Published papers

Background: Popliteal artery entrapment syndrome (PAES) is a rare cause of lower limb ischemia, typically affecting young adults. Case Report: This case report describes a 22-year-old man with severe left calf claudication due to type II PAES, confirmed by imaging. Surgical treatment involved resection of the aberrant gastrocnemius muscle and popliteal artery reconstruction using the great saphenous vein. Postoperative recovery was uneventful, with complete symptom resolution and no recurrence at 2-year follow-up. Conclusions: PAES should be considered in young patients with unexplained claudication, and surgery offers effective long-term outcomes. This article also briefly discusses the classification, diagnosis, and treatment strategies for PAES.

Background: Arterial thoracic outlet syndrome (ATOS), although the least common of thoracic outlet syndromes (<1%), often presents with severe upper limb ischemia as a sequel of subclavian artery (SA) dilatation, intimal injury, thrombus formation, and distal embolization, all secondary to extrinsic compression. Methods: Literature was reivewed to see the changing trends and current managment of ATOS. Results: The syndrome affects young adults and women more often than men. Although patients often present with a bony prominence in the neck or upper limb ischemia, rarely they may present with posterior circulation stroke or an asymptomatic ATOS may be detected during evaluation of the contralateral limb. Surgical decompression of the thoracic outlet along with treatment of the involved SA is the accepted treatment modality. Arterial thoracic syndrome is almost always operated via the supraclavicular or paraclavicualr and occasionally transaxillary approach. Stenting still does not find any significant role in the treatment of this disease. This review discusses the clinical presentation, evaluation, and surgical therapy including ways to repair the SA. It also discusses the common complications and their management. Finally, the outcomes of surgery for ATOS are discussed. Conclusions: ATOS can cause significant symptoms and disability. Diagnosis is based on clinical evaluation and imaging and must show evidence of injury to SA. Treatment is surgical and best performed using the supraclavicular or paraclavicular approach and offers good long-term results. A nonculprit first rib may be preserved as evidenced by multiple series showing good medium- to long-term results, and subclavian aneurysm can be treated by different methods.

Objective: The study aimed to assess a novel web-based surgical training approach among young vascular surgeons and validate web-based evaluation methods for assessing anastomosis skills through the online Distal Bypass Competition (DBC). Methods: The OSATS was used to assess anastomosis proficiency using a simulator among 42 participants (17 junior and 25 senior surgeons) in the DBC 2021. An initial evaluation of basic anastomosis skills was conducted via recorded videos, comparing OSATS scores with instructor-derived impression-based scores (Comprehensive Evaluation Score [CES]) during the nomination round. Real-time evaluations conducted over Zoom focused on assessing technical and composition scores of the anastomoses to determine finalists. The ice-skating method addresses potential variability among judges by excluding the highest and lowest scores for each procedural element from the final evaluation. This method, demonstrated in real time, provides trainees with valuable feedback on which movements are highly rated, enhancing the educational impact. Evaluation criteria included precision in needlework, external appearance, handling of the intima, and internal morphology of the anastomosis. Furthermore, voluntary survey questionnaires were administered to gather participant feedback on their experience with DBC 2021. Results: The OSATS was associated with a lower coefficient of variation (CV) than was the CES (0.19 ± 0.07 vs 0.24 ± 0.09) (P = .01) with regard to the evaluation of basic anastomotic skills in the nomination round. Interestingly, there was no significant difference in CV between the Procedural Element Score based on OSATS and CES in the senior class (0.16 ± 0.06 vs 0.22 ± 0.09) (P = .13), but a significant difference was particularly evident in the junior class (0.12 ± 0.07 vs 0.27 ± 09) (P = .03). Lower scores were associated with higher CVs in both classes, but the OSATS improved the CV among participants who had inadequate anastomosis skills. In real-time evaluation, composition scores exhibited higher CVs compared with technical scores, even among high-scoring participants. Notably, the internal morphology of the anastomosis had the largest CV in the composition scores. The ice-skating method decreased the CV as compared with the original data evaluated using the OSATS (0.15 ± 0.04 vs 0.09 ± 0.02 for the technical score [P < .01] and .18 ± 1.00 vs 0.07 ± 0.05 for the composition score [P = .03]); accordingly, the ice-skating method was more conducive to objective, real-time evaluation. The results of the post-DBC survey indicated that 89% of participants reported increased training time, and one-half of these participants indicated that their confidence in their clinical skills related to this procedure increased owing to the process of training for the DBC. Conclusions: The OSATS yielded more detailed evaluations of anastomosis skill with a lower variability compared with the instructor's impression-based evaluation in this web-based training. Real-time evaluation methods, such as the ice-skating method, have proven to be valuable tools for the standardized assessment of web-based surgical education.

Background: Despite the widespread use of PROPATEN®, a bioactive heparin-bonded expanded polytetrafluoroethylene graft, in bypass surgery, there are only a few reports of long-term results. We evaluated the long-term results of PROPATEN® use for above-knee femoropopliteal bypass (AKFPB). Methods and Results: After PROPATEN®-based AKFPB, patients were prospectively registered at 20 Japanese institutions between July 2014 and October 2017 to evaluate long-term results. During the median follow-up of 76 months (interquartile range 36–88 months) for 120 limbs (in 113 patients; mean [±SD] age 72.7±8.1 years; 66.7% male; ankle-brachial index [ABI] 0.45±0.27; lesion length 26.2±5.7 cm; chronic limb-threatening ischemia in 45 limbs), there were 8 major amputations; however, clinical improvement was sustained (mean [±SD] ABI 0.87±0.23) and the Rutherford classification grade improved in 105 (87.5%) limbs at the latest follow-up. At 8 years, the primary patency, freedom from target-lesion revascularization, secondary patency, survival, and amputation-free survival, as estimated by the Kaplan-Meier method, were 66.3±4.8%, 71.5±4.4%, 86.5±3.4%, 53.1±5.0%, and 47.4±5.3%, respectively. Conclusions: This multicenter prospective registry-based analysis showed sustained excellent clinical improvement and secondary patency for up to 8 years following PROPATEN®-based AKFPB. PROPATEN® constitutes a durable and good revascularization option for complex superficial femoral artery lesions, especially when endovascular treatment is inappropriate or an adequate venous conduit is unavailable.

Objective: This study aimed to evaluate indications and outcomes of open surgical conversion (OSC) after endovascular aneurysm repair (EVAR) for abdominal aortic aneurysm using a multicenter registry in Japan. Methods: Thirteen vascular centers retrospectively reviewed patients who underwent OSC after prior EVAR between 2006 and 2024. Baseline characteristics, indications, procedural details, and outcomes were analyzed. The primary end point was 30-day mortality. Secondary end points were overall survival, aneurysm-related mortality, and freedom from retreatment. Results: A total of 208 patients (85.6% males; median age, 78 years) were included. The median abdominal aortic aneurysm diameter was 62 mm. The median interval from initial EVAR to OSC was 5.2 years. Indications for OSC were type II endoleak with sac enlargement (47.1%), type I endoleak (23.1%), type V endoleak with sac enlargement (13.0%), infection (10.1%), and type III endoleak (9.6%). The most frequently used stent graft was the Excluder, followed by Endurant and Zenith. Complete stent graft removal was performed in 41 patients, partial removal in 51, and 116 underwent OSC with stent graft preservation. Thirty-eight patients (18.3%) presented with rupture and 48 (23.1%) underwent urgent OSC. The 30-day mortality rate was 4.3% in the overall cohort, 2.4% in nonruptured cases, and 13.2% in ruptured cases. Rupture was a risk factor for 30-day mortality (hazard ratio, 5.93; 95% confidence interval, 1.59-22.1; P = .008). At 10 years, overall survival and aneurysm-related mortality were 58.4% and 14.8%, respectively, and freedom from retreatment rate was 87.5% at 10 years. Conclusions: Type II endoleak was the leading common indication for OSC after EVAR in this multicenter retrospective study in Japan. Rupture at OSC markedly increased 30-day mortality, even in patients with type II endoleak. Further studies are needed to refine elective indications for OSC to prevent aneurysmal rupture and avoid treatment delay.

Background: Vancomycin infusion reaction (VIR) is a common adverse reaction to vancomycin. We aimed to investigate the effects of infusion rate, age, infusion time, renal function and history of allergy on the incidence of VIR. Methods: We conducted a single-centre retrospective cohort study with 153 patients (aged 0–92.7 years) who received a single intravenous dose of vancomycin for perioperative prophylaxis. Patients treated for active infections were excluded. Medical records were retrospectively evaluated for VIR occurrence, defined as itching, flushing or rash documentation. Results: VIR incidence was 46.7% (7/15) in patients aged <10 years, 47.4% (9/19) in those aged 10–20 years and 44.4% (4/9) in those aged 20–30 years, versus 2.7% (2/74) in those aged ≥60 years. Multivariable logistic regression identified younger age [adjusted odds ratio (aOR) 0.95, 95% CI 0.93–0.97] and higher weight-adjusted infusion rate (aOR 1.22 per mg/kg/h increase, 95% CI 1.04–1.43) as independent risk factors for VIR. Receiver operating characteristic analysis of the infusion rate by age group showed that the optimal cut-off value for patients aged 30–60 years was 14.8 mg/kg/h, whereas for those aged <30 years, it was 14.0 mg/kg/h. No patients developed VIR when the infusion rate was <9.4 mg/kg/h. Conclusions: Age and higher weight-adjusted infusion rate were key risk factors for VIR. Tailoring infusion rate to age and weight may reduce VIR incidence without unnecessarily prolonging administration time.

Objective: TheGore EXCLUDER Conformable abdominal aortic aneurysm endoprosthesis with ACTIVE CONTROL System (EXCC; W. L. Gore & Associates) is designed to treat abdominal aortic aneurysms with a challenging proximal neck. This study was conducted to investigate the safety and efficacy of the EXCC device in patients with an angulated proximal neck at 23 Japanese institutions (Excluder Conformable endoprosThesis foR angulatEd proxiMal nEck anatomy [EXTREME registry]). Methods: A retrospective analysis was conducted on all endovascular aneurysm repairs (EVARs) using an EXCC device. The primary end point was freedom from late complications (composite outcomes of aneurysm-related death, reinterventions, and aneurysm sac enlargement of >5 mm after 30 postoperative days). Secondary end points included intraoperative major adverse events, intraoperative endoleaks, perioperative outcomes, postoperative endoleaks, and aneurysm size. Results: The EXTREME registry consisted of 215 patients, of whom 109 were included in the angulated neck group (angulation >60°) and 106 in the nonangulated group (angulation ≤60°) according to the proximal neck (infrarenal) angulation. Technical success rates were 93.5% and 94.3% (P = .81), the incidence of type Ia endoleak at final aortogram was 5.5% and 1.8% (P = .16), and the incidence of major adverse events was 1.8% and 0.9% (P = .54) in the angulated and nonangulated groups, respectively. On postoperative (in-hospital) computed tomography examination, the incidence of type Ia endoleak was higher in the angulated group (3.6%) than in the nonangulated group (0%; P = .12). The mean follow-up period was 404 ± 190 days. Freedom from reintervention rates were 98.9% and 96.6% in the angulated group and 99.0% and 95.7% in the nonangulated group at 6 and 12 postoperative months, respectively (log-rank P = .99). Freedom from late complications rates were 99.0% and 96.6% in the angulated group and 99.0% and 95.8% in the nonangulated group at 6 and 12 postoperative months, respectively (log-rank P = .63). Conclusions: Our multicenter study demonstrated the safety and efficacy of the EXCC device in patients with an angulated proximal neck (angle >60°), with low rates of type Ia endoleak. Long-term follow-up is required to understand the true efficacy of the EXCC device in challenging neck anatomy.

Popliteal artery adventitial disease (PAAD) underlies a significant portion of vascular conditions of the lower extremities, often culminating in critical limb ischemia and warranting a greater clinical understanding for effective management. Characterized by the cystic degeneration of the adventitia of the popliteal artery, PAAD remains a challenging condition both in terms of diagnosis and treatment. This review seeks to explore the complex pathophysiology, diagnostic criteria, and current management strategies, as well as discussing emerging therapies and future outlook for patients with PAAD.

Objective: Robotic surgery is rarely used in vascular surgery but has demonstrated significant potential compared with open or laparoscopic techniques in reports of abdominal aortic surgery. Enabling a standardised retroperitoneal approach (RPA) to abdominal aortic repair might reduce the peri-operative mortality and morbidity rates associated with a transabdominal approach. The aim of this experimental study was to establish surgical techniques for robotically assisted infrarenal abdominal aortic repair using a single port RPA. Methods: Retroperitoneal abdominal aortic repair was performed in four live porcine models by a group of experienced and novice robotic surgeons. The procedures were performed using the da Vinci SP (single port) surgical system (Intuitive Surgical Inc., Sunnyvale, CA, USA). Polytetrafluoroethylene grafts (W.L. Gore & Associates, Inc., Newark, DE, USA) were implanted after aortic resection. Operating times for the main procedure steps were recorded. Results: Abdominal aortic repair was feasible in all porcine models applying an RPA through a single incision with the da Vinci SP system. Creating the retroperitoneal access and docking the da Vinci SP was quick, with durations ranging from eight to 20 minutes. Proximal and distal anastomoses were completed in 26 minutes (range 19–33 minutes) and 31.3 minutes (range 23–42 minutes), respectively. In porcine models 2–4, the anastomoses were patent without haemorrhage, with aortic pulsations confirmed on release of the cross clamps. Porcine model 1 was pulseless owing to uncontrolled haemorrhage caused by left external iliac artery penetration at the end of the procedure, and patency could not be tested. Conclusion: Retroperitoneal single port robotic aortic repair was technically feasible with high accuracy in live porcine models. Anastomotic times were reasonable and surgeon comfort level was adequate, which may enable transfer into clinical routine in the future when true clinical benefits will need to be proven in additional studies.

Purpose: Invasive pulmonary aspergillosis (IPA) after liver transplantation (LT) is most often fatal. We analyzed the outcomes of IPA in a single center. Methods: We reviewed, retrospectively, the medical records of recipients of living donor LT (LDLT) or deceased donor LT (DDLT) performed between 1995 and 2019 at our institute. We analyzed the incidence of IPA and assessed the treatment courses of patients treated successfully and those not treatment successfully. Results: Among 326 recipients, IPA was diagnosed in 6 (1.8%). The incidence of IPA was significantly higher in patients with acute liver failure (ALF, 9.8%) than in those without ALF (0.4%), after DDLT (8.8%) than after LDLT (1.0%), and in recipients who received preoperative steroid pulse therapy (16.0%) than in those who did not (0.7%). Complete cure of IPA was achieved in the most recent three patients, by administering voriconazole immediately after the diagnosis of IPA and performing lung resection, while the IPA lesion was single and localized. Conclusions: Patients with risk factors for IPA must be monitored closely. Our three successfully treated cases demonstrate that initiating immediate voriconazole treatment and making a calculated decision about lung resection can contribute to a favorable outcome.

Purpose: The precise role of downstaging or bridge therapy for cirrhotic patients with hepatocellular carcinoma (HCC) beyond or within the Milan criteria (MC) before living donor liver transplantation (LDLT) remains undefined. Methods: We conducted a single-center, retrospective cohort study of 40 cirrhotic patients with HCC who underwent LDLT from 2000 to 2018. Dynamic computed tomography images at the initial presentation and immediately before LDLT as well as the final histopathological findings were reviewed to determine whether they met or exceeded MC. Results: Overall, 29 patients underwent various pre-transplant HCC treatments, including ablation and embolization (bridge therapy, n = 20; downstaging, n = 9). Of the 9 patients who were initially beyond the MC, 4 (44.4%) were successfully downstaged to within the MC. Five patients beyond the MC immediately before LDLT demonstrated a significantly worse 5-year overall survival rate than patients within the MC (16.7% vs. 82.2%, P = 0.004), regardless of the radiological HCC stage at presentation or the final pathological tumor status. All 3 recurrent patients had HCC beyond the MC immediately before transplant and died of their disease at 13, 24, and 50 months after transplantation. Conclusions: Successful downstaging for HCC cases beyond the MC provides similar outcomes to those within the MC at presentation, regardless of the histopathological findings.

Introduction: In the novel coronavirus disease (COVID-19) pandemic era, it is essential to rule out COVID-19 effectively to prevent transmission in both communities and medical facilities. According to previous reports in high prevalence areas, CT screening may be useful in the diagnosis of COVID-19. However, the value of CT screening in low prevalence areas has scarcely been reported. Methods: This report examines the diagnostic efficacy of CT screening before admission to a hospital in Tokyo. We conducted a retrospective analysis at Keio University Hospital from April 6, 2020, through May 29, 2020. We set up an outpatient screening clinic on April 6 for COVID-19, administering both PCR with nasopharyngeal swabs and chest CT for all patients scheduled for surgery under general anesthesia. Results: A total of 292 asymptomatic patients were included in this study. There were three PCR-positive patients, and they all had negative CT findings, which revealed that both the sensitivity and positive predictive value of CT (PPV) were 0%. There were nine CT-positive patients; the specificity and the negative predictive value (NPV) were 96.9% and 98.9%, respectively. Conclusion: CT screening was not useful in low prevalence areas at this time in Tokyo, even with the inclusion of the most prevalent phase. Given that the utility of CT screening depends on disease prevalence, the criteria for performing CT screening based on the prevalence of COVID-19 should be established.

Objective: The optimal revascularization modality in secondary aortoenteric fistula (SAEF) remains unclear in the literature. The purpose of this investigation was to determine the revascularization approach associated with the lowest morbidity and mortality using real-world data in patients with SAEF. Methods: A retrospective, multi-institutional study of SAEF from 2002 to 2014 was performed using a standardized database. Baseline demographics, comorbidities, and operative and postoperative variables were recorded. The primary outcome was long-term mortality. Descriptive statistics, Kaplan-Meier survival analysis, and univariate and multivariate analyses were performed. Results: During the study period, 182 patients at 34 institutions from 11 countries presented with SAEF (median age, 72 years; 79% male). The initial aortic procedures that resulted in SAEF were 138 surgical grafts (76%) and 42 endografts (23%), with 2 unknown; 102 of the SAEFs (56%) underwent complete excision of infected aortic graft material, followed by in situ (in-line) bypass (ISB), including antibiotic-soaked prosthetic graft (53), autogenous femoral vein (neoaortoiliac surgery; 17), cryopreserved allograft (28), and untreated prosthetic grafts (4). There were 80 patients (44%) who underwent extra-anatomic bypass (EAB) with infected graft excision. Overall median Kaplan-Meier estimated survival was 319 days (interquartile range, 20-2410 days). Stratified by EAB vs ISB, there was no significant difference in Kaplan-Meier estimated survival (P =.82). In comparing EAB vs ISB, EAB patients were older (74 vs 70 years; P =.01), had less operative hemorrhage (1200 mL vs 2000 mL; P =.04), were more likely to initiate dialysis within 30 days postoperatively (15% vs 5%; P =.02), and were less likely to experience aorta-related hemorrhage within 30 days postoperatively (3% aortic stump dehiscence vs 11% anastomotic rupture; P =.03). There were otherwise no significant differences in presentation, comorbidities, and intraoperative or postoperative variables. Multivariable Cox regression showed that the duration of antibiotic use (hazard ratio, 0.92; 95% confidence interval, 0.86-0.98; P =.01) and rifampin use at time of discharge (hazard ratio, 0.20; 95% confidence interval, 0.05-0.86; P =.03) independently decreased mortality. Conclusions: These data suggest that ISB does not offer a survival advantage compared with EAB and does not decrease the risk of postoperative aorta-related hemorrhage. After repair, <50% of SAEF patients survive 10 months. Each week of antibiotic use decreases mortality by 8%. Further study with risk modeling is imperative for this population.

Few data regarding popliteal artery entrapment syndrome (PAES) is available in Japan. In this study, we investigated incidence, diagnosis and treatment of PAES in current vascular practice. A retrospective analysis of all patients with PAES visiting 31 participating institutes between 2003 and 2015 was conducted. Thirty-five limbs (28 patients) were identified during the 13-year study period, and the incidence of PAES was 0.12% of all peripheral artery disease cases revascularized. Mean age was 32.0 ± 16.9 years old, and 60 and more years old was 10.7%. Also, 92.9% were male and 39.3% were athletes. Most frequent initial symptoms were intermittent claudication in 23 limbs (65.7%); 4 limbs (11.4%) had chronic limb-threatening ischemia. CT scan was most frequently (94.3%) used for the diagnostic imaging followed by MRI (45.7%) and duplex ultrasound (45.7%). Stress test such as dorsal flexion during duplex ultrasound was used only in 28.6%. Thirty-two limbs (91.4%) received surgical treatment, including 23 arterial reconstructions (71.9%); there were no major perioperative complications. All patients achieved improvement of their symptoms, and the average ankle brachial index increased from 0.69 ± 0.22 to 1.00 ± 0.14 post-surgery. The average postoperative follow-up period was 26.0 months with only one reintervention during the follow-up. In conclusion, PAES was a rare condition and traditional surgical treatment was solid. However, given a broad spectrum of clinical feature of PAES and less usage of diagnostic duplex ultrasound with stress test, there might be a miss- or delayed diagnosis of PAES even in the current vascular practice.

Purpose: To directly compare the clinical outcomes of aortobifemoral bypass surgery (ABF) and endovascular treatment (EVT) for chronic total occlusion (CTO) of the infrarenal abdominal aorta (IAA). Materials and Methods: In this retrospective, multicenter study, we used an international database of 436 patients who underwent revascularization for CTO of the IAA between 2007 and 2017 at 30 Asian cardiovascular centers. After excluding 52 patients who underwent axillobifemoral bypass surgery, 384 patients (139 ABFs and 245 EVTs) were included in the analysis. Propensity score-matched analysis was performed to compare clinical results in the periprocedural period and the long-term. Results: Propensity score matching extracted 88 pairs. Procedure time (ABF; 288 [240–345] minutes vs EVT; 159 [100–205] minutes, p<0.001) and length of hospital stay (17 [12–23] days vs 5 [4–13] days, p<0.001) were significantly shorter in the EVT group than in the ABF group, while the proportions of procedural success (98.9% versus 96.6%, p=0.620), complications (9.1% versus 12.3%, p=0.550), and mortality (2.3% versus 3.8%, p=1.000) were not different between the groups. At 1 months, ABI significantly increased more in the ABF group for both in a limb with the lower (0.56 versus 0.50, p=0.018) and the higher (0.49 versus 0.34, p=0.001) baseline ABI, while the change of the Rutherford category was not significantly different between the groups (p=0.590). At 5 years, compared with the EVT group, the ABF group had significantly better primary patency (89.4±4.3% versus 74.8±4.3%, p=0.035) and survival rates (86.9±4.5% versus 66.2±7.5%, p=0.007). However, there was no significant difference between the groups for secondary patency (100.0%±0.0% versus 93.5%±3.9%, p=0.160) and freedom from target lesion revascularization (TLR) (89.3±4.3% vs 77.3±7.3%, p=0.096). Conclusion: Even with recent advancements in EVT, primary patency was still significantly better for ABF in CTO of the IAA. However, there was no difference between the groups in terms of secondary patency and freedom from TLR at 5 years. Furthermore, there was no difference in procedural success, complications, mortality, and improvement in the Rutherford classification during the periprocedural period, with significantly shorter procedure time and hospital stay in the EVT group.

Objective: Surgical thromboendarterectomy (TEA) is the standard treatment for an occlusive lesion of the common femoral artery (CFA). However, there is limited knowledge on the need for patch angioplasty in CFA TEA. The objective of this study was to compare the peri-operative and two year results of CFA TEA with or without patch angioplasty. Methods: A multicentre retrospective observational study was performed at 34 Japanese centres. Comparisons were made between patients undergoing CFA TEA with or without patch angioplasty after propensity score matching (PSM). The primary endpoints were primary patency and freedom from target lesion revascularisation (TLR) of the TEA lesion. The secondary endpoints were hospital outcomes, limb salvage, and overall survival. Results: Between 2018 and 2020, 428 TEA procedures (237 with patch angioplasty and 191 with primary closure) were performed. PSM extracted 151 pairs with no significant intergroup differences in baseline characteristics. Peri-operative death and complications occurred in 0.7% vs. 1.3% (p = 1.0) and 6.0% vs. 6.6% (p = 1.0), respectively. The follow up rate was 96% over a median follow up of 14.9 months (interquartile range 8.3, 24.3). Loss of primary patency occurred in 18 patients. The two year primary patency of patch angioplasty cases was statistically significantly higher than that of primary closure cases (97.0% vs. 89.9%; p = .021). TLR was performed in 14 patients. The two year freedom from TLR in patch angioplasty cases was also statistically significantly higher than in primary closure cases (98.6% vs. 92.9%; p = .003). During follow up, seven limbs required major amputation and 40 patients died. There was no statistically significant difference in limb salvage and survival between the two groups after PSM. Conclusions: This is the first report to show that patch angioplasty may decrease re-stenosis and target lesion revascularisation of CFA TEA lesions.

Aim: To evaluate the use of donor-derived cell-free DNA (dd-cfDNA) in diagnosing graft injuries in Japanese liver transplantation (LTx), including family-related living donors. Methods: A total of 321 samples from 10 newly operated LTx recipients were collected to monitor the early dynamics of dd-cfDNA levels after LTx. Fifty-five samples from 55 recipients were collected during protocol biopsies (PB), whereas 36 samples from 27 recipients were collected during event biopsies, consisting of 11 biopsy-proven acute rejection (AR), 20 acute dysfunctions without rejection (ADWR), and 5 chronic rejections. The levels of dd-cfDNA were quantified using a next-generation sequencer based on single nucleotide polymorphisms. Results: The dd-cfDNA levels were elevated significantly after LTx, followed by a rapid decline to the baseline in patients without graft injury within 30 days post-LTx. The dd-cfDNA levels were significantly higher in the 11 samples obtained during AR than those obtained during PB (p < 0.0001), which decreased promptly after treatment. The receiver operator characteristic curve analysis of diagnostic ability yielded areas under the curve of 0.975 and 0.897 for AR (rejection activity index [RAI] ≥3) versus PB and versus non-AR (ADWR + PB). The dd-cfDNA levels during AR were elevated earlier and correlated more strongly with the RAI (r = 0.740) than aspartate aminotransferase/alanine aminotransferase. The dd-cfDNA levels were neither associated with graft fibrosis based on histology nor the status of donor-specific antibodies in PB samples. Conclusions: Donor-derived cell-free DNA serves as a sensitive biomarker for detecting graft injuries in LTx. Further large-scale cohort studies are warranted to optimize its use in differentiating various post-LTx etiologies.

Background: The main causes of liver cirrhosis have changed over the past decade. In Japan, the number of deceased donors is increasing but is still insufficient relative to the number of patients awaiting a liver transplant. In the present study we aimed to assess the outcomes of candidates for liver transplantation. Methods: This was a retrospective study of adult patients who visited our department for consultation regarding liver transplantation from January 2009 to December 2020. Of a total of 601 patients, 336 were followed-up. The following data were collected and analyzed: patient's characteristics, liver etiology, Child-Pugh and MELD scores, and the eventual outcome, that is, whether liver transplantation was performed. Results: Only 153 of 336 (45.5%) patients underwent liver transplantation, of which 42 (27.5%) received deceased donor liver transplantation, and 129 (38.4%) died without transplantation. The proportion of patients who underwent liver transplantation was low among patients with nonalcoholic steatohepatitis (NASH) (10.7%) (P <.001). The rate of qualified living donors was the lowest for patients with NASH (28.6%) and that for the other etiologies ranged from 55.6% to 67.4% (P =.050). Conclusion: Patients with liver cirrhosis due to NASH may have a lesser chance of undergoing liver transplantation from both living and deceased donors.