES-ISR was assessed by restenosis and major adverse limb events (MALE). Results Classes I, II, and III accounted for 50%, 25%, and 25% of DES-ISR, respectively. Factors associated with the morphology of DES-ISR were the presence of chronic total occlusion and the size of the external elastic membrane area before DES implantation (p = 0.009 and 0.017). Compared with the class I restenotic lesion, the class II and III lesions had a significantly higher risk of restenosis (74% and 78% vs. 53%: p = 0.048 and 0.019, respectively) and MALE (56% and 56% versus 32%: p = 0.025 and 0.022, respectively) 1 year after re-EVT. Conclusions We evaluated the characteristics of ISR after DES implantation for FP lesions and 1-year prognosis of re-EVT for DES-ISR. The morphology of DES-ISR had a significant association with 1-year prognosis after re-EVT.

SUMMARY In this paper, an angle detecting system is proposed that calculates the offset correction values for the sine and cosine signals of angle sensors. The offset correction values are calculated not from the offset errors of the sine and cosine signals but from the 1f angle error (the fundamental frequency component of the sine and cosine signals) of the angle signals. Therefore, the system can correct the 1f angle error even when the sine and cosine signals contain the double-frequency components of the sine and cosine signals, as well as the dc offset errors. Moreover, it is possible to use low-cost microcomputers with low computing speed, because the offset correction values are dc quantities.

Aim The optimal fractional flow reserve (FFR) measurement method for superficial femoral artery (SFA) lesions remains to be established. We clarified the optimal measuring procedure for FFR for SFA lesions and investigated the necessary dose of papaverine for inducing maximal hyperemia in SFA lesions. Methods Forty-eight patients with SFA lesions who underwent measurement of peripheral FFR (pFFR: distal mean pressure divided by proximal mean pressure) after endovascular treatment by the contralateral femoral crossover approach were prospectively enrolled. In the pFFR measurement, a guide sheath was placed on top of the common iliac bifurcation and pressure equalization was performed. After advancing the pressure wire distal to the SFA lesion, sequential papaverine administration selectively to the affected common iliac artery was performed. Results There were no symptoms, electrocardiogram changes, and significant pressure drops at the guide sheath tip with increasing papaverine dose. pFFR changes following 20, 30, and 40 mg of papaverine were 0.87±0.10, 0.84±0.10, and 0.84±0.10, respectively (P＜0.001). Although not significantly different, pFFR decreased more in several patients at 30 mg of papaverine than at 20 mg. The pFFR at 40 mg of papaverine was almost similar to that at 30 mg of papaverine. The necessary papaverine dose was not changed according to sex and number of run-off vessels. Conclusions The contralateral femoral crossover approach is useful in FFR measurement for SFA lesions, and maximal hyperemia is induced by 30 mg of papaverine.

Wound severity is assessed mainly by the Rutherford classification for critical limb ischemia (CLI) with tissue loss. The Rutherford classification is based on the extent of tissue loss; however, its classification criteria are ambiguous and do not include information regarding wound depth. We investigated the effects of wound depth on clinical outcomes in CLI with tissue loss after endovascular treatment (EVT).Between April 2007 and August 2013, we enrolled 210 consecutive patients (247 limbs) who received EVT for CLI with tissue loss. In the limbs examined, 271 individual wounds existed. We evaluated wound depth using the University of Texas grade (grade 1: superficial wound not involving the tendon, capsule, or bone, n = 97; grade 2: wound penetrating the tendon or capsule, n = 124; and grade 3: wound penetrating the bone or joint, n = 50). We also investigated the wound healing rate at 12 months and limb salvage and major amputation-free survival rates 3 years after EVT.The wound healing rates at 12 months in Texas 1, 2, and 3 were 88%, 48%, and 24%, respectively (log-rank P.001). The limb salvage and major amputation-free survival rates at 3 years were lower in deep wounds than in shallow wounds (limb salvage rates: 98%, 82%, and 67%, respectively; P.001; major amputation-free survival rates: 78%, 52%, and 42%, respectively; P.001). In only minor tissue loss, the wound healing rates at 12 months and the limb salvage and major amputation-free survival rates at 3 years were stratified according to wound depth (wound healing rates: 92% in Texas 1 and 51% in Texas 2 or 3; P.001; limb salvage rates: 99% in Texas 1 and 86% in Texas 2 or 3; P = .001; major amputation-free survival rates: 79% in Texas 1 and 57% in Texas 2 or 3; P = .001). In only major tissue loss, deep wounds also caused poor outcomes compared with shallow wounds (wound healing rates: 70% in Texas 1 and 36% in Texas 2 or 3; P = .019; limb salvage rates: 94% in Texas 1 and 73% in Texas 2 or 3; P = .050; major amputation-free survival rates: 75% in Texas 1 and 45% in Texas 2 or 3; P = .039).Wound depth is an important indicator of wound status and affects the clinical outcomes of CLI with tissue loss.

High efficiency electrical machines such as rotating machines and transformers are expected to be realized for solving the environmental problem. It is well known that the iron loss of stator core for rotating machines increases by a mechanical stress caused by the shrink fitting of the stator housing. In order to clarify the influence of the mechanical stress to the characteristics of rotating machines, several papers [1]– [6] describe the simulation technic such as the combined analysis of a mecahnical stress and an electromagnetic field. In this paper, we develops the variable applying stress system with the hydraulic unit to clarify the influence of the shrink fitting to the motor characteristics. Fig. 1 shows the schematic of the variable applying stress system. We designed these system following three requirement. (a) The circumferential compressive stress of the stator core caused by these system is more than 100 MPa. (b) These system can adjusts the circumferential compressive stress of the stator core at an interval of 1 MPa. (c) These system uniformly applies the circumferential compressive stress of the stator core in the axial and circumferential direction. In order to realize the concept of these three points, these system is adopted the hydraulic mechanism. When the hydraulic unit applies the oil pressure to the oil room, the pressure bulk head is deformed by the oil pressure and consequently the circumferential compressive stress is generated in the stator core. These system can adjusts the circumferential compressive stress of the stator core by the oil pressure of the hydraulic unit. The circumferential compressive stress, which is measured by eight biaxial strain gages installed on the surface of the back-iron for the stator core, is changed linearly with respect to the applied oil pressure by the hydraulic unit, and the maximum circumferential compressive stress is generated more than 100 MPa under the oil pressure 15 MPa. Fig. 2 shows the measurement results of the iron loss in no-load with respect to the applied oil pressure by the hydraulic unit. The load motor rotates the test motor, which is adopted the interior permanent magnet motor with concentrated winding, at a constant rotating speed. Then, the loss of the test motor with the unmagnetized and magnetized permanent magnet rotor in no-load is measured by the torque detector. The iron loss of the test motor is calculated by a difference between the loss of the test motor with the magnetized permanent magnet rotor ant it with the unmagnetized permanent magnet rotor, which is included only the mechanical loss without the iron loss. As the applied oil pressure increases, the iron loss is gradually increased and the iron loss under the circumferential compressive stress of 100 MPa (applied oil pressure 15 MPa) in the stator core is increased by 2 times compared with the non-stress. As explained above, the proposed system can measures the iron loss of the actual motor under mechanical stress with various operating point. The more measurement results will be included in the full paper.

Increased re-hospitalization due to acute decompensated heart failure (ADHF) is a modern issue in cardiology. The aim of this study was to investigate risk factors for re-hospitalization due to worsening heart failure, and the effect of tolvaptan (TLV) on decreasing the number of re-hospitalizations. This was a multicenter, retrospective study. The re-hospitalization factors for 1191 patients with ADHF were investigated; patients receiving continuous administration of TLV when they were discharged from the hospital (n = 194) were analyzed separately. Patients were classified into 5 risk groups based on their calculated Preventing Re-hospitalization with TOLvaptan (Pretol) score. The total number of patients re-hospitalized due to worsening heart failure up to one year after discharge from the hospital was 285 (23.9%). Age ≥80 years, duration since discharge from the hospital after previous heart failure 7.2 mg/dl, left ventricular ejection fraction (LVEF) 44.7 ml/m2, loop diuretic dose ≥20 mg/day, hematocrit

Objectives We evaluated and compared the incidence and characteristics of late catch-up phenomenon (LCU) between everolimus-eluting stent (EES) and sirolimus-eluting stent (SES) implantations. Background Late catch-up phenomenon after everolimus-eluting stent (EES) implantation has not yet been evaluated sufficiently. Methods Between April 2007 and May 2011, 1,234 patients with coronary artery disease were treated with SES and 502 patients with EES. Following propensity score matching, we evaluated 495 SES-treated patients and 495 ESS-treated patients. The incidences of LCU (i.e., late target lesion revascularization [TLR] [1–3 years]) were compared. Results The cumulative incidence of TLR at 3 years was 11.9% in the SES group and 6.1% in the EES group (P = 0.001). The incidence of late TLR was 7.5% in the SES group and 3.4% in the EES group (P = 0.004). Even though not statistically significant, intravascular ultrasound showed a higher tendency of stent fracture (SF) in late restenosis lesions in the SES group than in the EES group (37.0% vs 7.7%; P = 0.052). Moreover, the SF rate tended to increase in late restenosis compared with early restenosis (within 1 year) in the SES group compared with the EES group (SES: 37.0% vs 22.2%; P = 0.293, EES: 7.7% vs 10.0%; P = 0.846), although the increase was not significantly different. Conclusions EES was superior to SES in terms of LCU. SF may be associated with LCU after SES implantation. (J Interven Cardiol 2015;28:551–562)

To investigate 5-year clinical outcomes after infrapopliteal endovascular therapy (EVT) for critical limb ischemia (CLI) patients on or not on hemodialysis (HD), and compare the clinical efficacy of EVT between the 2 groups.The subjects were 1091 CLI patients (1310 limbs) who underwent EVT for isolated infrapopliteal lesions from 2004 to 2012, and were classified into 2 groups for comparative study: the patients on HD group (670 patients, 830 limbs) and not on HD group (421 patients, 480 limbs).The HD group had a significantly lower rate of freedom from major adverse limb events or perioperative death (HD 78.4% vs. non-HD 86.0% at 1 year, HD 70.3% vs. non-HD 82.4% at 5 years, P = 0.01), or amputation-free survival (AFS) rate (HD 65.7% vs. non-HD 78.7% at 1 year, HD 34.4% vs. non-HD 59.8% at 5 years, P0.01) after EVT compared with the non-HD group. Independent predictors of AFS in HD patients were nonambulatory, diabetes mellitus, albumin3.0 g/dL, ejection fraction ≤0.48, and no patent pedal arch arteries before EVT. AFS at 1 year was 81% in patients with 0 or 1 predictor, surpassing the suggested AFS objective performance goal (OPG) end points of 68%, but AFS in patients with 2 or more predictors failed to reach the OPG.In comparison with non-HD patients, the clinical efficacy of infrapopliteal EVT for HD patients was poor. Preoperative risk stratification based on AFS predictors can be used as an index for predicting the prognosis.

Objectives This study sought to assess the rate and predictors of 1-year restenosis after drug-eluting stent implantation for femoropopliteal (FP) lesions in patients with peripheral arterial disease. Background Zilver PTX, a paclitaxel-eluting stent for FP lesions, provides superior outcomes to angioplasty and bare-metal stents in clinical trials. However, its real-world outcomes and the associated features remain unclear. Methods This was a prospective multicenter study enrolling 831 FP lesions (797 limbs, 690 patients) treated by Zilver PTX implantation. The primary endpoint was 1-year restenosis. Secondary endpoints included major adverse limb event and stent thrombosis. Results Mean lesion length was 17 ± 10 cm. One-year restenosis, major adverse limb event, and stent thrombosis rates were 37%, 22%, and 2%, respectively. The generalized linear mixed model showed that lesion length ≥16 cm assessed by angiography and distal external elastic membrane area ≤27 mm2 and minimum stent area ≤12 mm2 assessed by intravascular ultrasound were independent risk factors for restenosis. One-year restenosis rates were 15% in cases with none of these risk factors and 50% in those with ≥2 risk factors. Conclusions The current study demonstrated 1-year real-world outcomes after drug-eluting stent treatment for FP lesions, including challenging ones in clinical practice. Lesion length, external elastic membrane area, and minimum stent area were independent predictors for restenosis. (Zilver PTX for the Femoral Artery and Proximal Popliteal Artery—Prospective Multicenter Registry [ZEPHYR]; UMIN000008433)

Objectives and Background Among hemodialysis (HD)-dependent patients with critical limb ischemia (CLI), Endovascular therapy (EVT) of isolated infrapopliteal lesions improves limb salvage. Accordingly, we sought to determine the outcomes of this group of patients based on the extent of tissue loss at baseline. Methods From 2004 to 2011, 449 consecutive HD patients with CLI had ischemic wounds and underwent EVT for isolated infrapopliteal lesions. The “minor tissue loss” (MI) group was confirmed by 340 HD patients with wounds located distal to the metatarsophalangeal joints, and the “major tissue loss” (MA) group included 109 HD patients with wounds that extended beyond this point. The two groups were compared for limb salvage and amputation free survival (AFS) rates by Kaplan-Meier analysis. Results There was no significant difference in the percentage of diabetic patients (MI: 76.5 vs. MA: 75.2%). The percentage with direct flow to the wound site was lower in the MA group than in the MI group (MI: 63.5 vs. MA: 45.9%, P 80% limb salvage rates at 3 years. However, AFS rates in all HD patients with tissue loss are

BACKGROUND Bypass surgery (BSX) as first-line therapy for Trans-Atlantic Inter-Society Consensus-II (TASCII) C/D femoropopliteal (FP) lesions is recommended. Recent reports have shown that a drug-eluting stent (DES) provides good durability up to the mid-term. We investigated clinical outcomes after BSX vs. DES for TASCII C/D FP lesions. METHODS AND RESULTS As treatment of de novo TASCII C/D FP lesions, 274 patients who underwent DES implantation and 201 patients who had BSX were identified and analyzed. Each group had at least 1 year of follow-up data. The primary endpoint was binary restenosis. Secondary endpoints were major amputation, reintervention, reocclusion and major adverse limb event (MALE; including major amputation or any reintervention and restenosis). Before matching, the binary restenosis rate was significantly higher in the DES group than in the BSX group (42% vs. 18%, P

Background Little is known regarding the impact of diastolic function on cardiac output ( CO ) in patients with heart failure, particularly in patients with lower ejection fraction. This study aimed to evaluate the impact of end‐diastolic pressure–volume relationship ( EDPVR ) on CO and end‐diastolic pressure ( EDP ). Methods and Results We retrospectively analyzed 1840 consecutive patients who underwent heart catheterization. We divided patients into 8 groups according to ejection fraction ( EF ) (35–45%, 46–55%, 56–65%, and 66–75%) and EDP (>16 or ≤16 mm Hg). We estimated EDPVR from single measurements in the catheterization data set. Then, we replaced EDPVR s of high‐ EDP groups with those of normal‐ EDP groups and compared CO before and after EDPVR replacement. Normalized EDPVR significantly increased CO at EDP =10 mm Hg regardless of EF ( EF 35–45%, from 4.5±1.6 to 4.9±1.0; EF 46–55%, 4.6±1.3 to 5.1±1.1; EF 56–65%, 4.9±1.5 to 5.2±1.0; EF 66–75%, 4.9±1.5 to 5.2±1.1). Changes in CO were similar across EF groups. Conclusions Diastolic function normalization was associated with higher CO irrespective of EF . Diastolic dysfunction plays an important role in determining CO irrespective of EF in heart failure patients.

To examine the effectiveness of vascular elastography (VE) for the assessment of totally occluded lower limb arteries prior to endovascular treatment (EVT).Of 812 consecutive patients who underwent EVT between April 2010 and April 2012, VE was used to evaluate the hardness of chronic total occlusions of the femoropopliteal segment prior to EVT in 65 consecutive patients (48 men; mean 73.9 years, range 63-86). Elastograms of the CTOs proximally and distally were scored using a 5-point scale, and outcomes in limbs with hard lesions (VE score 0-2) were compared to those with soft lesions (VE score 3-4) according to lesion length. The interventionists who performed the endovascular procedures were not informed of the VE score results.CTO characteristics could be evaluated in all cases. A VE score ≤2 was found in 14 of the 23 lesions150 mm in length. A flexible guidewire was sufficient for recanalization in more of the soft lesions than in the hard lesions [6/9 vs. 2/14, respectively]. In 39 lesions150 mm, a VE score of 3 was recorded in most lesions proximally, while lesions distally were hard in many cases (VE score 1 or 2). A flexible guidewire alone was sufficient in many soft CTOs (8/13, p0.01). In 16 cases, hard calcified plaque was indicated by difficulty in penetrating the lesion even with a stiff guidewire; all these cases had a VE score of 1 or 2. A retrograde approach was required only in hard CTOs (p0.01). The procedure time was significantly longer for the hard lesion group (152.9±63.2 vs. 87.0±29.8 minutes, p=0.001). In 11 in-stent occlusions, only VE scores of 3 (n=4) or 4 (n=7) were recorded, indicating soft thrombus, which was aspirated under distal protection in 7 cases.VE may be a useful method for determining the hardness of CTO lesions noninvasively before endovascular therapy, providing information that can help plan the procedure.

Objectives To evaluate the predictors of non-healing in patients with critical limb ischemia (CLI) after successful endovascular therapy (EVT). Background Occasionally, wound healing in patients with CLI and tissue loss cannot be achieved even after successful EVT. Patient's co-morbidities, vascular anatomy, wound features, and interventional strategies/outcomes are associated with the probability of wound healing. Methods Between April 2007 and October 2012, 182 patients with CLI (220 limbs) with tissue loss were treated with EVT in our institute. Of these, 164 individual wounds (130 patients, 149 limbs) out of 243 individual wounds were successfully treated. Successful EVT was defined as revascularization by achieving visible blood flow to the wounds, as evaluated by digital subtraction angiography performed just after EVT. A Cox proportional hazards model was used to analyze predictors associated with wound healing. Results The mean follow-up period was 23 ± 18 months. The wound healing rates were 40.2%, 57.3%, 62.2%, and 70.7% at 3, 6, 9, and 12 months, respectively. Multivariate Cox proportional hazards analysis revealed that insulin use [hazard ratio (HR), 0.541; 95% confidence interval (CI), 0.329–0.890; P = 0.016], dependence on hemodialysis [HR, 0.429; 95% CI, 0.272–0.678; P

Aim: We assessed the wire behavior by using intravascular ultrasound when knuckle wire technique is performed for chronic total occlusion of the superficial femoral artery. We investigate the relationship between the angiogram and the wire behavior. Methods: This retrospective multicenter study enrolled 48 patients (50 limbs) in whom intravascular ultrasound could be performed successfully after knuckle wire technique. Results: The wire passed intraluminally from the proximal cap to the reentry site in nine cases (18%). Once the wire entered the subintimal space, it remained in the subintimal space through the occlusion (32/34 cases; 95%). Conclusion: The wire was more likely to advance intraluminally if the chronic total occlusion had a tapered proximal cap and an abrupt distal margin.

PURPOSE To compare the safety and success of a retrograde approach using a microcatheter vs. a sheath in the treatment of superficial femoral artery (SFA) chronic total occlusions (CTOs). METHODS From April 2007 to December 2012, 188 consecutive patients underwent EVT for 229 de novo SFA CTOs using the retrograde approach in 68 patients (35 men; mean age 72 years). This cohort was divided into cases performed with a 4-F or 6-F sheath (n=28, 36 limbs) and those with a 2.1-F microcatheter (n=35, 49 limbs). The primary outcomes were mean time to hemostasis and number of intra- and postoperative puncture site complications, as well as the success of popliteal artery puncture, lesion crossing, and reperfusion. RESULTS There were no significant differences between two groups in baseline characteristics. PA puncture was successful in all limbs, and the success in crossing the lesion with the wire was not significantly different (91.9% in the sheath group vs. 89.8% in the microcatheter group). Mean time to hemostasis was 8.9±8.8 minutes in the microcatheter group vs. 47.7±13 minutes in the sheath group (p

Background The differences in wound healing according to wound location remain unclear. Methods and results Between April 2007 and October 2011, 138 patients (166 limbs) with critical limb ischemia with tissue loss were treated with endovascular treatment. On these limbs, 177 individual wounds were identified on the foot and were evaluated for wound healing rates and time to healing according to their locations. Wound locations were divided into 3 groups: group T (Toe wounds, n=112), group H (Heel wounds, n=25), and group E (Extensive wounds extending onto the fore- or mid-foot along with dorsum or plantar surfaces, n=40). The mean follow-up period was 23±19 months. At 3, 6, 9, and 12 months, wound healing rates were 51%, 64%, 75%, and 75%, respectively, in group T; 12%, 36%, 36%, and 52%, respectively, in group H; and 0%, 5%, 8%, and 13%, respectively, in group E. The median time to healing was 64 days (interquartile range 25-156 days) in group T, 168 days (interquartile range 123-316 days) in group H, and 267 days (interquartile range 177-316 days) in group E (P=0.038). Conclusions Extensive wounds extending onto the fore- or mid-foot along with dorsum or plantar surfaces were the most difficult type of wound to heal.

A 54-year-old male patient presented with a symptomatic bifurcation lesion of 75% stenosis in LAD ([Figure 1A][1]). Physiological evaluation was performed using instantaneous wave-free ratio (iFR) roadmap (Philips Healthcare, Best, the Netherlands) functionality [(1)][2]. First, we ran a

Advances in coronary intervention have increased the opportunity to intervene on complex lesions, resulting in an increase in PCI-related complication, including coronary artery perforation. However, treatment options for coronary perforation are limited, with delivery of devices to complex lesions being problematic. Balloon hemostasis is the usual bailout method, despite the risk of myocardial ischemia. In this report, we describe an over-the-wire balloon method to treat a patient with coronary perforation. Ischemia was avoided by injecting autologous blood through the catheter, while hemostasis was achieved by prolonged balloon inflation. This new technique is applicable when a perfusion balloon is not indicated.

Purpose: To assess the influence of repeat intervention on the risk of major amputation after infrapopliteal angioplasty for patients with critical limb ischemia (CLI). Methods: A multicenter database of Japanese CLI patients was interrogated to identify patients who underwent balloon angioplasty for isolated infrapopliteal lesions from April 2004 to December 2012. In that time frame, 1298 limbs of 1065 patients (mean age 72±10 years; 739 men) were eligible for this analysis. The prevalence of tissue loss was 76%, with 33% accompanied by infection. The association between repeat intervention and future risk for major amputation was evaluated using a mixed effects logistic regression model. A stratification analysis was also performed with baseline variables. A supplementary analysis compared baseline characteristics between the cases with and without repeat intervention. Hazard ratios (HR) and their 95% confidence intervals (CI) are reported. Results: Median follow-up was 1.2 years (interquartile range 0.4–2.5), during which time 143 (11.0%) limbs had major amputations and 499 (38.4%) underwent repeat intervention. The mixed effects modeling revealed that repeat intervention was significantly associated with future risk for major amputation (unadjusted HR 3.01, 95% CI 2.05 to 4.41, p=0.001). From the stratification analysis, repeat intervention significantly increased future risk of major amputation in cases with regular dialysis (HR 3.35, 95% CI 2.14 to 5.26, p

Purpose: To compare drug-eluting stent (DES) implantation with percutaneous transluminal angioplasty (PTA) in the treatment of femoropopliteal in-stent restenosis (ISR). Methods: A comparison was performed of data from 112 ZEPHYR registry patients (mean age 74±9 years; 60 men) with 119 femoropopliteal ISR lesions treated with a drug-eluting stent (Zilver PTX) with historical data from 116 patients (mean age 72±8 years; 83 men) with 133 lesions treated with PTA. The patients were stratified for analysis by lesions with (101/252, 40%) and without (n=151) in-stent occlusion. The primary outcome measure was the 1-year incidence of recurrent restenosis; the secondary outcome was major adverse limb events (MALE). Multivariate logistic regression analysis was performed to look for any independent association of DES implantation with 1-year recurrent restenosis in the respective subgroups; results are presented as the odds ratio (OR) and 95% confidence interval (CI). Results: In the subgroup without in-stent occlusion, there was no significant difference between DES and PTA in the 1-year incidence of recurrent restenosis (40.5% vs 45.7%, p=0.583, respectively) or MALE (27.8% vs 20.7%, p=0.322, respectively). However, in the subgroup with in-stent occlusion, DES implantation was associated with significantly lower incidences of recurrent restenosis (44.1% vs 90.3% for PTA, p

Purpose: To present a propensity score matching analysis comparing the 1-year outcomes of de novo femoropopliteal lesions treated with drug-eluting stents (DES) or bare nitinol stents (BNS). Methods: A retrospective review was conducted of 452 limbs in 389 patients (mean age 74±8 years; 284 men) treated with DES implantation and 1808 limbs in 1441 patients (mean age 72±9 years; 1023 men) implanted with BNS for de novo femoropopliteal lesions. One-year follow-up data were available on all patients. The primary endpoint was 12-month restenosis assessed by duplex ultrasonography or follow-up angiography within ±2 months. Secondary endpoint was major adverse limb events (MALE) including major amputation, any reintervention, and restenosis. Results: The BNS group was more likely to have current smoking, chronic total occlusion, and poor below-the-knee runoff. The stratification analysis demonstrated that diabetes mellitus (DM) and reference vessel diameter (RVD) had a significant interaction on the association of DES vs BNS implantation with restenosis (interaction p

Objective To (1) compare the outcome of self-expandable stents with versus without jailed deep femoral artery (DFA) for proximal superficial femoral artery (SFA) lesions, and to (2) ascertain the fate of jailed DFA. Background Complex SFA lesions involving the femoral bifurcation (FB) was mostly treated surgically, and the role played by endovascular procedures is uncertain. Methods We retrospectively identified 104 consecutive, de novo lesions involving the SFA ostium, stented between April 2005 and September 2010. Depending on the proximal stent edge location, the sample was divided between 60 distal common femoral artery (CFA) stenting with jailed DFA and 44 ostial SFA stenting without jailed DFA. The FB was the segment beginning in the distal CFA, 10 mm proximal to the DFA ostium and ending in the SFA and 10 mm distal to the carina. Stented CFA lesions proximal to the FB were excluded. The bifurcation was classified as patent when free of restenosis and repeat revascularization. Results The overall 12-month bifurcation and primary patency rates were 72.5% and 52.0%, respectively. Predictors of loss of bifurcation patency were ostial SFA stenting and a small stent in the FB. Bifurcation patency (83.3% vs. 56.3%; P < 0.01) and primary patency of the SFA (56.2% vs. 37.5%; P = 0.088) were higher after distal CFA than after ostial SFA stenting. In 95.7% of distal CFA and 100% of ostial SFA stenting, DFA remained patent at 12-month follow-up (P = 0.237). Conclusions The 12-month fate of jailed DFA after distal CFA stenting was acceptable, and the bifurcation patency rate was higher than after ostial SFA stenting. © 2012 Wiley Periodicals, Inc.

Increase in cerebrospinal fluid (CSF) Na(+) concentration ([Na(+)]) precedes hypertension and is a key step in the development of salt-induced hypertension. In the choroid plexus (CP), epithelial Na(+) channels (ENaCs) have an important role in Na(+) transport from the blood into the CSF. However, it remains unknown whether the mineralocorticoid receptors (MR)/ENaCs pathway in the CP of stroke-prone spontaneously hypertensive rats (SHRSP) is involved in neural mechanisms of hypertension. Therefore, we examined the role of the MR/ENaCs pathway in the CP in the development of hypertension in SHRSP associated with an increase in CSF [Na(+)]. As a marker of MR activation, serum/glucocorticoid-inducible kinase 1 (Sgk1) expression levels in the CP were measured and found to be greater in SHRSP than in Wistar-Kyoto (WKY) rats. CSF [Na(+)] levels were also higher in SHRSP than in WKY rats. In SHRSP, high-salt intake (8%) increased blood pressure and urinary norepinephrine excretion compared with those in animals fed a regular salt diet (0.5%) for 2 weeks. Furthermore, the expression levels of MR, Sgk1 and ENaCs in the CP and the increase in CSF [Na(+)] were greater in SHRSP fed a high-salt diet than in those fed a regular salt diet. These alterations were attenuated by intracerebroventricular infusion of eplerenone (10 μg kg(-1) per day), except for α-ENaC and β-ENaC. We conclude that activation of the MR/ENaCs pathway in the CP contributes to hypertension via an increase in CSF [Na(+)], thereby exaggerating salt-induced hypertension with sympathetic hyperactivation in SHRSP.

Mineralocorticoid receptor (MR) is recognized as a target for therapeutic intervention in hypertension and heart failure. MRs in the central nervous system are thought to have an important role in blood pressure regulation. Thus, we examined whether activation of the MR pathway in the rostral ventrolateral medulla (RVLM) of the brainstem contributes to the neural mechanism of hypertension in stroke-prone spontaneously hypertensive rats (SHRSPs). We microinjected eplerenone, aldosterone or Na(+)-rich artificial cerebrospinal fluid (aCSF) into the RVLM of anesthetized Wistar-Kyoto (WKY) rats and SHRSPs. Arterial pressure (AP), heart rate (HR) and renal sympathetic nerve activity (RSNA) were recorded. The expressions of the MR protein and the serum- and glucocorticoid-regulated kinase protein (Sgk1), which is a marker of MR activity, in the RVLM were measured by western blot analysis. Bilateral microinjection of eplerenone into the RVLM decreased AP and RSNA in WKY rats and SHRSPs, and the decreases in those variables were significantly greater in SHRSPs than WKY rats. Microinjection of aldosterone or Na(+)-rich aCSF into the RVLM increased AP and RSNA dose-dependently. The increases in those variables were significantly greater in SHRSPs than in WKY rats. The pressor responses of aldosterone or Na(+)-rich aCSF were attenuated by the prior injection of eplerenone in SHRSPs. Sgk1 expression levels in the RVLM were significantly greater in SHRSPs than in WKY rats. These findings suggest that activation of MRs in the RVLM enhances sympathetic activity, thereby contributing to the neural mechanism of hypertension in the SHRSP.

Patient initials or identifier number I.K ### Relevant clinical history and physical exam The patient was an 85 year-old male who presented with lack of appetite and chest discomfort. He had a history of hypertension and dyslipidemia. As blood tests showed elevated CK levels and the ECG

An 80-year-old woman was admitted to our emergency department with ongoing dyspnea for 2 weeks. The patient was immediately intubated endotracheally because of the hypoxia with flush pulmonary edema. Electrocardiogram showed ST depression and echocardiogram showed hypokinesis of anterior left ventricular wall with poor systolic function. Also her cardiac enzymes were elevated, emergency coronary angiogram was performed from radial artery because both femoral arteries were not fully palpable. Coronary angiogram showed three vessels disease including chronic total occlusion of right coronary artery and left main bifurcation lesion. Also blood flow of left anterior descending coronary artery was delayed. Acute coronary syndrome was the cause of acute heart failure and revascularization was needed but aortography revealed total occlusion of infrarenal aorta. Patient was relatively hemodynamically stable; we planned treating total occlusion of infrarenal aorta with endovascular therapy to maintain a rout for cardiopulmonary support system. With bi-directional approach from both femoral artery and left brachial artery, occlusion site with heavy calcification was finally passed through by guide wire from retrograde approach. After pull-through technique, self-expanding nitinol stent was implanted after pre dilation with small balloon. Considering her EURO score, supposed perioperative mortality was high, percutaneous coronary intervention was performed. A 7 fr sheath was inserted from right femoral artery and intra-aortic balloon pump was inserted from left femoral artery. Sirolimus-eluting stent was implanted to left circumflex artery and also from ostium of left main to mid left anterior descending coronary artery after using an atherectomy device. After successful revascularization, patient became hemodynamically stable and weaning off the respirator was successful. Reporting case achieved successful revascularization to severe coronary artery disease after endovascular recanalization with infrarenal aortic occlusion.

This paper presents a closed-form solution to the sag of the Cartesian oval and an alternate iterative method for obtaining the sag. The emphasis is in providing a methodology for determining the sag and derivatives of a Cartesian surface for optical design, ray-tracing purposes. We verify our results by comparison of our solutions and by real ray tracing.

Background: Stent deployment across side branch (SB) ostium is common in daily practice. The present study investigated the natural history of SBs jailed by drug-eluting stents (DES). Methods: The thrombolysis in myocardial infarction (TIMI) flow grades of 271 consecutive SBs jailed by DES in 196 patients was assessed immediately after the procedure and at 9 months of follow-up. Patients receiving any SB intervention were excluded. Results: Of 271 jailed SBs, occlusion occurred in 6.27% and deterioration of flow occurred in 6.27% immediately after stenting. In patients with these SB changes, periprocedural myocardial infarction was more likely than in those without (10.0% vs. 1.8%, P = 0.017), while there was no increase of cardiac death or life-threatening complications such as stent thrombosis and Q-wave myocardial infarction (Q MI) during follow-up. At 9 months, angiography showed that one-third of the initially obstructed SBs were still occluded. In contrast, flow was maintained in almost all (98.6%) SBs with early TIMI flow grade 3 and there was no delayed occlusion of these branches. Multiple regression analysis showed that lesion complexity (Medina bifurcation class, calcification, and preprocedural TIMI grade 2 flow in the SB) and technical factors (jailing by overlapping stents) were related to SB occlusion or flow deterioration. Conclusions: Jailed SBs showing good flow after stenting had a favorable angiographic and clinical outcome after 9 months of follow-up. However, preprocedural lesion complexity and technical factors should be considered to avoid SB occlusion/flow deterioration associated with periprocedural myocardial infarction. (J Interven Cardiol 2012;25:37–46)

Aims Depression often coexists with cardiovascular disease, such as hypertension and heart failure, in which sympathetic hyperactivation is critically involved. Reduction in the brain sigma-1 receptor (S1R) functions in depression pathogenesis via neuronal activity modulation. We hypothesized that reduced brain S1R exacerbates heart failure, especially with pressure overload via sympathetic hyperactivation and worsening depression. Methods and results Male Institute of Cancer Research mice were treated with aortic banding and, 4 weeks thereafter, fed a high-salt diet for an additional 4 weeks to accelerate cardiac dysfunction (AB-H). Compared with sham-operated controls (Sham), AB-H showed augmented sympathetic activity, decreased per cent fractional shortening, increased left ventricular dimensions, and significantly lower brain S1R expression. Intracerebroventricular (ICV) infusion of S1R agonist PRE084 increased brain S1R expression, lowered sympathetic activity, and improved cardiac function in AB-H. ICV infusion of S1R antagonist BD1063 increased sympathetic activity and decreased cardiac function in Sham. Tail suspension test was used to evaluate the index of depression-like behaviour, with immobility time and strain amplitude recorded as markers of struggle activity using a force transducer. Immobility time increased and strain amplitude decreased in AB-H compared with Sham, and these changes were attenuated by ICV infusion of PRE084. Conclusion These results indicate that decreased brain S1R contributes to the relationship between heart failure and depression in a mouse model of pressure overload.

To investigate the long-term outcome of Percutaneous transluminal intervention (PCI) for chronic total occlusion (CTO). The subjects were 606 patients (1,145 lesions) who were treated for CTO between January 1996 and December 2003 at our institution. Among them, 436 patients with early success and confirmed patency at the CTO by follow-up coronary angiography after 6 months were classified as the patent group (Group P), while 170 patients without early success or with occlusion on follow-up angiography were classified as the occluded group (Group O). In April 2006 (mean: 660 ± 602 days), the outcome of CTO was investigated and the major adverse cardiac events (MACE)-free rate was calculated. Multivariate analysis was performed to identify determinants of death. The early success rate was 76.4% before 2003 when Conquest guidewires were not available. However, it subsequently showed significant improvement to 89%. The cumulative survival rate was significantly higher for Group P (92%) than for Group O (64%) and the MACE-free rate (free from, death, bypass surgery, myocardial infarction, and revascularization) showed a similar trend. The cumulative survival rate of patients without myocardial viability in the territory of the vessel with CTO was significantly higher for Group P (88%) than for Group O (55%). The outcome was significantly worse for patients with occlusion of other vessels (90%) than for patients without additional occlusion (42%). It was significantly better when the left ventricular ejection fraction (LVEF) was ≥40% than when the LVEF was ≤40% (90 vs. 68%). Multivariate analysis identified occluded CTO, other vessel occlusion, low ejection fraction (EF), unimproved EF, and old age as determinants of death from CTO. If early success is obtained and patency is maintained, the long-term outcome after PCI for CTO is significantly better than when failure occurs Occluded CTO, other vessel occlusion, low EF, unimproved EF, and old age are important determinants of the outcome.

Sirolimus-eluting stent (SES) is established to be effective in reducing restenosis. Repeat revascularization, however, is still required in up to 5-8% of patients. In this study, we analyzed clinical and angiographic variables that might be related with SES re-restenosis and variables related with re-restenosis after repeat SES implantation for SES restenosis. We also assessed clinical outcomes at 2-year follow-up after percutaneous coronary intervention (PCI) for SES restenosis. Repeat revascularization for SES restenosis was performed in 113 patients with 140 lesions. Of the 140 lesions, follow-up coronary angiography (CAG) was performed on 117 lesions (101 patients) and revealed 46 SES re-restenotic and 71 non-re-restenotic lesions. In multivariate analysis, SES-in-SES-strategy and reference diameter before the second PCI were independent predictors of re-restenosis after PCI for SES restenosis. However, the reference diameter was the only independent predictor of re-restenosis after SES-in-SES. Major adverse cardiac events (MACE) at 2 years were found in 44 patients (43.5%), and target lesion revascularization (TLR) was performed in 33.7% of patients after SES restenosis. In conclusion, the incidence of MACE and TLR was relatively high in patients with SES restenosis, but the placement of another SES on larger-diameter vessels may be an effective strategy for the second PCI.

心原性脳塞栓症発症後の頸部血管エコーにてoscillating thrombusを検出した1例 (86歳女性) を経験した. 高血圧と非弁膜性心房細動に伴う心原性脳梗塞の既往があり, 抗凝固療法を受けていた. 意識障害と左片麻痺にて発症, 頭部MRIにて新鮮脳梗塞を確認し, 心原性脳塞栓症と診断した. 同日に施行した頸部血管エコー上右内頸動脈 (ICA) 起始部に可動性血栓 (oscillating thrombus) を認め, 右総頸動脈の拡張末期血流速度 (end-diastolic flow velocity : EDV) は0cm/sであった. 心原性脳塞栓症の再発予防に, ヘパリン持続点滴 (1万単位/日) を開始した. 第3病日には頸部血管エコー上可動性血栓は消失したが, EDVの左右比は4.53と上昇しており右ICA遠位部閉塞と考えられた. 第13病日にはEDVの左右差は消失しており, 右ICA再開通が示唆され, 同所見を頭部MRAで確認した. 本症例では内頸動脈遠位部閉塞によって生じたoscillating thrombusが抗凝固療法中に消失し, 再開通していく様を頸部血管エコーにて捉える事が出来た. 頸部血管エコーは内頸動脈閉塞とそれに続く再開通現象を捉える良い指標であると考えられた.

Purpose: To investigate the relationship between postprocedure intravascular ultrasound (IVUS) findings and restenosis after placement of drug-eluting stents (DES) for femoropopliteal lesions. Methods: Between July 2012 and May 2013, DES were placed in 64 patients with 88 de novo femoropopliteal lesions. In 40 patients (mean age 74.2±9.4 years; 27 men), DES were placed in 50 lesions under IVUS guidance, and restenosis was monitored for 1 year. All patients were symptomatic (Rutherford 2–6), and 17 patients (43%) suffered from critical limb ischemia. IVUS findings after stenting were compared for patients with vs without restenosis, which was defined as a peak systolic velocity ratio >2.4 on duplex ultrasonography or >50% diameter stenosis on angiography. Results: Ten patients (14 lesions) developed restenosis, while 30 patients (36 lesions) did not. There were no significant differences in the frequency of diabetes or dialysis between the 2 groups. Female patients were predominant in the restenosis group (p2 and 0.6, respectively. Conclusion: IVUS guidance of DES placement in femoropopliteal lesions can offer useful predictors of restenosis at 1 year. The utility of distal lumen CSA and the axial symmetry index in the prediction of restenosis after femoropopliteal DES placement should be confirmed in a larger cohort.

Purpose: To develop a scoring system to predict wound healing in critical limb ischemia (CLI) patients treated with endovascular therapy (EVT). Methods: Between July 2007 and January 2013, 184 patients (118 men; mean age 73.0 years) with CLI (217 limbs) and tissue loss underwent EVT. From this cohort 236 separate wounds were divided into development (n=118) and validation (n=118) groups. Predictors of wound healing were identified using multivariable analysis. Each predictor was assigned a score based on its regression coefficient, and total scores were calculated, ranging from 0 to 1 for low risk up to ≥4 for high risk of a nonhealing wound. The performance of the scoring system in the prediction of wound healing was evaluated by calculating the area under the receiver operating characteristics (ROC) curve. Results: By multivariable analysis, a University of Texas grade ≥2 (HR 0.524, 95% CI 0.288–0.951, p=0.034), an infected wound (HR 0.497, 95% CI 0.276–0.894, p=0.020), dependence on hemodialysis (HR 0.459, 95% CI 0.259–0.814, p=0.008), no visible blood flow to the wound (HR 0.343, 95% CI 0.146–0.802, p=0.014), and major tissue loss (HR 0.322, 95% CI 0.165–0.630, p=0.001) predicted a non-healing wound. The 1-year rates of wound healing in the low-, intermediate-, and high-risk groups were 94.6%, 67.6%, and 9.1%, respectively, in the development group (p

Endovascular therapy (EVT) has become first-line approach for critical limb ischemia (CLI), however, its high restenosis rate remains as a major problem. Generally, restenosis is associated with poor wound healing course, so usually repeat EVT is needed for the restenosis case. However, the clinical

This paper discusses an accurate magnetic field analysis that addresses stress distribution in the magnetic core by using the finite-element method (FEM) to estimate motor characteristics. This analysis method consists of the following steps: 1) measurement of the magnetic characteristics of electrical steel sheets in a state where stress is added; 2) calculation of deformation and stress distribution using structural analysis; 3) preprocessing of the magnetic field analysis, which generates the FEM mesh taking account of the deformation by stress and the changes of the magnetic properties in each of the core elements corresponding to stress distribution; and 4) magnetic field analysis using the data measured in step 1) and the FEM mesh generated in step 3). As an example, a result of a permanent magnet motor's cogging torque calculation is shown, focusing on stress in the stator core resulting from shrink fitting into the frame. As a result, the cogging torque waveform was shown to differ depending on the shape and the materials of the frame.

In this paper, we investigate the Eddy current (EC) losses in the rotors of surface permanent-magnet (PM) synchronous machines, which have concentrated armature windings. By the finite-element method (FEM) analysis, it is clear that the EC losses in rotors are apparently different at rated currents if the pole and slot combinations are different. The distribution of the EC density in the rotor is closely related with the asynchronous components of the armature magnetomotive force (MMF). If the armature MMF has a low order of spatial harmonic components, which is not synchronous with the rotor, the EC losses are of large amounts.

Our country is a super-aged society and this is an unlike any other in the world. We must consider the treatment strategy for their disease enough. In this study, we examined the clinical outcomes of percutaneous coronary intervention (PCI) for very elderly ischemic coronary artery disease patients

Background: Recent studies have suggested the possibility of late catch-up phenomenon after implantation of sirolimus-eluting stent (SES) for coronary artery disease (CAD) compared to bare metal stent. However, little is known about the incidence of late catch-up phenomenon after implantation of everolimus-eluting stent (EES). Methods: Between April 2007 and May 2011, 1234 patients with CAD were treated with SES and 502 patients were treated with EES in our institution. We used a propensity score matching method with 1:1 matching, including 495 patients treated with SES and 495 patients treated with EES. Late catch-up phenomenon which was defined as target lesion restenosis (1 year to 3 years) were compared between the 2 groups. Results: After the propensity matching, no difference was seen in baseline characteristics between the 2 groups. Cumulative incidence of TLR at 3 years was 7.1% in EES group and 13.5% in SES group (P=0.001, log-rank test). Incidence of late catch-up phenomenon was 4.2% in EES group and 7.8% in SES group (P=0.020, log-rank test). Multivariate Cox’s proportional hazard analysis revealed that sirolimus eluting stent usage (HR 4.7, 95%CI 2.8-7.9, P Conclusions: EES was significantly superior to SES in the incidence of late catch-up phenomenon.