• Title/Summary/Keyword: Direct revascularization

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Indirect revascularization surgery for moyamoya disease in children and its special considerations

  • Wang, Kyu-Chang;Phi, Ji Hoon;Lee, Ji Yeoun;Kim, Seung-Ki;Cho, Byung-Kyu
    • Clinical and Experimental Pediatrics
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    • v.55 no.11
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    • pp.408-413
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    • 2012
  • Moyamoya disease (MMD) is the most common pediatric cerebrovascular disease in Far Eastern countries. In children, MMD frequently manifests as ischemic symptomatology. Cerebral perfusion gradually decreases as the disease progresses, which often leads to cerebral infarction. The benefits of revascularization surgery, whether direct or indirect, have been well established in MMD patients with ischemic symptoms. In adults, the increase in cerebral blood flow achieved with indirect revascularization is often unsatisfactory, and direct revascularization is usually feasible. In children, however, direct revascularization is frequently technically not feasible, whereas the response to indirect revascularization is excellent, although 1 or 2 weeks are required for stabilization of symptoms. The authors describe surgical procedures and perioperative care in indirect revascularization for MMD. In addition, special considerations with regard to very young patients, patients with recent cerebral infarction, and patients with hyperthyroidism are discussed.

Arterial Spin Labeling MRI for Quantitative Assessment of Cerebral Perfusion Before and After Cerebral Revascularization in Children with Moyamoya Disease

  • Ji Young Ha;Young Hun Choi;Seunghyun Lee;Yeon Jin Cho;Jung-Eun Cheon;In-One Kim;Woo Sun Kim
    • Korean Journal of Radiology
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    • v.20 no.6
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    • pp.985-996
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    • 2019
  • Objective: To determine the correlation between cerebral blood flow (CBF) on arterial spin labeling (ASL) MRI and the degree of postoperative revascularization assessed on digital subtraction angiography in children with moyamoya disease (MMD). Materials and Methods: Twenty-one children (9 boys and 12 girls; mean age, 8.4 ± 3.6 years; age range, 3-16 years) with MMD who underwent both pseudocontinuous ASL MRI at 1.5T and catheter angiography before and after superficial temporal artery encephaloduroarteriosynangiosis were included in this retrospective study. The degree of revascularization in the middle cerebral artery (MCA) territory was evaluated on external carotid angiography and was graded on a 3-point scale. On ASL CBF maps, regions of interest were manually drawn over the MCA territory of the operated side at the level of the centrum semi-ovale and over the cerebellum. The normalized CBF (nCBF) was calculated by dividing the CBF of the MCA territory by the CBF of the cerebellum. Changes in nCBFs were calculated by subtracting the preoperative nCBF values from the postoperative nCBF values. The correlation between nCBF changes measured with ASL and the revascularization grade from direct angiography was evaluated. Results: The nCBF value on the operated side increased after the operation (p = 0.001). The higher the degree of revascularization, the greater the nCBF change was: poor revascularization (grade 1), -0.043 ± 0.212; fair revascularization (grade 2), 0.345 ± 0.176; good revascularization (grade 3), 0.453 ± 0.182 (p = 0.005, Jockheere-Terpstra test). The interobserver agreement was excellent for the measured CBF values of the three readers (0.91-0.97). Conclusion: The nCBF values of the MCA territory obtained from ASL MRI increased after the revascularization procedure in children with MMD, and the degree of nCBF change showed a significant correlation with the degree of collateral formation evaluated via catheter angiography.

Hybrid Coronary Revascularization Using Limited Incisional Full Sternotomy Coronary Artery Bypass Surgery in Multivessel Disease: Early Results

  • Kang, Joonkyu;Song, Hyun;Lee, Seok In;Moon, Mi Hyung;Kim, Hwan Wook;Jo, Gyun Hyun
    • Journal of Chest Surgery
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    • v.47 no.2
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    • pp.106-110
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    • 2014
  • Background: There are several modalities of coronary artery revascularization for multivessel coronary artery disease. Hybrid coronary revascularization (HCR) with minimally invasive direct coronary artery bypass grafting was introduced for high-risk patients, and recently, many centers have been using it. Limited incisional full sternotomy coronary artery bypass (LIFCAB) involves left internal thoracic artery (LITA)-to-left anterior descending coronary artery (LAD) anastomosis through a sternotomy with a minimal skin incision; it could be considered another technique for minimally invasive LITA-to-LAD anastomosis. Our center has performed HCR using LIFCAB, and in this paper, we report our short-term results, obtained in the past 3 years. Methods: The medical records of 38 patients from May 2010 to June 2013 were analyzed retrospectively. The observation period after HCR was 1 to 37 months (average, $18.3{\pm}10.3$ months). The patency of revascularization was confirmed with postoperative coronary angio-computerized tomography or coronary angiography. Results: There were 3 superficial wound complications, but no mortalities. All the LITA-to-LAD anastomoses were patent in the immediate postoperative and follow-up studies, but stenosis was detected in 3 cases of percutaneous coronary intervention. Conclusion: HCR using LIFCAB is safe and yields satisfactory results from the viewpoint of revascularization for multivessel disease.

A Retrospective Study on the Treatment of Dens Evaginatus for the Last 5 Years (최근 5년간 시행된 치외치 치료에 대한 후향적 연구)

  • Jonghwa, Lim;Gimin, Kim;Jaesik, Lee;Soonhyeun, Nam;Hyunjung, Kim
    • Journal of the korean academy of Pediatric Dentistry
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    • v.49 no.2
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    • pp.158-169
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    • 2022
  • The purpose of this study was to analyze treatment methods, results, timings and clinical signs and symptoms in failed cases of each treatment method of dens evaginatus on the premolar areas. In this study, 151 patients and 417 teeth were included. Resin restoration and direct pulp capping as preventive treatment and pulp revascularization, apexification and conventional endodontic treatment as endodontic treatment were included for treatment methods. In the preventive resin restoration, successful results were shown in the intact tubercles and also effective when the tubercles were fractured. In the direct pulp capping, resolved clinical symptoms and growth of the roots were shown when there was only pain during chewing without apical lesion. Apical lesion was the most common pretreatment signs and symptoms of the pulp revascularization, apexification and conventional endodontic treatment. In the pulp revascularization, successful results was obtained in most cases. But in some cases, root length or root wall thickness was not increased. Effective results were shown both of the apexification and conventional endodontic treatment. In order to increase success rate of preventive treatment of dens evaginatus, resin restoration was required to be done when tubercle did not occluded or in the presence of intact tubercles. When tubercle was fractured, root development stage and pulp condition should be considered for successful treatment.

Revascularization Strategies in Patients With ST-Segment Elevation Myocardial Infarction and Multivessel Disease: Is FFR-Guided Strategy Still Valuable?

  • Doosup Shin;Tae-Min Rhee;Seung Hun Lee ;Joo Myung Lee
    • Korean Circulation Journal
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    • v.52 no.4
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    • pp.280-287
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    • 2022
  • Several studies have shown the benefit of complete revascularization (CR) over culprit-only percutaneous coronary intervention (PCI) in patients with ST-segment elevated myocardial infarction (STEMI) and multivessel disease (MVD). Nevertheless, optimal strategy to select targets for non-culprit PCI has not been clarified. In this paper, we critically discuss and compare the safety and efficacy of different strategies for CR in patients with STEMI and MVD using a Bayesian network meta-analysis including all previous randomized controlled trials (RCTs). In Bayesian network meta-analysis of 13 RCTs, culprit-only PCI was associated with higher risk of major adverse cardiac events (MACE), compared with angiography-guided or fractional flow reserve (FFR)-guided CR strategies. However, there was no significant difference between angiography-guided and FFR-guided CR strategies in the risk of MACE and its individual components including all-cause death, cardiac death, myocardial infarction (MI), and revascularization. These evidence support that both angiography-guided and FFR-guided complete revascularization strategies would be reasonable treatment option in patients with STEMI and MVD. If the non-culprit lesion is severe on visual assessment, angiography-guided PCI can be considered. If the non-culprit lesion is intermediate in severity or unclear based on visual assessment, FFR-guided strategy can be used as a reliable and objective tool, providing similar benefits with less stents compared with an angiography-guided strategy. Further RCT is needed to evaluate direct comparison between angiography-guided and FFR-guided CR strategies in patients with STEMI and MVD. Ongoing FRAME-AMI trial (NCT02715518) will provide more evidence regarding this issue.

Economic Value of the Sirolimus Eluting Stent($CYPHER^{TM}$) in Treating Acute Coronary Heart Disease (관상동맥질환 치료를 위한 시롤리무스 방출 스텐트 ($CYPHER^{TM}$)의 경제성 분석)

  • Lee, Hoo-Yeon;Park, Eun-Cheol;Park, Ki-Dong;Park, Ji-Eun;Kim, Young;Lee, Sang-Soo;Kang, Hye-Young
    • Journal of Preventive Medicine and Public Health
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    • v.36 no.4
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    • pp.339-348
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    • 2003
  • Objective : To quantify the economic value of the Sirolimus fluting Stent ($CYPHER^{TM}$) in treating acute coronary heart disease (CMD), and to assist in determining an adequate level of reimbursement for $CYPHER^{TM}$ in Korea. Methods : A decision-analytical model, developed by the Belgium Health Economics Disease Management group, was used to investigate the incremental cost-effectiveness of $CYPHER^{TM}$ versus conventional stenting. The time horizon was five years. The probabilities for clinical events at each node of the decision model were obtained from the results of large, randomized, controlled clinical trials. The initial care and follow-up direct medical costs were analyzed. The initial costs consisted of those for the initial procedure and hospitalization, The follow-vp costs included those for routine follow-up treatments, adverse reactions, revascularization and death. Defending on the perspective of the analysis, the costs were defined as insurance covered or total medical costs (=sum of insurance covered and uncovered medical costs). The cost data were obtained from the administrative data of 449 patients that received conventional stenting from five participating Korean hospitals during June 2002. Sensitivity analyses were peformed for discount rates of 3, 5 and 7%. Since the major clinical advantage of $CYPHER^{TM}$ over conventional stenting was the reduction in the revascularization rates, the economic value of $CYPHER^{TM}$, in relation to the direct medical costs of revascularization, were evaluated. If the incremental cost of $CYPHER^{TM}$ per revascularization avoided, compared to conventional stenting, was no higher than that of a revascularization itself, $CYPHER^{TM}$ would be considered as being cost-effective. Therefore, the maximum acceptable level for the reimbursement price of $CYPHER^{TM}$ making the incremental cost-effectiveness ratio equal to the cost of a revascularization was identified. Results : The average weighted initial insurance covered and total medical costs of conventional stenting were about 6,275,000 and 8,058,000 Won, respectively. The average weighted sum of the initial and 5-year follow-up insurance covered and total medical costs of conventional stenting were about 13,659,000 and 17,353,000 Won, respectively. The estimated maximum level of reimbursement price of $CYPHER^{TM}$ from the perspectives of the insurer and society were $4,126,897{\sim}4,325,161$ and $4,939,939{\sim}5,078,181$ Won, respectively. Conclusion : By evaluating the economic value of $CYPHER^{TM}$, as an alternative to conventional stenting, the results of this study are expected to provide a scientific basis for determining the acceptable level of reimbursement for $CYPHER^{TM}$.

Ischemic Complications Occurring in the Contralateral Hemisphere after Surgical Treatment of Adults with Moyamoya Disease

  • Jung, Young-Jin;Ahn, Jae-Sung;Kwon, Do-Hoon;Kwun, Byung-Duk
    • Journal of Korean Neurosurgical Society
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    • v.50 no.6
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    • pp.492-496
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    • 2011
  • Objective : Direct revascularization surgery is regarded as the most effective method of treatment of adults with moyamoya disease. These patients, however, have a higher risk of perioperative ischemic complications than do patients with atherosclerotic stroke, and are at risk for ischemic complications in the hemisphere contralateral to the one operated on. We investigated the incidence and risk factors for ischemic stroke in the contralateral hemisphere after surgical treatment of adults with moyamoya disease. Methods : We retrospectively reviewed the medical records and results of neuroimaging studies on 79 hemispheres of 73 consecutive patients with adult moyamoya disease ($mean{\pm}SD$ age, $37.96{\pm}11.27$ years; range, 18-62 years) who underwent direct bypass surgery over 6 years. Results : Ischemic complications occurred in 4 of 79 (5.1%) contralateral hemispheres, one with Suzuki stage 3 and three with Suzuki stage 4. Three patients showed posterior cerebral artery (PCA) involvement by moyamoya vessels. Advanced stage of moyamoya disease (Suzuki stages 4/5/6; $p$=0.001), PCA involvement ($p$=0.001) and postoperative hypotension (mean arterial blood pressure <80% of preoperative mean arterial blood pressure) on the first ($p$<0.0001) and second ($p$=0.003) days after surgery were significantly correlated with postoperative contralateral ischemic complications. Conclusion : In patients with advanced moyamoya disease and involvement of the PCA, intentional hypotension can result in ischemic stroke in the hemisphere contralateral to the one operated on. Careful control of perioperative blood pressure is crucial for good surgical results.

Comparison between Kissing Stents and Direct Surgical Bypass for Aortoiliac Occlusive Disease

  • Chung Won Lee;Up Huh;Miju Bae;Changsung Han;Hoon Kwon;Gwon-min Kim
    • Journal of Chest Surgery
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    • v.56 no.4
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    • pp.264-271
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    • 2023
  • Background: The optimal management strategy for aortoiliac occlusive disease (AIOD) remains debatable. This study compared early and late outcomes between direct surgical bypass and kissing stents for AIOD treatment. Methods: We retrospectively reviewed data, including age, sex, risk factors, comorbidities, symptoms, TransAtlantic Inter-Society Consensus (TASC) II classification, operation time, perioperative complications, in-hospital mortality, and length of hospital stay, from a cohort of 46 patients treated for AIOD (24 with kissing stents and 22 with direct surgical bypass) at Pusan National University Hostpital from January 2007 to December 2016. The primary, assisted primary, and secondary patency rates in both groups were compared. Results: The hospital stay (direct surgical bypass vs. kissing stents: 16.36±5.19 days vs. 9.08±10.88 days, p=0.007) and operation time (direct surgical bypass vs. kissing stents: 316.09±141.78 minutes vs. 99.54±37.95 minutes, p<0.001) were significantly shorter for kissing stents. Kaplan-Meier analysis revealed that the primary, assisted primary, and secondary patency rates in the direct surgical bypass group were 95.5%, 95.5%, and 95.5%, respectively, at 1 year; 86.4%, 86.4%, and 95.5% at 3 years; and 77.3%, 77.3%, and 95.5% at 5 years. The primary, assisted primary, and secondary patency rates in the kissing stent group were 100.0%, 100.0%, and 100.0%, respectively, at 1 year; 95.8%, 95.8%, and 100.0% at 3 years; and 95.8%, 95.8%, and 100.0% at 5 years. Conclusion: Except for special cases wherein endovascular revascularization is difficult, kissing stents are more advantageous for TASC II C and D lesions.

Nationwide Trends of Gatekeeper to Invasive Coronary Angiography in Suspected Coronary Artery Disease

  • Min Jae Cha;William D Kim;Hoyoun Won;Jaeeun Joo;Hasung Kim;In-Cheol Kim;Jin Young Kim;Seonhwa Lee;Iksung Cho
    • Korean Circulation Journal
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    • v.52 no.11
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    • pp.814-825
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    • 2022
  • Background and Objectives: Real-world trends in the utility and type of gatekeeping studies in invasive coronary angiography (ICA) requires further investigation. Methods: We identified outpatients who underwent noninvasive cardiac tests or directly ICA for suspected coronary artery disease (CAD) from the nationwide Korea Health Insurance Review and Assessment Service-National Patient Sample database between 2012 and 2018. Results: Among 71,401 patients, the percentage of patients who were evaluated for suspected CAD was 34.7% for treadmill test (TMT), 4.2% for single-photon emission computed tomography (SPECT), 24.2% for coronary computed tomography angiography (CCTA), 1.6% for multiple gatekeepers, and 32.3% for directly ICA without noninvasive studies. The proportion of CCTA as a gatekeeper showed linear increase, (18.6% in 2012 and 28.8% in 2018; p<0.001), while those of TMT, SPECT, and direct ICA have decreased (p<0.001, p=0.03, and p<0.001, respectively). The overall incidence of downstream ICA after gatekeeper was 13.8% (6,662/48,346), and SPECT showed higher ICA rate in pairwise comparison with TMT and CCTA (p<0.001). Patients who performed gatekeepers before ICA showed higher rate of subsequent PCI (34.7% vs. 32.3%; p<0.001) and CABG (3.5% vs. 1.0%; p<0.001), compared to those who directly underwent ICA, and CCTA was associated with higher revascularization rate after ICA in pairwise comparison with TMT and SPECT (p<0.001). Conclusions: Nationwide database demonstrated that CCTA is utilized increasingly as a gatekeeper for ICA and is associated with high revascularization rate after ICA in outpatients with suspected CAD.

Management of Femoropopliteal Vascular Injuries after Trauma: Surgical Outcomes (외상 후 대퇴-오금 혈관손상의 치료: 수술 성적)

  • Chang, Sung Wook;Han, Sun;Ryu, Kyoung Min;Ryu, Jae-Wook
    • Journal of Trauma and Injury
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    • v.28 no.1
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    • pp.15-20
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    • 2015
  • Purpose: Vascular injuries caused by traffic, industrial accidents and by outside activities have increased in Korea. Especially, vascular injuries to the extremities can lead to limb loss and even mortality if they are not appropriately treated. The aim of the study was to evaluate the surgical outcomes of femoropopliteal vascular management after trauma. Methods: The medical records of 12 patients with femoropopliteal vascular injuries who were treated at Dankook University Hospital from 2011 to 2013 were reviewed. Iatrogenic vascular injuries were excluded. The clinical data including the causes of injury, associated injuries and surgical outcomes were analyzed retrospectively. Results: All patients were male, with a mean age of $46.8{\pm}16.3years$ (range: 26~69 years). The causes of vascular injuries were four traffic accidents, three industrial accidents, two iron plates, one outside activity, one glass injury and one knife injury. The average transit time between the place of the accident place and the emergency department was $3.0{\pm}2.1$ (0.5~12.5) hours, and the average preparation time for surgery was $8.0{\pm}6.7$ (1.7~23.3) hours. The anatomic injuries included the popliteal vessel in seven cases and the femoral vessel in five cases. The average Injury Severity Score (ISS) was $12.0{\pm}5.0$ (5~17), and the average Mangled Extremity Severity Score (MESS) was $5.7{\pm}2.1$ (2~9). The operation methods were four interposition grafts, three end-to-end anastomoses, two direct repairs and three patch angioplasties. One case required amputation of the injured extremity. Conclusion: Early recognition and revascularization of the injured vessel are mandatory to reduce limb loss and to obtain satisfactory outcomes. Therefore, careful/rapid evaluation of the vascular injuries and timely/successful surgical treatment are the keys to salvaging an injured limb.

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