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Tricuspid pouch forms during the spontaneous closure of a ventricular septal defect (VSD). Cases have been reported in which the tricuspid pouch was discovered for the first time during surgery and could not be distinguished from an aneurysm of the membranous septum( AMS). A 58-year-old woman had a heart murmur. Transthoracic echocardiography showed an aneurysm-like pouch protruding into the right ventricle. Magnetic resonance imaging could not distinguish between AMS and tricuspid pouch;however, contrast-enhanced computed tomography showed a VSD. The membranous structure comprised multiple lobules, and the tendon of the papillary muscles was continuous with the tricuspid valve. Intraoperatively, the tricuspid valve septal leaflet was adhered to the defect hole. It was incised along the annulus, the VSD was closed with a bovine pericardial patch, and the annulus of the tricuspid valve septal leaflet was suture closed. The patient was discharged after a good postoperative course.

We investigated the clinical impact of hemodialysis on long-term outcomes of bypass surgery in patients with peripheral artery disease. We evaluated 660 consecutive patients who underwent successful bypass surgery (392 hemodialysis and 268 non-hemodialysis). The endpoint was amputation-free survival (AFS). To minimize differences in clinical characteristics between the 2 groups, propensity score matching was performed. The AFS rates for 10-year follow-up were 39.3% and 67.7% in hemodialysis and non-hemodialysis patients [hazard ratio (HR) 2.21, 95% confidence interval (CI) 1.65–3.01, P < .0001]. Cumulative incidence of amputation was higher in the hemodialysis group than in the non-hemodialysis group [(19.4 vs 8.4%, HR 2.15, 95% CI 1.29–3.74, P = .0027). In a matched cohort (n = 210 each), AFS was still lower in the hemodialysis patients (53.1 vs 66.3%, HR 1.94, 95% CI 1.36–2.82, P = .0003). However, there was no significant difference in amputation rate between the groups (10.5 vs 10.6%, HR .97, 95% CI 0.49–1.87, P = .93). In a sub-analysis of patients with critical limb ischemia, similar results were obtained. The 10-year AFS was consistently lower in the hemodialysis group than in the non-hemodialysis group. However, the amputation rate was comparable between the groups when matched for the differences in clinical characteristics.

ObjectiveProtein-energy wasting is associated with chronic inflammation and advanced atherosclerosis in haemodialysis (HD) patients. We investigated association of geriatric nutritional risk index (GNRI), C reactive protein (CRP) with prediction of mortality after coronary revascularisation in chronic HD patients.MethodsWe enrolled 721 HD patients electively undergoing coronary revascularisation. They were divided into tertiles according to preprocedural GNRI levels (tertile 1 (T1):98.1) and CRP levels (T1:≤1.4 mg/L, T2: 1.5–7.0 mg/L and T3:≥7.1 mg/L).ResultsKaplan-Meier 10 years survival rates were 32.3%, 44.8% and 72.5% in T1, T2 and T3 of GNRI and 60.9%, 49.2% and 23.5% in T1, T2 and T3 of CRP, respectively (pConclusionPreprocedural declined GNRI and elevated CRP were closely associated with mortality after coronary revascularisation in chronic HD patients. Furthermore, combination of both variables not only stratified risk of mortality but also improved the predictability.

Background and Aims Although lower extremities bypass surgery has been commonly performed as the standard option to treat peripheral artery disease with critical limb ischemia (CLI) even in patients on haemodialysis (HD) as well as general population, higher amputation and/or mortality rates still remains major clinical problems after bypass surgery in this population. In this 10-year follow-up study, we investigated the impact of HD on outcomes after surgical revascularization in patients with CLI. Method A total of 464 patients undergoing successfully elective bypass surgery were enrolled. We compared 304 HD patients with 335 limbs and 160 non-HD (NHD) patients with 183 limbs during 10 years follow-up period. Primary outcome was amputation-free survival (AFS) rate defined as freedom rate from composited endpoint with major amputation (limb amputation above ankle level) or all-cause mortality. To minimize the differences of clinical characteristics between the two groups, propensity score-matching with all baseline variables was performed. Results Prevalence of diabetes (55.6% vs. 33.8%), ulcer/gangrene (99.1% vs. 63.5%) and infra-popliteal artery disease (58.9% vs. 32.5%) were significantly higher in HD group compared to NHD group (p Conclusion The long-term AFS rate and survival rate were markedly lower in HD patients compared to NHD patients. However, the limb salvage rate was even between HD and NHD after adjustment for clinical characteristics. These results suggest that detection at the early stage of PAD may potentially improve the poor outcome. Pre-procedural inflammation status may also specifically affects the poor outcome in HD group.

Background and Aims Although lower extremity revascularization has been commonly performed in chronic haemodialysis (HD) patients with peripheral artery disease (PAD), poorer prognosis still remains major problems in such population. Recently, protein-energy wasting (PEW) or malnutrition have been considered to be strongly associated with chronic inflammation and advanced atherosclerosis in HD patients. We investigated the association of geriatric nutritional risk index (GNRI) as a surrogate marker of the PEW, C-reactive protein (CRP) and these joint role with prediction of amputation and/or mortality after lower extremity revascularization in chronic HD patients. Method We enrolled a total of 862 HD patients (age 67±10 years, diabetes 62.9%, critical limb ischemia 53.5%) who successfully underwent lower extremity revascularization (552 with endovascular therapy and 310 with bypass surgery). Patients were divided into tertiles according to GNRI levels; tertile 1 (T1): 96.6, and CRP levels; T1: 12.6mg/l, respectively. They were followed up for up to 8 years. Results During follow-up period (median: 43 months), 63 (7.3%) patients needed major amputation and 202 (23.4%) patients died. Kaplan-Meier analysis shows that amputation-free survival rates for 8 years were 47.5%, 51.6% and 66.5% in T1, T2 and T3 of GNRI, and were 65.8%, 58.7% and 33.2% in T1, T2 and T3 of CRP, respectively (p Conclusion Among HD patients undergoing lower extremity revascularization, those with pre-procedural declined GNRI and elevated CRP frequently experienced amputation and/or mortality, furthermore, combination of both variables could stratify the risk of amputation and/or mortality.

A 79-year-old man with appetite loss and nausea for 1 month was admitted to our hospital. His thoracic aortic aneurysm had gradually increased in size due to perigraft endoleak after the previous aneurysm repair surgery. Although he showed no hematemesis, melena, or a fever, gastrointestinal endoscopy and contrast-enhanced computed tomography (CT) revealed an aortoesophageal fistula (AEF). He developed septic shock due to a perigraft abscess and eventually died, although aortic graft replacement and esophageal transection were performed. Clinical suspicion is the most important factor for obtaining an accurate diagnosis and improving the prognosis in cases of AEF.

Background It remains controversial whether coronary artery bypass graft (CABG) or percutaneous coronary intervention (PCI) should be optimized to treat coronary artery disease in patients on chronic hemodialysis (HD). Recently, further refinement of drug-eluting stents, such as the everolimus-eluting stent (EES), has led to marked development in this field. We compared long-term clinical outcomes after CABG versus PCI with EES implantation in patients on chronic HD. Patients and methods We compared 138 patients undergoing CABG and 187 patients treated with EES implantation. The endpoint was major adverse cardiac events (MACE) as a composite outcome, including any revascularization, nonfatal myocardial infarction, or mortality. To reduce the selection bias for the two procedures, propensity score-matching was performed. Results During the follow-up period (43 months), 95 (29.2%) MACEs, including 43 (13.2%) revascularizations, 14 (4.3%) nonfatal myocardial infarctions, and 63 (19.4%) deaths, occurred. The freedom rate from MACE and mortality at 5 years were comparable between groups (69.7 vs. 66.7%, P=0.82 and 75.0 vs. 80.6%, P=0.10, respectively); however, those from revascularization at 5 years was higher in the CABG group than the EES group (89.4 vs. 81.0%, P=0.030). In propensity score-matched patients (n=92), the freedom rate from revascularization at 5 years was still higher in the CABG group than in the EES group (93.4 vs. 79.1%, P=0.013). Similarly, the freedom rates from MACE and mortality were comparable (70.0 vs. 66.3%, P=0.69 and 73.8 vs. 79.7%, P=0.30, respectively). Conclusion Even in the second-generation drug-eluting stent era, CABG is still superior for preventing revascularization in patients on chronic HD. However, PCI with EES implantation might not have disadvantages compared with CABG in terms of MACE.

Aim: To investigate the long-term clinical outcome of endovascular therapy (EVT) or bypass surgery in patients on hemodialysis (HD) with critical limb ischemia due to isolated infrapopliteal disease. Methods: We enrolled 254 consecutive HD patients successfully undergoing infrapopliteal revascularization by EVT (126 patients) and bypass surgery (128 patients). They were followed up for five years. Amputation-free survival (AFS) and incidence of any re-intervention were evaluated. A propensity score from all baseline variables was incorporated into Cox analysis. Results: In the EVT group, age was higher (p = 0.039), diabetes and coronary artery disease were more frequent (p = 0.004 and p = 0.0052, respectively), and tissue loss was more rarely observed (p < 0.0001) than in the bypass group. During the follow-up period, 21 major amputations and 64 deaths occurred. The propensity score-adjusted AFS rate at 5 years was comparable between groups (61.0% in EVT group vs. 55.1% in the bypass group, adjusted hazard ratio [HR] 0.87, 95% confidence interval [CI] 0.52–1.42, p = 0.58). The adjusted survival rates were also similar between groups for amputation and all-cause mortality. However, freedom from any reintervention was markedly lower in the EVT than in the bypass group (48.6% vs. 84.6%, adjusted-HR, 3.56, 95% CI 1.95–6.75, p < 0.0001). Conclusions: The rate of AFS was broadly comparable between the two strategies, although compared with bypass surgery, EVT had much higher rates for re-intervention.

Right-sided infective endocarditis (IE) accounts for 3-14% of all cases of IE. Compared with leftsided IE, its antibiotic treatment is more effective. Therefore, the timing of its surgical treatment is still controversial. We report 2 cases of tricuspid valve IE and ventricular septal defect (VSD) associated with multiple lung abscesses and infarctions. After successful antibiotic treatment, they underwent vegetectomy, tricuspid valve plasty and VSD patch closure. Antibacterial treatment preceding surgical treatment is effective for tricuspid endocarditis complicated with multiple lung abscesses.

Protein-energy wasting (PEW) is highly prevalent in hemodialysis (HD) patients. We investigated the association of abnormal ankle brachial index (ABI), PEW, and chronic inflammation status with clinical prognosis in HD patients. A total of 973 HD patients were enrolled and were followed-up for 8 years. As a marker of the PEW, geriatric nutritional risk index (GNRI) was used. Cut-off levels were 91.2 for GNRI defined from previous studies and 1.9 mg/L for C-reactive protein (CRP) as median value, respectively. Abnormal ABI was seen in 332 (34.1%) patients. Declined GNRI and elevated CRP levels were independently associated with abnormal ABI (odds ratio (OR) 0.97, 95% confidence interval (CI) 0.96–0.99, p = 0.0009 and OR 1.40, 95% CI 1.07–1.83, p = 0.013, respectively). GNRI levels were also independently correlated with CRP levels (β = −0.126, p < 0.0001). During follow-up period, 283 (29.1%) patients died, including 123 (12.6%) due to cardiovascular disease (CVD). Abnormal ABI (adjusted hazard ratio (HR) 1.62, 95% CI 1.13–2.32, p = 0.0096), GNRI < 91.2 (adjusted HR 1.57, 95% CI 1.06–2.33, p = 0.023) and CRP > 1.9 mg/L (adjusted HR 1.89, 95% CI 1.31–2.77, p = 0.0007) independently predicted mortality due to CVD, respectively. In conclusion, abnormal ABI, GNRI, and CRP levels were closely associated with each other, and the combination of these variables increase their predictive values for the risk of mortality due to CVD and all-cause mortality in HD patients.

Hideki Hirakata, Kosaku Nitta, Masaaki Inaba, Tetsuo Shoji, Hideki Fujii, Shuzo Kobayashi, Kaoru Tabei, Nobuhiko Joki, Hiroki Hase, Masato Nishimura, Shigeyuki Ozaki, Yuji Ikari, Yoshitaka Kumada, Kazuhiko Tsuruya, Shouichi Fujimoto, Tohru Inoue, Hiroyoshi Yokoi, Sumio Hirata, Kazuaki Shimamoto, Kiyotaka Kugiyama, Takashi Akiba, Kunitoshi Iseki, Yoshiharu Tsubakihara, Tadashi Tomo, and Tadao Akizawa

Background Although percutaneous transluminal angioplasty (PTA) has become a common therapeutic standard for peripheral artery disease (PAD), high restenosis rates in the superficial femoral artery (SFA) remain a major problem. Nitinol stent implantation is reported to reduce restenosis in SFA after PTA in the general population; however, little is known about whether the nitinol stent improves primary patency after PTA in hemodialysis patients who are at higher risk of revascularization failure. The aim of this study was to clarify the effects of nitinol stent implantation for primary patency in SFA after PTA in hemodialysis patients with PAD. Methods Eighty consecutive hemodialysis patients (167 SFA lesions) who underwent PTA with nitinol stents from January 2006 to January 2008 were compared with 64 hemodialysis patients (128 SFA lesions) who received stainless steel stents in the preceding 2 years. In the follow-up study to 2 years, incidence of restenosis, amputation, and all-cause mortality were analyzed. End points between the groups were examined with the Kaplan-Meier and log-rank methods. Prognostic values for end points were calculated by a Cox univariate analysis and Cox multivariable regression models. To statistically minimize the differences in each stent group, a propensity-matched analysis was also performed using the model including male gender, age, diabetes, hypertension, hyperlipidemia, smoking, incidence of ulcer/gangrene, and TransAtlantic Inter-Society Consensus (TASC) type C+D. Results The 2-year primary patency rate was 58% in the nitinol group vs 42% in the stainless steel group (hazard ratio [HR], 0.58; 95% confidence interval [CI], 0.39-0.84; P = .0045), despite a higher prevalence of TASC C+D lesion in the nitinol group (68% vs 49%, P = .0014). In 108 lesions matched after propensity score analysis, the primary patency for 2 years was 64% in the nitinol group vs 42% in the stainless steel group (HR, 0.39; 95% CI, 0.24-0.65; P = .0003). Cox multivariate models showed nitinol stent (HR, 0.42; 95% CI, 0.25-0.73; P = .002), age (HR, 1.04; 95% CI, 1.01-1.08; P = .031), and incidence of ulcer/gangrene (HR, 2.35; 95% CI, 1.17-4.75; P = .017) were independent predictors of restenosis. Conclusion These data suggest that nitinol stent implantation improves primary patency in SFA after PTA compared with the stainless steel stent, even in hemodialysis patients with PAD.

Circulating CD34-positive (CD34(+)) cells, a population that includes endothelial progenitor cells, are believed to contribute to vascular homeostasis. Here we determine the prognostic value of CD34(+) cell measurements in 216 chronic hemodialysis patients. A total of 43 cardiovascular events and 13 deaths occurred over an average 23 months follow-up in this cohort. A cutoff number for circulating CD34(+) cells was determined by receiver operating characteristic curve analysis to maximize the power of the CD34(+) cell count in predicting future cardiovascular events. Based on this, 93 patients were categorized as having low and 123 patients as having high numbers of CD34(+) cells, determined by flow cytometry at the time of enrollment. Both cumulative cardiovascular event-free survival and all-cause survival were significantly less in the group of patients with low numbers of CD34(+) cells. By multivariate analyses, a low level of circulating CD34(+) cells was an independent and significant predictor for both cardiovascular events and all-cause mortality. Our study shows that a reduced number of circulating CD34(+) cells is significantly associated with vascular risks and all-cause mortality in patients on chronic hemodialysis. These cells may be a useful biomarker.

Objective: We investigated the effect of immersion of feet in CO2-enriched water for preventing expansion and formation of ischemic ulcer in critical limb ischemia of diabetic patients after surgical revascularization. Materials and methods: Eligible patients were allocated CO2 group (CO2 immersion plus standard care) or control group (standard care alone) and were followed up for 3 months after surgical revascularization. The end point is defined as an expansion of a target ulcer (more than 101% of original size) or the formation of new ulcers during the follow-up period. Results: Fifty-nine patients out of originally enrolled 66 patients with type II diabetes were included in intention-to-treat population. The cumulative prevention rate for ischemic ulcer after 3 months was 97.1% in the CO2 group, while, in the control group, it was 77.8%, i.e., significantly lower than the CO2 group (P = 0.012, log-rank test). The transcutaneous oxygen pressure increased significantly only in the CO2 group, from 56 ± 14 to 63 ± 15 mmHg (P < 0.01, Wilcoxon signed rank test), in 3 months. Conclusion: These results suggest that addition of CO2 immersion to standard care of critical limb ischemia in diabetic patients improves early postoperative outcome after vascular surgery.

1999年5月から2004年8月までに経験した慢性透析患者の弁膜症手術症例43例を対象として術後成績と問題点を明らかにし,代用弁の選択について検討した.手術術式は大動脈弁置換術(AVR)20例,僧帽弁置換術(MVR)9例,AVR+MVR8例,僧帽弁形成術(MVP)6例,代用弁の種類はAVRで機械弁23例,生体弁5例,MVRで機械弁13例,生体弁4例であった.病院死亡を3例(7%)に認め,死因は心不全1例,肺炎1例,敗血症1例であった.遠隔期死亡は10例(23%)で心不全2例,肺炎2例,創部感染1例,脳梗塞1例,悪性腫瘍2例,閉塞性動脈硬化症1例,不明1例であった.1,3,5年生存率はそれぞれ81%,74%,47%,出血・血栓塞栓症といった合併症は術後早期・遠隔期を通して機械弁を使用した群(機械弁群)では29例中3例(10%),生体弁を使用した群(生体弁群)で9例中0例(0%)であり,両群間に有意差は認めなかった(p=0.25).また,生体弁の早期劣化(19ヵ月,24ヵ月,50ヵ月)による再手術を3例経験した.慢性透析患者における代用弁の選択は,機械弁群と生体弁群で出血・血栓塞栓症といった合併症に差はなく,諸外国に比べ比較的予後の良好なわが国では,生体弁の早期劣化による再手術の危険性を考慮すると,基本的には機械弁を選択するのが良いと考えられた.

Although lower limb revascularization has been commonly performed to treat critical limb ischemia (CLI) in patients with chronic kidney disease, the clinical outcomes such as limb salvage or survival rate have been reportedly poorer compared with those without chronic kidney disease after both

Background Cilostazol has been reported to prevent atherosclerotic events in the general population. However, data have been limited whether there are beneficial effects of cilostazol use on long-term clinical outcomes after endovascular therapy in hemodialysis (HD) patients with peripheral artery disease (PAD). Methods and results This study consisted of 595 HD patients undergoing endovascular therapy for a clinical diagnosis of PAD. They were divided into two groups: patients receiving 100 mg cilostazol twice daily in conjunction with standard therapy ( n = 249 patients, cilostazol group) and those not administered cilostazol ( n = 346 patients, control group). A propensity score analysis was performed to adjust for baseline differences between the two groups. The propensity score-adjusted 10-year event-free survival rate from major adverse cardiovascular events (MACE) was significantly higher in the cilostazol group than in the control group [58.6% vs. 43.7%, hazard ratio (HR) 0.57; 95% confidence interval (CI) 0.41–0.79; p = 0.0010]. Notably, the adjusted stroke-free rate was significantly higher in the cilostazol group than in the control group (81.6% vs. 74.7%; HR = 0.48; 95% CI, 0.25–0.92, p = 0.028). Even after adjusting for other confounders, treatment with cilostazol was an independent predictor for prevention of MACE and stroke ( p = 0.0028 and p = 0.039, respectively). Conclusions Cilostazol administration improves long-term clinical outcomes including prevention of MACE and stroke after endovascular therapy in HD patients with PAD.

A case of diffuse supravalvular aortic stenosis (SVAS) with Williams syndrome is reported. In this case of severe diffuse SVAS, we performed the diamond-patch aortoplasty in a child. However he has been suffering from residual SVAS. At 9-years old, the myocardial injury was noted by myocardial scintigraphy. Preoperative cardiac catheterization and angiography revealed the hypoplastic ascending aorta and arch with a pressure gradient of 89 mmHg at the distal site from the left subclavian artery. Through only a median stenotomy, an extended patch aortoplasty between the valsalva sinus and distal arch was performed and an extraanatomic bypass from the ascending aorta to the descending aorta was employed using a 10 mm tube graft. We realize this technique is available because this method can relieve the left ventriculus of the pressure load and operate via only median sternotomy.

Leiomyosarcomas are extremely rare primary cardiac tumors. We report a rapidly growing primary leiomyosarcoma of the right ventricle, which obstructed the right ventricular outflow tract within one month after symptom onset in a 68-year-old man. Two-dimensional echocardiography was useful in diagnosing the extent and progression of the tumor. The tumor was surgically resected on an emergency basis, and the right ventricle and pulmonary artery were successfully reconstructed. Recurrence of the tumor on the right ventricle was observed, and the patient was overcome by sudden dyspnea and died three months after surgery.

腹部悪性腫瘍と併存する腹部大動脈瘤 (AAA) の外科的治療方針について, 当科で経験した症例に基づき検討した. 最近8年間にAAAと腹部悪性腫瘍を併存した6例 (結腸癌3例, 胃癌2例, 肝臓癌1例) を対象とした. AAA術前に胃癌と診断されていた2例に対して, AAAと腹部悪性腫瘍の手術を一期的に行った. AAAに肝臓癌と虚血性心疾患が併存した症例に対して, AAAを経過観察とし, 冠血行再建術と肝切除術を一期的に行い, 瘤径が拡大した4か月後に人工血管置換術を行った. また, 術前に結腸癌を診断された症例に対して, 術中の人工血管の感染性の問題を考慮し, AAA手術を先行し, 50日後に右半結腸切除術を行った. AAA手術中に結腸癌を発見された2例のうち, 1例は瘤径が比較的小さかったため, 結腸切除術を先行したが, 術後肝転移を指摘され, 生命予後を考慮しAAA放置することとなり, 術後7か月目に癌死した. 他の1例はAAAと結腸癌の両者ともそれぞれ瘤径, stage からみて待機不可能であったため, 一時的人工肛門造設を伴う一期的手術を施行した. 人工血管への汚染などに留意し, AAAに対して人工血管置換術を行った5例はいずれの症例も, 人工血管感染等の術後合併症を回避することができた. 術後肝転移で放置した1例を除く5例のAAA症例は現在も健在であり, 悪性疾患併存例の術後最長生存期間は46か月である. AAAと腹部悪性腫瘍の両者とも, 外科的に治癒が可能な場合, 基本的に一期的に手術を行う当科の治療方針において, 良好な結果を得た. 下部消化管疾患が併存した場合は, 症例ごとにAAA破裂の危険性や悪性腫瘍根治性の問題などについて十分検討した上で一期的手術か, 二期的手術かを決定すべきである.

PurposeEndovascular therapy (EVT) has been widely performed for peripheral artery disease. However, the high restenosis rate after EVT remains a major problem in patients on hemodialysis. Recent studies suggest that C-reactive protein (CRP) reflects vascular wall inflammation and can predict adverse events. We evaluated the possible prognostic values of CRP on outcomes in hemodialysis patients undergoing EVT.MethodsA total of 234 hemodialysis patients undergoing EVT for peripheral artery disease were enrolled and followed-up for up to 5 years. They were divided into tertiles according to serum CRP levels (lowest tertile

Chronic hemodialysis (HD) patients are at an increased risk for peripheral artery disease (PAD). Although percutaneous transluminal angioplasty (PTA) has become a widely used therapeutic intervention for PAD, its outcome in HD patients remains poorly understood. The aim of this study was to clarify the long-term outcome after PTA in HD patients with PAD. Consecutive 241 HD patients with 418 lesions and 152 non-HD patients with 201 lesions who underwent successful PTA as a first-choice therapeutic option for PAD were enrolled. They were followed for 8 years. Outcome measures included target lesion revascularization (TLR), major amputation, and all-cause mortality. Mean age was younger and prevalence of coronary artery disease and femoropopliteal lesion were significantly more frequent in HD patients (66±10years vs. 71±10years, p=0.0001, 52% vs. 41%, p=0.035 and 71% vs. 52%, p=0.0002, respectively). Prevalence of critical limb ischemia and TASC C+D lesion types were comparable in both groups (45% vs. 34% and 37% vs. 38%, respectively). During 46±38months, the 8-year freedom from TLR (64% vs. 76%, p=0.0057) limb salvage (82% vs. 97%, p=0.0001) and survival rates (52% vs. 87%, p

Background : We have shown that immersion of feet in warmed water enriched with carbon dioxide (CO 2 immersion) improves subcutaneous microcirculation in critical limb ischemia (CLI) with ischemic ulcer/gangrene. Using an animal model, other group has reported that the CO 2 immersion enhances collateral blood flow in ischemic limb via mobilization of endothelial progenitor cells and activation of NO-cGMP system. For CLI patients with ulcer/gangrene, infrainguinal bypass surgery is the standard therapy. However, ulcer healing and prevention of amputation still remain suboptimal. In order to know whether the CO 2 immersion improves the clinical efficacy, here we performed the CO 2 immersion after infrainguinal bypass surgery. Methods : This study was designed as a prospective controlled trial. Fifty-five patients with ischemic ulcer/gangrene underwent the standard care including successful infrainguinal bypass surgery were enrolled and were randomly divided into the two groups; patients underwent standard care added CO 2 immersion (CO 2 group, 27 patients with 30 limbs) and patients received standard care alone (control group, 28 patients with 30 limbs). The patients in the CO 2 group immersed their feet in CO 2 enriched water (depth of 20 –30 cm, 37–38°C, duration for 10 minutes) twice a day. Primary endpoint was defined as complete healing of ischemic ulcers. Results : Baseline demographical data, traditional risk factors, surgical procedure, ankle pressure and transcutaneous oxygen pressure (tcPO 2 ) were comparable between the two groups. Rate of the complete ulcer healing after 1-year was much higher in the CO 2 group than in the control group (43.3% vs. 20.0%, HR 2.72, 95%CI 1.03–7.17, p=0.043). Cox multivariate analysis revealed that CO 2 immersion (HR 4.13, 95%CI 1.09 –15.75, p=0.038), diabetes (HR 0.020, 95%CI 0.01–.303, p=0.005) and tcPO 2 (HR 1.04, 95%CI 1.00 –1.09, p=0.050) were independent predictors for complete ulcer healing. In contrast, rates of 1-year mortality, graft patency and limbs salvage showed no significant differences between 2 groups (p=0.55, p=0.47 and p=0.16, respectively). Conclusion : The CO 2 immersion after infrainguinal bypass surgery provided additional benefit for the ulcer healing in CLI patients with ulcer/gangrene.

Background: It has been established that elevated brain natriuretic peptide (BNP) and C-reactive protein (CRP) levels are increasingly associated with cardiovascular (CV) morbidity. We examined the prognostic usefulness of combining BNP and CRP for predicting CV mortality in hemodialysis (HD) patients. Methods: Plasma BNP and serum CRP were measured consecutively in 500 HD patients. These patients were divided into 4 groups according to plasma BNP levels; Quartile 1 (Q1): < 45 ng/L, Q2: 145–266 ng/L, Q3: 267– 628 ng/L, and Q4: >628 ng/L, and serum CRP levels; Q1: 1.17mg/dl, respectively. All patients were followed up for 8 years. Results: On Cox proportional hazards analysis, hazard ratio (HR) of elevated BNP levels was 3.93 (95%CI 2.06 –7.52 for Q4 vs Q1) for CV mortality and 3.51 (95%CI 2.18 –5.64 for Q4 vs Q1) for all-cause mortality, respectively (both p ). These variables were significant after adjustment for other CV risk factors. Conclusions: Elevated BNP and CRP interactively increased CV and all-cause mortality risk in HD patients. The combination of BNP and CRP is useful for risk stratification in HD patients because the combination of these variables is more closely related to outcome than either variable alone.

Background: Percutaneous transluminal angioplasty (PTA) has become common therapeutic standard for peripheral artery disease (PAD). Although initial success rate of PTA is high, higher restenosis rate is a limitation in hemidialysis (HD) patients. Cilostazol is a PDE3 inhibitor with anti-platelet and vasodilatory effects, and also inhibits the proliferation of the smooth muscle cells, and has been reported to reduce target lesion revascularization (TLR) in PAD patients. The aim of this study was to clarify the effects of cilostazol administration for long-term patency after PTA in HD patients. Methods: Consecutive 372 lesions of 193 HD patients undergoing successfully PTA were enrolled. They were divided into two groups; patients administered cilostazol (130 lesions of 71 patients) and those without cilostazol as a control (242 lesions of 122 patients). They were followed-up using Doppler ultrasound and/or angiography for 5 years. To minimize the selection bias for cilostazol administration, a propensity-matched analysis using the model including male, age, diabetes, critical limb ischemia (CLI), TASC C+D type, femoropopoliteal (FPA) lesion and stenting was performed. The propensity score was matched 1:1 with two-digit (AUC=0.69 using ROC analysis). Results: Mean follow-up period was 28±24months. Primary patency rate for 5 years was significantly higher in the cilostazol group than in the control group (53% vs 33%, p = 0.0003). Also, rates for freedom from TLR and for limb salvage were higher in cilostazol group than in control group (67% vs. 50%, p=0.011 and 88% vs. 72%, p =0.031, respectively). In 102 lesions matched after propensity score analysis, the primary patency for 5-year was significantly higher in the cilostazol group (58%) than in the control group (35%) (HR 0.48, 95%CI 0.30 – 0.76, p = 0.0017). Upon multivariate Cox analysis, Cilostazol (HR 0.50, 95%CI 0.26 – 0.87, p = 0.014), age (HR 1.03, 95%CI 1.01–1.07, p = 0.041), FPA lesion (HR 2.62, 95%CI 1.22–5.62, p = 0.013), TASC C+D type (HR 2.85, 95%CI 1.56 –5.20, p = 0.0006) and CLI (HR 4.09, 95%CI 2.10 –7.94, p Conclusion: These data suggest that cilostazol administration improves long-term patency after PTA in HD Patients with PAD.

Several reports over the past 15 years describe severe group A streptococcal infections causing septic shock, soft-tissue necrosis, and multiple organ failure; a phenomenon known as streptococcal toxic shock-like syndrome (TSLS). However, primary peritonitis associated with TSLS is rare. We report the case of a 40-year-old man admitted with pain in both thighs, hypotension, and severe abdominal pain. His daughter had been diagnosed with streptococcal pharyngitis 3 days earlier. We performed an emergency laparotomy for peritonitis, and culture of the ascites was positive for group A beta -hemolytic streptococcus (GAS). Further serotyping of the isolated GAS strain revealed the T-type 22 and the pyrogenic exotoxin gene, spe-C. The criteria for TSLS were clearly met, including the isolation of GAS from ascites, hypotension, liver failure, renal failure, coagulopathy, myositis, and a generalized erythematous macular rash with desquamation.

Objective. The purpose of this study is to assess whether or not dielectric properties could predict the severity of ischemic injury of the skeletal muscle before reperfusion to prevent the myonephropathic metabolic syndrome (MNMS). Methods. Japanese White rabbits were anesthetized and their hind limbs were subjected to 0, 2, 4, and 6 h of ischemia and then 10 h of reperfusion ( n = 4, 5, 6, and 6). Dielectric properties of the gastrocnemius muscle were measured and tan δ m and D were calculated from them. To assess ischemic injury, we also measured (a) creatine phosphate kinase (CPK) and aldolase, (b) spectrophotometric assay of triphenyltetrazolium chloride assay, and (c) histological evaluation by H & E staining, 10 h after reperfusion. Results. The tan δ m increased and D decreased significantly compared with those in preischemia ( P m value just before reperfusion significantly correlated positively with the maximum value of CPK (CPK max ) or the maximum value of aldolase (ALD max ) ( r = 0.73, 0.69) and negatively with %TTC ( r = 0.66). The D value just prior to reperfusion significantly correlated negatively with CPK max and ALD max ( r = 0.81, 0.86) and positively with %TTC ( r = 0.79) after reperfusion, respectively. Histologically, skeletal muscle necrosis was detected in 11 out of 12 skeletal muscles with tan δ m values which were 3.70 or more and 11 out of 14 muscles with D values which were 1.47 or less. Conclusion. The severity of skeletal muscle ischemic injury can be evaluated before reperfusion by measuring the dielectric properties during ischemia.

Deceasing sarcoplasmic reticular (SR) calcium may contribute to the myocardiac protection against ischemia and reperfusion-induced injury. Therefore, using the isolated working rat heart model, we investigated the effect of Thapsigargin (TH)-induced SR calcium diminution on the myocardial protection when added either before onset of ischemia or at time of reperfusion under conditions of normothermic ischemia. Hearts (n = 6/group) from male Wistar rats were aerobically (37 degrees C) perfused (20 min) with bicarbonate buffer. In the experimental protocol A, this was followed by a 3 min infusion of St. Thomas' Hospital cardioplegic solution No. 2 (STS) containing various concentrations of TH. Hearts were then subjected to 34 min of normothermic (37 degrees C) global ischemia and 35 min of reperfusion (15 min Langendorff, 20 min working). Reperfusion cardiac functions at 20 min of working perfusion was measured and compared with the preischemia values. STS added to 0.1 and 0.25 mumol/L TH improved recovery of aortic flow after 20 min reperfusion from 47 +/- 3% in the TH free controls to 62 +/- 3, 63 +/- 2% (n = 6) (p0.05). There was no difference in creatine kinase (CK) leakage during Langendorff reperfusion between the TH treated groups and the control group. In the experimental protocol B, 3 min of cardioplegia without TH and 34 min of ischemia (37 degrees C) were followed by a 10 min Langendorff reperfusion with various concentrations of TH, then 10 min Langendroff reperfusion for washing out, and 20 min working reperfusion. When TH was added to reperfusate the recovery of aortic flow did not change, 0.5 mumol/L TH group had the detelious effect. Thus, TH, when added to the cardioplegia, enhanced myocardial protection. We conclude that lessened uptake of Ca2+ into sarcoplasmic reticulum by inhibitors of the Ca(2+)-ATPase pump can decrease ischemia and reperfusion-induced injury.

ObjectiveLower extremity bypass surgery has been widely performed to treat critical limb ischemia (CLI) in patients on hemodialysis (HD). However, the clinical outcome still remains unclear. We investigated the limb salvage rate after infrapopliteal bypass surgery in HD patients with CLI.MethodsFrom April 2006 to January 2013, 226 patients with 236 limbs who electively underwent bypass surgery for treatment of CLI due to infrapopliteal disease were enrolled. Patients were grouped by those who were on HD (n = 177) and those who were not (n = 49). They were monitored for 5 years or until December 2013 if the follow-up period was