A Type IV endoleak is a very rare complication following endovascular aneurysm repair (EVAR) and differential diagnosis can be difficult. Reported here is a case that showed the development of a Type IV endoleak after an EVAR procedure, for which a novel software was useful to differentiate that from Type I based on visual confirmation. The 89-year-old man was diagnosed with a large abdominal aortic aneurysm, sized 70 mm, as shown by computed tomography (CT). EVAR was performed in a routine fashion using an Endurant II stent graft. Postoperative CT revealed a massive endoleak around the neck that was difficult to differentiate between Types I and IV. The use of the novel software Viewtify (SCIEMENT, Inc., Tokyo, Japan) to visualize the endoleak with surrounding tissues as real-time three-dimensional computer graphics (3DCG) resulted in confirmation that the endoleak was not from the proximal end but rather the stent graft body. CT findings obtained one week later showed that the endoleak had diminished and no additional procedures were needed. Following a diagnosis of endoleak after EVAR, images viewed with Viewtify helped to confirm the appropriate diagnosis. This novel software was found useful to clarify the position and mechanism of a Type IV endoleak.
The most difficult aspect of chordal replacement during mitral valve repair is to determine the correct length of the new chordae. A simple technique of chordal replacement was developed employing the new mitral leaflet retractor that enables easy adjustment of the length of artificial chordae.For prolapse of the anterior mitral leaflet (AML), the level of the normal opposing posterior leaflet can be used to determine the length of new chordae. We developed a double-headed leaflet retractor with which both mitral leaflets can be retracted simultaneously at the same level. This retractor makes it easy to tie the slippery Gore-Tex sutures for artificial chordae adjusting the length of the new chordae on AML to the level of the opposing normal posterior leaflet. We employed this retractor for the creation of artificial chordae in 55 consecutive patients with degenerative AML prolapse between 2005 and 2013. A ring annuloplasty was concomitantly performed to stabilize the reconstruction.We had no hospital death. Follow-up was 100% complete with a mean follow-up duration of 1181 ± 839 (range 50-2892) days. Reoperation-free survival at 5 years was 98.2%. Freedom from moderate-to-severe mitral regurgitation was 88.0% at 5 years. At follow-up, all non-reoperated survivors were in New York Heart Association Class I or II.We have reported the chordal replacement using the new double-headed mitral leaflet retractor. Our leaflet retractor is a convenient tool representing an easy creation of artificial chordae in mitral valve repair.
The purpose of the present study was to investigate the effect of the C1 esterase inhibitor (C1-INH) molecule against human complement attack on a swine endothelial cell (SEC) membrane. Human C1-INH functions as an inhibitor for complement reaction in the first step of the classical pathway in the fluid phase.A surface-bound form of human C1-INH (C1-INH-PI) consisting of a full-length coding sequence of C1-INH and a glycosylphosphatidylinositol (GPI) anchor of the decay-accelerating factor (CD55) was constructed, and stable Chinese hamster ovarian tumor (CHO) cell lines and SEC lines expressing C1-INH-PI were then prepared by transfection of the constructed cDNA. The basic function of the transfected molecules on the xenosurface was investigated using CHO transfectants for the sake of convenience. The efficacy of C1-INH-mediated protection of SEC from human complement was then assessed as an in vitro hyperacute rejection model of a swine-to-human discordant xenograft.Flowcytometric profiles of the stable CHO and SEC transfectants with C1-INH-PI showed a medium level of expression of these molecules. The C1-INH levels were significantly reduced as a result of phosphatidylinositol-specific phospholipase C (PI-PLC) treatment, suggesting that the molecules were present as the PI-anchor form. Approximately 51.3 x 10(4) and 13.3 x 10(4) molecules of C1-INH-PI blocked human complement-mediated cell lysis by approximately 75% on the CHO cell and by 60-65% on the SEC cell, respectively. In addition, the complement-inhibiting activity of human C1-INH molecules is not homologously restricted.The results suggest that the surface-bound form of C1-INH represents a good candidate as a safeguard against hyperacute rejection of xenografts.
Our objective was to determine the relationship between plasma levels of hemostatic molecular markers – D-dimer and thrombin-antithrombin III complex (TAT) – and circulating biochemical markers of collagen metabolism – aminoterminal propeptide of type III procollagen (PIIIP) and carboxyterminal propeptide of type I procollagen (PICP) – in patients with aortic aneurysm. The subjects were 43 patients with aortic aneurysm (AA; mean age 71 years) and 26 age-matched controls (mean age 75 years). The mean D-dimer, TAT and PIIIP levels were higher in the patients than in the controls (p < 0.0001, 0.0001 and 0.012, respectively), while the mean PICP level was similar to that in the controls. Increased D-dimer had a significant correlation with PIIIP (r = 0.412, p = 0.006) and PICP (r = 0.342, p = 0.0246), while TAT correlated with PIIIP (r = 0.3194, p = 0.0374), but not with PICP. There was also a significant correlation (r = 0.306, p = 0.0463) between PIIIP and PICP. As shown by the significant positive correlations among D-dimer, TAT and PIIIP, accelerated fibrinolysis and thrombogenesis induce an increase of collagen degradation and procollagen synthesis in atherosclerotic lesions. These findings show that D-dimer and TAT, especially the former, may be useful markers to monitor the progression and predict the prognosis of AA.
The purpose of this study was to investigate whether platelet indexes [platelet count, mean platelet volume (MPV), platelet-large cell ratio (P-LCR), and platelet distribution width (PDW)] could serve as diagnostic tools to evaluate the potential significance of platelet heterogeneity on thrombus formation. Blood samples were obtained from 54 patients with aortic aneurysm (AA; mean age 73 years; 40 males, 14 females), from 120 age-matched controls (AC; mean age 74 years; 61 males, 59 females), and from 38 young controls (YC; mean age 30 years; 20 males, 18 females). We measured the blood platelet indexes using an automated counter, as well as plasma D-dimer and thrombin-antithrombin III complex (TAT) using ELISA. The AA patients were divided into two groups, group A (platelet count more than 150 × 10<sup>9</sup>/l, n = 36) and group B (platelet count below 150 × 10<sup>9</sup>/l, n = 18). There was no difference in the platelet count between AC and YC. However, P-LCR was significantly higher (p = 0.0113) in AC. MPV and PDW were also higher, but not significantly so. The platelet count was not different between group A and AC. MPV (p = 0.0024 and <0.0001, respectively), P-LCR (p < 0.0012 and <0.0001, respectively) and PDW (p = 0.0006 and 0.0005, respectively) were significantly lower in group A than in group B and AC. The platelet indexes were significantly lower in the 54 AA patients than in the AC. There were significant inverse relationships between the platelet count and other indexes in the AC and 54 AA patients; however, no relationships were observed in group A, B and YC. The D-dimer and TAT levels were significantly higher in group B than in groups A and YC. In conclusion, these findings suggest that large platelets decrease rather than increase in patients with AA.
As ostial stenoses of internal thoracic artery (ITA) grafts rarely occur after coronary artery bypass grafting, little is known about their Doppler flow profile. This report describes changes in the Doppler flow of ITA grafts with ostial stenosis after surgical repair of the stenosis. A 54-year-old male underwent coronary artery bypass grafting (CABG) in which the left ITA was anastomosed to the left anterior descending coronary artery. The follow-up coronary angiography revealed an ostial 90% stenosis of the ITA. The patient underwent elective surgery during which the radial artery was interposed between the left subclavian artery and the ITA. Intraoperative ultrasonography was performed immediately before cut down of the ITA graft and again immediately after completion of all anastomoses. Both diastolic and systolic velocities and the velocity time integral increased more than 2-fold after the repair. Neither the diastolic-to-systolic peak velocity ratio nor the diastolic velocity time integral fraction showed remarkable change. These profiles were different from those reported previously for distal stenosis.
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