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Objective: In paramalleolar bypass for critical limb-threatening ischemia (CLTI), excessive skin tension may occur for the closure of surgical wounds around the ankle. Furthermore, these surgical incisions are often proximal to infectious ischemic ulcers. Wound dehiscence caused by skin tension and surgical site infection carries a risk of graft exposure, anastomotic disruption, or graft insufficiency. Patients and Methods: Tension-free wound management was adopted in eight patients who underwent paramalleolar bypass for CLTI. Tension-free closure was adopted for surgical incisions for distal anastomotic site of the paramalleolar bypass, whereas the incisions for saphenous vein harvest were left open. A relief incision was made as needed. The opened incisions were covered with artificial dermis. Results: All surgical incisions and ischemic wounds healed successfully within 1.8 months after bypass. Two postoperative graft stenoses occurred, which were rescued by additional endovascular intervention. Secondary graft patency, wound healing, and limb salvage rates were 100% during an average follow-up period of 30 months. Conclusion: Tension-free wound closure using artificial dermis was effective in selected cases of paramalleolar bypass for CLTI.

Femoral-popliteal (F-P) bypass is the standard treatment for lower extremity peripheral artery disease with severe femoropopliteal (FP) artery lesions. However, in clinical settings, these patients are treated with endovascular therapy (EVT) because of frailty and difficulties with general anesthesia. We compared the clinical outcomes of F-P bypass and EVT for severe FP artery lesions and investigated the types of patients for whom EVT would be as appropriate as F-P bypass.This multicenter, retrospective study included 452 Trans-Atlantic Inter-Society Consensus (TASC) II C and D FP artery lesions in 352 patients. A total of 350 lesions in 260 patients (74 ± 9 years, 66% male, 60% claudication) were treated with EVT with nitinol self-expandable stents, and 102 lesions in 92 patients (71 ± 9 years, 75% male, 40% claudication) were treated with F-P bypass. The primary outcome measure was primary patency, and the influence of baseline characteristics on its association with the treatment strategy (EVT versus F-P bypass) was assessed using a Cox proportional hazards regression model.Kaplan-Meier analysis indicated that the 3-year primary patency rate was significantly lower for EVT than F-P bypass (60% vs. 74%, P 0.01). The body mass index (BMI) and C-reactive protein (CRP) levels significantly interacted with the treatment strategy for restenosis (P 0.05). The adjusted hazard ratios of EVT versus F-P bypass for restenosis were 0.77 (P = 0.46) in cases with a low BMI (≤18 kg/mIn TASC II C and D lesions, EVT appears to yield patency comparable to that of F-P bypass in patients with a low BMI or an elevated CRP level, but lower patency in other patients.

Aim: The treatment strategy for hemodialysis (HD) patients with critical limb ischemia (CLI) has been clinically debatable. Here we compared clinical outcomes after bypass surgery (BSX) and after endovascular therapy (EVT) using propensity score matching. Methods: A retrospective multicenter database of 246 (68 BSX and 178 EVT) consecutive HD patients with CLI (79% with tissue loss) who underwent infrainguinal revascularization from 2007 to 2009 was used to compare clinical outcomes, including overall survival (OS), major amputation (MA), major adverse limb event (MALE: repeat EVT, surgical reconstruction, or MA), and MALE-free survival after BSX vs. EVT using propensity score matching. Results: The median (interquartile range) follow-up duration after revascularization was 21 (8–33) months. The analysis of the 63 propensity score-matched pairs revealed no significant difference in OS (53% vs. 52%, P = 0.96), MA (25% vs. 14%, P = 0.71), MALE (42% vs. 58%, P = 0.63), and MALE-free survival (33% vs. 11%, P = 0.37) at 3 year after BSX vs. EVT. Conclusions: In HD patients with CLI who underwent infrainguinal revascularization, OS, MA, MALE, and MALE-free survival rates were not significantly different after EVT vs. BSX. The less invasive EVT should be considered as the first-choice therapeutic strategy for HD patients with CLI.

Objectives This study sought to investigate the 3-year follow-up results of OLIVE registry patients. Background Although favorable 12-month clinical outcomes after endovascular therapy (EVT) in OLIVE registry patients with critical limb ischemia (CLI) from infrainguinal disease have been reported, long-term results after EVT remain unknown. Methods This was a prospective multicenter registry study that consecutively enrolled patients who received infrainguinal EVT for CLI. The primary outcome was 3-year amputation-free survival (AFS), whereas secondary outcome measures were 3-year freedom from major adverse limb events (MALE), wound-free survival, and wound recurrence rate. Prognostic predictors for each outcome were also elucidated by Cox proportional hazard regression analysis or the log-rank test. Results The completion rate of 3-year follow-up was 95%. Three-year AFS, freedom from MALE, and wound-free survival rates were 55.2%, 84.0%, and 49.6%, respectively. Wound recurrence out to 3 years was 43.9%. After multivariable analysis, age (hazard ratio [HR]: 1.43, p = 0.001), body mass index ≤18.5 (HR: 2.17, p = 0.001), dialysis (HR: 2.91, p Conclusions In CLI patients with infrainguinal lesions, 3-year clinical results of EVT were reasonable despite high reintervention and moderate ulcer recurrence rate. (A Prospective, Multi-Center, Three-Year Follow-Up Study on Endovascular Treatment for Infra-Inguinal Vessel in Patients With Critical Limb Ischemia [OLIVE 3-Year Follow-Up Study]; UMIN000014759 )

Purpose: To examine the 2-year mortality in hemodialysis (HD) patients with critical limb ischemia (CLI) and determine predictors that may aid in the selection of a revascularization strategy [bypass surgery or endovascular therapy (EVT)] according to current guidelines. Methods: From 2007 to 2009, 246 consecutive CLI patients (mean age 69±10 years; 170 men) on HD underwent revascularization for de novo infrainguinal lesions (178 EVT and 68 bypass grafting). The majority of the patients had diabetes (170, 69%) and tissue loss (194, 79%); nearly half (111, 45%) were nonambulatory. Overall survival after revascularization was estimated by Kaplan-Meier analysis. Predictors for 2-year mortality after revascularization were determined using a Cox proportional hazards model; results are given as the hazard ratio (HR) and 95% confidence interval (CI). Results: Overall survival rate was 77% at 1 year and 66% at 2 years. Predictors of 2-year mortality after revascularization were age >75 years (HR 1.82, 95% CI 1.14 to 2.91, p=0.012), albumin

Background: Although skin perfusion pressure (SPP) is widely used clinically to predict probability of wound healing, correlation between clinical outcomes and SPP has not been systematically studied. Methods: This subanalysis of the prospective multicenter OLIVE registry of patients who received infrainguinal endovascular therapy (EVT) for critical limb ischemia (CLI) assessed the association between clinical outcomes and postoperative SPP in 211 consecutive patients. Logistic regression analysis was performed, with amputation-free survival (AFS), modified major adverse limb events (MALEs), and complete wound healing as dependent variables and postprocedural SPP as independent variable. Result: Pre- and postprocedural SPP was 28 ± 11 and 46 ± 18 mm Hg, respectively. In logistic regression analysis, postprocedural SPP correlated with 1-year AFS ( P = .018), modified MALEs ( P < .001), and wound healing ( P = .022). Conclusion: Postprocedural SPP correlates with clinical outcomes after EVT for patients with CLI.

Objective: The aim of this study was to evaluate outcomes of combined popliteal-to-distal bypass and endovascular treatment (EVT) for femoropopliteal lesions in patients with critical limb ischemia (CLI). Patients and Methods: We reviewed data of 14 CLI patients who were treated by popliteal-to-distal bypass combined with femoropopliteal EVT. The femoropopliteal lesions included 3 TASC II-A, 8 TASC II-B, and 3TASC II-C but no TASC II-D, and balloon dilatation was performed in 9 cases and a stent was placed in 5 cases. The saphenous vein graft was used in all bypasses, and the target arteries were the dorsalis pedis artery in 12 cases and the posterior tibial artery in 2 cases. Results: At 12 and 24 months, primary patency rates were both 79%, primary assisted and secondary patency rates were both 93%, limb salvage rates were both 93%, and survival rates were 92% and 84%, respectively. Restenosis after femoropopliteal EVT occurred in 2 cases, and both were successfully revised by additional endovascular balloon dilatation. Conclusion: Combined popliteal-to-distal bypass and femoropopliteal EVT might be a useful therapeutic option for appropriately selected CLI patients. Intensive follow-up for endovascular treated lesions and vein graft is mandatory.

Treatment must be conducted after proper assessment of diabetic foot wounds. This implies appropriate foot care and the use of proper footwear from the perspectives of prophylaxis and walking. Diabetic foot wounds have some wound impairment factors, including peripheral neuropathy (PN), peripheral arterial disease (PAD), and infection; such wounds comprise combinations of these lesions. An additional goal besides wound healing is gait salvage. Here, we propose a simple new four-level classification of diabetic foot ulcerations, which we have termed the Kobe classification, in order to assess the wounds more easily and treat them systematically; the classification is as follows: Type I, mainly PN; Type II, mainly PAD; Type III, mainly infection; Type IV, PN+PAD+infection.

BACKGROUND We retrospectively reviewed the outcomes of distal bypass for critical limb ischemia and investigated the impact on outcomes of prior unsuccessful ipsilateral infrapopliteal endovascular treatment (EVT). METHODS Between January 2005 and December 2014, we performed 142 infrainguinal bypasses for critical limb ischemia with ischemic gangrene (Rutherford classes V or VI), including 80 distal bypasses in 74 patients (male 54, female 20, median age 68.4 years, range 51-81 years). All distal bypasses used an autologous saphenous vein graft. Surgical outcomes were compared between 37 distal bypasses without prior infrapopliteal EVT (NEVT group) and 43 distal bypasses after unsuccessful infrapopliteal EVT (PEVT group). Infrapopliteal EVT was performed with balloon dilatation without stenting in all cases. RESULTS There were no significant differences in preoperative conditions or risk factors between the NEVT and PEVT groups, except for the era of bypass surgery and dependence on hemodialysis. The 3-year primary and secondary patencies were 69% and 72% in the NEVT group and 78% and 80% in the PEVT group (P=0.86, P=0.79). The 3-year limb salvage rates were 81% in the NEVT group and 82% in the PEVT group (P=0.52), and the 3-year amputation-free survival rates were 56% and 57% in the respective groups (P=0.32). Standard errors of the mean for all Kaplan-Meier curves were

We describe a rare case of traumatic disruption of saphenous vein graft bypassed to the dorsalis pedis artery. The vein graft was disrupted at the level of ankle joint by blunt trauma and symptoms of acute foot ischemia were recognized. The injured vein graft was reconstructed with cephalic vein graft interposition. He has been free from any events of foot ischemia at 10 months follow-up with patent vein graft to the dorsalis pedis artery.

Two cases of von Recklinghausen's disease developing hemorrhagic shock by intratumorous bleeding were successfully treated by arterial embolization followed by surgical resection. Case 1 involved a 38-year-old woman who had been having a subcutaneous tumor with the size of infant's head in the left hip for several years. The patient was transferred to th hospital because of abrupt pain and enlargement of the tumor (27×18×15cm) leading to hemorrhagic shock. Case 2 involved a 53-year-old man who was emergently admitted to the hospital because of an enlarging huge hematoma (30×37×35cm) in the right shoulder to back. The systolic pressure was 40mmHg and the patient was in a shock state. Both cases had no epidode of trauma before admission. Emergency arterial embolization was performed in both cases to achieve the sufficient hemostsis and prevent the progression of hemorrhagic shock. Thereafter, one and two weeks later, elective resection of the neurofibroma with hematoma was successfully performed in both cases. It has been reported that acute hemorrhage is a rare complication for elephantiasis neurofibroma, but easily develops deep shock and becomes lethal. And the emergent operation is unavoidable of massive amount of intraoperative bleeding. We emphasize that combined treatment of preoperative arterial embolization with surgical resection should be recommended to treat this fatal complication of von Reclinghausen's disease.

Background— Recent technical advances have made endovascular treatment (EVT) an alternative first-line treatment for critical limb ischemia. Methods and Results— A prospective multicenter study was conducted to evaluate the clinical outcomes of 314 Japanese critical limb ischemia patients (mean age, 73±10 years) with infrainguinal arterial lesions who underwent EVT. Patients were enrolled from December 2009 to July 2011 and were followed-up for 12 months. The primary end point was amputation-free survival (AFS) at 12 months. Secondary end points were anatomic, clinical, and hemodynamic measures, including 12-month freedom from major adverse limb events. The 12-month AFS rate was 74%, with body mass index P =0.008), heart failure (HR, 1.73; P =0.04), and wound infection (HR, 1.89; P =0.03) associated with a poor prognosis for AFS. The 12-month major adverse limb event-free rate was 88%, with hemodialysis (HR, 1.98; P =0.005), heart failure (HR, 1.69; P =0.02), and Rutherford classification 6 (HR, 2.25; P =0.002) associated with a poor prognosis for major adverse limb events. The median time for wound healing was 97 days, with body mass index P =0.03) and wound infection (HR, 0.60; P =0.04) being significant risk factors for unhealed wounds after EVT. At 12 months, 34% had undergone reintervention (bypass surgery, 2.6%; repeat EVT, 31.7%), and 73% were major adverse event–free. Conclusions— The high reintervention rate notwithstanding, EVT was an effective treatment for Japanese critical limb ischemia patients with infrainguinal disease, with satisfactory AFS and major adverse limb event-free rates. The results of this study will be helpful for the future evaluation of critical limb ischemia therapy. Clinical Trial Registration— URL: http://www.umin.ac.jp/ctr . Unique identifier: UMIN000002830.

A 26-year-old man who underwent aortic valve replacement for aortic regurgitation due to Takayasu's arteritis 2 years earlier experienced left amaurosis persisting for some minutes. Computed tomography showed aneurysmal dilation of the ascending aorta to a diameter of 60 mm and occlusion of the left carotid artery. Cardiac echography showed perivalvular leakage. Following administration of a calcium antagonist, the patient's amaurosis subsided and brain bloodstream scintigraphy showed no abnormalities. We resected the aneurysm instead of using Bentall's operation. Following an uncomplicated postoperative course, the patient was discharged 21 days after surgery and echocardiography has shown no perivalvular leakage to date.

We present a case report on a 54-year-old woman with extraskeletal osteosarcoma of the left atrium featuring severe congestive heart failure. We resected the tumor, which occupied the left atrium and had widely infiltrated the atrial wall, but the patients died of the tumor 9 months after surgery. This is to our knowledge the 32nd case of cardiac osteosarcoma ever reported.

The incidence of the diabetic foot is increasing worldwide. Because evidence has shown that transmetatarsal amputation is associated with fewer failures in amputations of the diabetic foot with or without peripheral arterial disease, improving its management and surgical technique is a mission for the surgeon. Conventional transmetatarsal amputation has held firm, however, for more than 150 years. With a new concept for the transmetatarsal amputation method aimed at a better outcome, we propose a modified procedure for preserving the soft tissue between the metatarsal bones (the vasculature complex with the muscles, periostea, and vessels) and applying it to the distal bone stumps. The purpose of this method is to secure a functional foot by preserving the longitudinal arch. The new method was applied to 11 patients with diabetes mellitus or peripheral arterial disease, or both. All wounds closed successfully. Of the 11 patients, 8 were still alive with no complications. Of these 8 patients, 6 were able to ambulate with a custom-made shoe and 2 used a wheelchair, just as preoperatively. Of the 3 patients who died, 1 died a natural death, 1 died of sepsis, and 1 of cerebral infarction. We believe that the modified transmetatarsal amputation that we have described in this report is a potential breakthrough in the care of patients with forefoot gangrene and may gain acceptance over time.

A 46-year-old female with alcoholic liver dysfunction was admitted for mitral regurgitation due to infective endocarditis. She underwent mitral valvuloplasty and resection of the vegetation without complication. After removal of the chest tube, late cardiac tamponade occurred and subsequently recurred. On the 64th day after mitral valvuloplasty, we performed redo median sternotomy with small laparotomy trying to reveal and repair injured lymphatic vessels in the pericardial space and successfully cured the leakage of lymph. The post reoperative course was uneventful and the patient was discharged 20 days after reoperation. We review a rare complication of recurrent cardiac tamponade of lymphatic leakage associated with liver dysfunction.

A 68-year-old man was hospitalized with the complaints of left back pain and fever. He had a history of using steroids to treat uveitis for about thirty years. Computed tomography on the chest demonstrated an impending rupture in an aortic arch aneurysm, which was consequently surgically excised. Candida albicans was identified in the wall of the aneurysm, so fluconazole and itraconazole were administered. The patient was discharged at 120 days after surgery without recrudescence of the candida. To our knowledge, this is the fifteenth case of a successfully treated aneurysm caused by candida infection.

La fracture de stent avec formation d’un faux anevrysme femoropoplite a rarement ete rapportee. Nous presentons le cas d'un homme de 72 ans avec une rupture de stent auto-expansible en nitinol et formation d’un faux anevrysme de l'artere poplitee sus-articulaire. L'artere poplitee a ete reconstruite avec succes par interposition d’une courte greffe veineuse saphene.

Stent fracture with pseudoaneurysm formation in the femoropopliteal artery has uncommonly been reported. We present the case of a 72-year-old man with a fracture of self-expanding nitinol stent and a pseudoaneurysm formation in the suprageniculate popliteal artery. The popliteal artery was successfully reconstructed with a small saphenous vein graft interposition.