Details of a Researcher - Obara, Hideaki

Papers - Obara, Hideaki

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Clinical features of irreversible rejection after allogeneic uterus transplantation in cynomolgus macaques

Kisu I., Emoto K., Masugi Y., Yamada Y., Matsubara K., Obara H., Matoba Y., Banno K., Kato Y., Saiki Y., Itagaki I., Kawamoto I., Iwatani C., Murase M., Nakagawa T., Tsuchiya H., Ishigaki H., Urano H., Ema M., Ogasawara K., Aoki D., Nakagawa K., Shiina T.

Scientific Reports (Scientific Reports) 10 ( 1 ) 2020.12

Uterus transplantation (UTx) is a potential option for women with uterine factor infertility to have a child. The clinical features indicating irreversible rejection of the uterus are unknown. In our experimental series of allogeneic UTx in cynomolgus macaques, six female macaques were retrospectively examined, which were unresponsive to treatment with immunosuppressants (i.e. irreversible rejection). Clinical features including general condition, hematology, uterine size, indocyanine green (ICG) fluorescence imaging by laparotomy, and histopathological findings of the removed uterus were evaluated. In all cases, general condition was good at the time of diagnosis of irreversible rejection and thereafter. Laboratory evaluation showed temporary increases in white blood cells, lactate dehydrogenase and C-reactive protein, then these levels tended to decrease gradually. In transabdominal ultrasonography, the uterus showed time-dependent shrinkage after transient swelling at the time of diagnosis of irreversible rejection. In laparotomy, a whitish transplanted uterus was observed and enhancement of the transplanted uterus was absent in ICG fluorescence imaging. Histopathological findings in each removed uterus showed hyalinized fibrosis, endometrial deficit, lymphocytic infiltration and vasculitis. These findings suggest that uterine transplantation rejection is not fatal, in contrast to rejection of life-supporting organs. Since the transplanted uterus with irreversible rejection atrophies naturally, hysterectomy may be unnecessary.

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Living donor liver transplantation for idiopathic portal hypertension with extrahepatic portal vein stenosis and splenic artery aneurysms: a case report and review of the literature

Kawachi S., Chiba N., Nakagawa M., Kobayashi T., Hikita K., Sano T., Tomita K., Hirano H., Abe Y., Obara H., Shimazu M.

BMC Surgery (BMC Surgery) 20 ( 1 ) 2020.12

Background: Idiopathic portal hypertension (IPH) generally has a good prognosis and rarely results in liver transplantation. Furthermore, there are few reports of living donor liver transplantation (LDLT) for IPH with extrahepatic portal vein stenosis. Case presentation: We report the case of a 51-year-old female patient diagnosed with IPH more than 20 years ago. She suffered severe jaundice, massive ascites, and encephalopathy at the time of her visit to our hospital. The patient’s extrahepatic portal vein showed a scar-like stenosis, and the portal flow was completely hepatofugal. Collateral circulation such as the splenorenal shunt was well developed, and multiple splenic artery aneurysms up to 2 cm were observed in the splenic hilum. Her Model for End-Stage Liver Disease score increased to over 40 because of renal dysfunction, requiring temporary dialysis. We performed LDLT using her husband’s right lobe graft and splenectomy. The extrahepatic stenotic portal vein was completely resected, and the superficial femoral vein (SFV) graft collected from the recipient’s right leg was used for portal reconstruction as an interposition graft. Although the clinical course after LDLT had many complications, the patient was discharged on postoperative day 113 and has been fine for 2 years after LDLT. Histopathologically, the explanted liver had obliterative portal venopathy, nodular regenerative hyperplasia, and incomplete septal cirrhosis. Conclusion: This case showed that severe IPH is occasionally associated with extrahepatic portal vein stenosis and can be treated with LDLT with portal vein reconstruction using an interposition graft. It was also suggested that the SFV is a useful choice for the interposition graft.

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Control of a Nosocomial Outbreak of COVID-19 in a University Hospital

Harada S., Uno S., Ando T., Iida M., Takano Y., Ishibashi Y., Uwamino Y., Nishimura T., Takeda A., Uchida S., Hirata A., Sata M., Matsumoto M., Takeuchi A., Obara H., Yokoyama H., Fukunaga K., Amagai M., Kitagawa Y., Takebayashi T., Hasegawa N.

Open Forum Infectious Diseases (Open Forum Infectious Diseases) 7 ( 12 ) 1 - 9 2020.12

Background: Nosocomial spread of coronavirus disease 2019 (COVID-19) causes clusters of infection among high-risk individuals. Controlling this spread is critical to reducing COVID-19 morbidity and mortality. We describe an outbreak of COVID-19 in Keio University Hospital, Japan, and its control and propose effective control measures. Methods: When an outbreak was suspected, immediate isolation and thorough polymerase chain reaction (PCR) testing of patients and health care workers (HCWs) using an in-house system, together with extensive contact tracing and social distancing measures, were conducted. Nosocomial infections (NIs) were defined as having an onset or positive test after the fifth day of admission for patients and having high-risk contacts in our hospital for HCWs. We performed descriptive analyses for this outbreak. Results: Between March 24 and April 24, 2020, 27 of 562 tested patients were confirmed positive, of whom 5 (18.5%) were suspected as NIs. For HCWs, 52 of 697 tested positive, and 40 (76.9%) were considered NIs. Among transmissions, 95.5% were suspected of having occurred during the asymptomatic period. Large-scale isolation and testing at the first sign of outbreak terminated NIs. The number of secondary cases directly generated by a single primary case found before March 31 was 1.74, compared with 0 after April 1. Only 4 of 28 primary cases generated definite secondary infection; these were all asymptomatic. Conclusions: Viral shedding from asymptomatic cases played a major role in NIs. PCR screening of asymptomatic individuals helped clarify the pattern of spread. Immediate large-scale isolation, contact tracing, and social distancing measures were essential to containing outbreaks.

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Late-onset acute liver failure due to Wilson’s disease managed by plasmapheresis and hemodiafiltration successfully serving as a bridge for deceased donor liver transplantation: a case report and literature review

Sukezaki A., Chu P.s., Shinoda M., Hibi T., Taniki N., Yoshida A., Kawaida M., Hori S., Morikawa R., Kurokouchi A., Wakino S., Kameyama K., Obara H., Kitagawa Y., Saito H., Kanai T., Nakamoto N.

Clinical Journal of Gastroenterology (Clinical Journal of Gastroenterology) 13 ( 6 ) 1239 - 1246 2020.12

ISSN 18657257

Late-onset acute liver failure due to Wilson’s disease (WD-ALF) is rare. A 44-year-old female patient presenting acute hepatic decompensation with extreme coagulopathy was transferred to our hospital for evaluation for liver transplantation (LT). Alveolar hemorrhage and Coombs-negative acute hemolysis occurred during workup. Mechanical ventilation, plasmapheresis, and hemodiafiltration with zinc and chelation were started immediately before placing the patient on the waitlist for deceased donor LT (DDLT), with a tentative diagnosis of WD-ALF using the Leipzig score and quick diagnostic criteria suggested by the Acute Liver Failure Study Group Registry. The peak MELD score was 40, and the revised version of King’s score for WD was 13. Serum free copper levels and the patient’s overall general condition were stabilized with artificial support systems, although triphasic wave on electroencephalogram and liver atrophy were noted. She successfully underwent emergent DDLT approximately 2 weeks after suffering from acute hemolysis and survived. The genetic tests confirmed mutations at 2 loci in the ATP7B gene and, therefore, the diagnosis of WD. This is the first and oldest patient reported in Japan to present late-onset WD-ALF that was successfully treated with emergent DDLT.

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Effectiveness of active nasal surveillance culture for Methicillin-resistant Staphylococcus aureus in patients undergoing colorectal surgery

Kondo T., Okabayashi K., Sugiura K., Obara H., Takeuchi H., Wada N., Takano Y., Iwata S., Hasegawa N., Kitagawa Y.

Journal of Infection and Chemotherapy (Journal of Infection and Chemotherapy) 26 ( 12 ) 1244 - 1248 2020.12

ISSN 1341321X

Objective: The aim of this study was to clarify the role of Methicillin-resistant Staphylococcus aureus (MRSA) carriers in the development of surgical site infection (SSI) after colorectal surgery. Summary background data: MRSA is commonly implicated in hospital-acquired infections. Active surveillance culture (ASC) using the nasal swab test is useful to detect MRSA in surgical patients. We hypothesized that MRSA carriers would be more susceptible to SSI after colorectal surgery Methods: Patients who underwent ASC between 2010 and 2013 were included in this study. The incidence of SSI was compared between MRSA carriers and non-carriers using the chi-square test. The odds ratio for SSI was computed using logistic regression analyses. Results: Among 355 patients, 12 (3.4%) were identified as MRSA carriers and 343 as non-carriers. Of all the patients, 65 patients (18.3%) developed an SSI. Of these, 6 cases were in MRSA carriers and 59 cases were in non-carriers (p < 0.01). This meant that half of the 12 MRSA carriers developed an SSI, compared with only 17.2% of non-carriers (59 cases out of 343 patients). Therefore, MRSA carriers had a significantly higher risk of SSI (adjusted odds ratio = 4.77 [1.37 to 16.6], p = 0.01). Conclusions: Detection of MRSA via ASC is significantly associated with the development of SSI after colorectal surgery. These findings indicate that ASC for MRSA is useful to predict an SSI.

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Experimental techniques for the development of a uterus transplantation model in cynomolgus macaques

Kisu I., Banno K., Obara H., Kato Y., Yamada Y., Matsubara K., Matoba Y., Adachi M., Emoto K., Masugi Y., Saiki Y., Ishigaki H., Itagaki I., Kawamoto I., Iwatani C., Nakagawa T., Murase M., Tsuchiya H., Nakagawa K., Shiina T., Aoki D.

Journal of Obstetrics and Gynaecology Research (Journal of Obstetrics and Gynaecology Research) 46 ( 11 ) 2251 - 2260 2020.11

ISSN 13418076

Uterus transplantation (UTx) is now a treatment for women with uterine factor infertility to have a child. However, UTx is still largely at the experimental stage, and many medical issues remain unsolved. Therefore, adequate studies in large animals including non-human primates are required for validation of these issues. UTx research, especially in non-human primates, can provide important information for its full establishment in humans due to the anatomical and physiological similarities between the two. We accumulated data from UTx studies using cynomolgus macaques since 2009 and established autologous and allogeneic UTx models which led to deliveries after performing the procedure. In this paper, we summarized key points to develop UTx models in cynomolgus macaques based on our experience. UTx models in non-human primates can surely contribute new and beneficial knowledge in this field and can be useful for the further development of UTx in humans.

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Aqueous olanexidine versus aqueous povidone-iodine for surgical skin antisepsis on the incidence of surgical site infections after clean-contaminated surgery: a multicentre, prospective, blinded-endpoint, randomised controlled trial

Obara H., Takeuchi M., Kawakubo H., Shinoda M., Okabayashi K., Hayashi K., Sekimoto Y., Maeda Y., Kondo T., Sato Y., Kitagawa Y.

The Lancet Infectious Diseases (The Lancet Infectious Diseases) 20 ( 11 ) 1281 - 1289 2020.11

ISSN 14733099

Background: Surgical site infection (SSI) is the most common problem after surgery. Although several guidelines have indicated the efficacy of antiseptics, such as chlorhexidine-alcohol and povidone-iodine, in reducing SSI rate, the optimal recommendation is still not established. Olanexidine might have higher bactericidal activity than other antiseptic agents. However, no randomised study has evaluated the efficacy and safety of olanexidine over conventional antiseptics. We compared the effect of aqueous olanexidine and aqueous povidone-iodine on the incidence of SSI following clean-contaminated surgery. Methods: This was a multicentre, prospective, randomised, blinded-endpoint superiority trial for surgical skin antisepsis in clean-contaminated gastrointestinal and hepatobiliary pancreatic surgeries in four Japanese hospitals. Patients aged 20 years or older who underwent elective clean-contaminated wound surgery were randomly assigned in a 1:1 replacement ratio using a computer-generated block randomisation. Patients were randomly assigned to surgical skin antisepsis with an aqueous formulation of 1·5% olanexidine or surgical skin antisepsis with an aqueous formulation of 10% povidone-iodine before surgery. We used olanexidine in a ready-to-use applicator, and povidone-iodine was administered by a brush or by compression using pliers. Both antiseptics were applied from the papilla with a cranial limit and to the upper thigh with a caudal limit. The antiseptics were allowed to dry for 3 min, and then surgery started. Participants, some investigators, and data analysts were masked to treatment allocation. Participant enrolment was done by non-masked investigators. The primary outcome was 30-day SSI assessed in the intention-to-treat population. The surgical wound site of each participant was observed daily. After discharge, participants underwent at least one outpatient visit within 30 days after surgery. This trial is registered with University hospital Medical Information Network, 000031560. Findings: Between June 10, 2018, and April 18, 2019, 883 patients were assessed for eligibility. 587 patients were eligible and 294 received olanexidine and 293 received aqueous povidone-iodine before surgery. 30-day SSI occurred in 19 (7%) patients in the olanexidine group and 39 patients (13%) patients in the povidone-iodine group (adjusted risk difference −0·069; 90% CI −0·109 to −0·029; adjusted risk ratio [RR] 0·48, 90% CI 0·30 to 0·74; p=0·002). Five patients (2%) in the olanexidine group and five (2%) in the povidone-iodine group developed adverse skin reactions (adjusted RR 0·99, 95% CI 0·29 to 3·40; p=1·00). Interpretation: Olanexidine significantly reduced the occurrence of overall SSI and superficial incisional SSI compared with aqueous povidone-iodine in clean-contaminated surgery. Our results indicate that olanexidine might have a role to prevent SSI in patients who undergo clean-contaminated surgeries. Funding: Keio University and Ohyama Health Foundation.

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The perioperative presepsin as an accurate diagnostic marker of postoperative infectious complications after esophagectomy: a prospective cohort study

Takeuchi M., Yokose T., Kawakubo H., Matsuda S., Mayanagi S., Irino T., Fukuda K., Nakamura R., Wada N., Obara H., Kitagawa Y.

Esophagus (Esophagus) 17 ( 4 ) 399 - 407 2020.10

ISSN 16129059

Background: Presepsin is suggested to be an accurate sepsis diagnostic biomarker, playing an important role in distinguishing infection from no-infection status. However, to date, there is no study determining presepsin’s role in diagnosing post-esophagectomy infectious complications. Methods: Thirty patients who underwent esophagectomy for esophageal carcinoma were included in this prospective observational study. We investigated preoperative presepsin levels’ changes and evaluated the relationship between infectious complications and presepsin levels. Moreover, we analyzed the classification and regression tree (CART) to determine presepsin’s optimal cutoff values for discriminating infectious complications. Results: For 10 patients with infectious complications, median presepsin levels were 168, 337, 303, 271, 314, 978, and 752 pg/ml, pre- and immediately post-surgery, and 1, 2, 3, 5, 7 days post-surgery, respectively. Presepsin levels were significantly higher in the infectious complication group exclusively from preoperation to POD 7 (p = 0.048). Furthermore, area under the curve’s value of presepsin on POD 5 and 7 was higher than the other three biomarkers included for discriminating infectious complications (i.e., procalcitonin, leukocyte, and C-reacted protein). We set an optimal cutoff value for presepsin calculated by CART. Specifically, on POD 5, the cutoff was 888 pg/ml with a sensitivity of 60% and a specificity of 90%, and on POD 7, the cutoff was 668 pg/ml with a sensitivity of 60% and a specificity of 85%. Conclusions: Presepsin levels on POD 5 and 7 after esophagectomy are a valuable indicator of infectious complication’s detection vs. leukocyte, C-reacted protein, and procalcitonin.

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Two-year results of a multicenter prospective observational study of the Zenith Spiral-Z limb deployed in the external iliac artery during endovascular aneurysm repair

Fujimura N., Imazuru T., Matsumura H., Shibata T., Furuyama T., Kaneko K., Uchiyama H., Morikage N., Uchida T., Teshima E., Yamaoka T., Masuhara H., Ueda H., Arakawa M., Norimatsu T., Obara H., Onitsuka S.

Circulation Journal (Circulation Journal) 84 ( 10 ) 1764 - 1770 2020.09

ISSN 13469843

Background: Limited data is available on the use of a polyester graft limb with a helical stent configuration deployed in the external iliac artery (EIA) during endovascular aneurysm repair (EVAR), so we prospectively analyzed the efficacy of the Zenith Spiral-Z limb deployed in the EIA. Methods and Results: Patients undergoing EVAR using a Zenith stent-graft and Spiral-Z limb deployed in the EIA were prospectively registered in 24 Japanese institutions from June 2017 to November 2017. In total, 65 patients (74 limbs) (mean age: 77.1±8.0 years, 87.7% men, mean abdominal aortic aneurysm (AAA) diameter: 51.9±7.2mm, mean iliac artery aneurysm (IAA) diameter: 38.3±10.0mm) were registered and followed up. The most common reason for deployment in the EIA was a common IAA (43 limbs, 58.1%), and 8 limbs (10.8%) had a bare nitinol stent placed at the Spiral-Z limb. A total of 61 patients (70 limbs) completed a 24-month follow-up. There were 2 Spiral-Z limb stenoses and 1 occlusion, leading to a primary patency of 95.5% and a secondary patency of 100%, at 24 months. Buttock claudication occurred in 24.3% of the limbs treated at 1 month but decreased to 4.3% at 24 months. Conclusions: Our multicenter prospective study showed that Spiral-Z limb deployed in the EIA was associated with satisfactory results and seems to be a durable option, even in the era of iliac branch devices.

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Importance of Distal Sealing during Endovascular Aneurysm Repair Using Aneurysmal Common Iliac Artery as Landing Zone

Shintani T., Mitsuoka H., Hasegawa Y., Hayashi M., Natsume K., Ookura K., Sato Y., Obara H.

Annals of Vascular Surgery (Annals of Vascular Surgery) 66 120 - 131 2020.07

ISSN 08905096

Background: Although the use of aneurysmal common iliac artery (CIA) as the landing zone during endovascular aortic aneurysm repair EVAR remains an essential procedure, this procedure may increase the risk of late complications such as ongoing CIA dilatation and type Ib endoleak (CIA-related complications). We hypothesized that incomplete sealing of the aneurysmal CIA segment during EVAR could increase the incidence of CIA-related complications. In this study, we evaluated the midterm results of EVAR with aneurysmal CIA used as the landing zone and assessed the importance of distal sealing in this procedure. Methods: We retrospectively reviewed all cases of endovascular aneurysm repair using CIA as landing zone between 2007 and 2015 that had at least 3 years’ follow-up. We defined aneurysmal CIA as maximum diameter ≥18 mm. The main outcome was the incidence of CIA-related complications. We compared midterm results between normal CIA and aneurysmal CIA. Next, we analyzed risk factors for CIA-related complications in aneurysmal CIA. Results: Four complications occurred in normal CIA (mean follow-up, 66.5 ± 22.1 months); 21 occurred in aneurysmal CIA (mean follow-up, 62.2 ± 20.5 months). The 5-year portion of freedom from CIA-related complications was 97.3% in normal CIA and 69.4% in aneurysmal CIA (P < 0.001). Multivariable analysis in aneurysmal CIA showed that unsealed CIA segment length was only risk factor for CIA-related complications. Given the receiver operating characteristic curve results, we defined the unsealed CIA segment ≥10 mm as incomplete sealing. The hazard ratio for incomplete sealing associated with CIA-related complications was 3.92 (95% confidence interval 1.62–9.46, P = 0.02). Conclusions: Use of aneurysmal CIA as landing zone increases the risk of CIA-related complications. However, maximum sealing of the aneurysmal CIA segment could prevent these complications.

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Midterm Results of a Japanese Prospective Multicenter Registry of Heparin-Bonded Expanded Polytetrafluoroethylene Grafts for Above-the-Knee Femoropopliteal Bypass

Shibutani S., Obara H., Matsubara K., Toya N., Isogai N., Ogino H., Watada S., Asami A., Kudo T., Kanaoka Y., Fujimura N., Harada H., Uchiyama H., Sato Y., Ohki T.

Circulation journal : official journal of the Japanese Circulation Society (Circulation journal : official journal of the Japanese Circulation Society) 84 ( 3 ) 501 - 508 2020.02

BACKGROUND: This study prospectively analyzed the midterm results of above-the-knee femoropopliteal bypass (AKb) using bioactive heparin-bonded expanded polytetrafluoroethylene (HB-ePTFE) graft in patients with femoropopliteal occlusive disease.Methods and Results:This prospective, multicenter, non-randomized study reviewed limbs undergoing AKb with HB-ePTFE graft for femoropopliteal lesion in 20 Japanese institutions between July 2014 and October 2017. Primary efficacy endpoints were primary, primary assisted, and secondary graft patency. Safety endpoints included any major adverse limb event and perioperative mortality. During the study period, 120 limbs of 113 patients (mean age, 72.7 years) underwent AKb with HB-ePTFE grafts. A total of 45 patients (37.5%) had critical limb ischemia and 17 (15.0%) were on hemodialysis (HD). Median duration of follow-up was 16 months (range, 1-36 months). Estimated 1- and 2-year primary, primary assisted, and secondary graft patency rates were 89.4% and 82.7%, 89.4% and 87.2%, and 94.7% and 92.5%, respectively. On univariate analysis of 2-year primary graft patency, having 3 run-off vessels, cuffed distal anastomoses, no coronary artery disease, and no chronic kidney disease requiring HD were significantly associated with favorable patency. CONCLUSIONS: AKb using HB-ePTFE grafts achieved favorable 2-year graft patency. AKb using HB-ePTFE grafts may therefore be an acceptable, highly effective treatment option for femoropopliteal artery lesions.

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Preliminary Experience of Viabahn Stent Graft Inside the Occluded Prosthetic Bypass Graft for the Treatment of Above Knee Femoropopliteal Bypass Occlusion

Fujimura N., Obara H., Iwasa K., Hattori T., Yamamoto H., Watada S., Kobayashi T., Suematsu N., Mitsuoka H., Soga Y., Nakama T., Sakamoto R., Ichihashi S.

CardioVascular and Interventional Radiology (CardioVascular and Interventional Radiology) 43 ( 2 ) 223 - 230 2020.02

ISSN 01741551

Purpose: To describe a multi-center preliminary experience of treating prosthetic above knee femoropopliteal (AKFP) bypass occlusion by placing a Viabahn stent graft inside the occluded prosthetic bypass graft. Materials and Methods: Retrospective analysis of consecutive 14 patients (mean age 73.2 ± 10.2, 78.6% male) receiving Viabahn stent graft inside the occluded prosthetic bypass graft for the treatment of prosthetic AKFP bypass occlusion in the collaborating hospitals from November 2016 to June 2019 was performed. Results: Technical success was achieved in all patients. Mean lesion length was 34.0 ± 3.5 cm, concomitant thrombectomy or thrombus aspiration was performed in 11 patients (78.6%), and average of 1.57 ± 0.65 Viabahn stent grafts were used. Mean ankle–brachial index improved from 0.24 ± 0.23 to 0.98 ± 0.14 after the treatment. All patients had preoperative ischemic symptoms with 9 patients (64.3%) having Rutherford class > 4 symptoms; however, all preoperative symptoms resolved after the treatment. During the mean follow-up of 450.9 ± 234.7 days, there were two target lesion revascularizations, leading to a primary patency rate of 92.9% and a secondary patency of 100.0% at 1 year. Conclusion: Placing a Viabahn stent graft inside the occluded prosthetic bypass graft for the treatment of prosthetic AKFP bypass occlusion appears to be effective from our preliminary experience. Even though sample size is limited in our study, it may be considered as a potential treatment option before surgical reintervention.

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Current management strategies for visceral artery aneurysms: an overview

Obara H., Kentaro M., Inoue M., Kitagawa Y.

Surgery Today (Surgery Today) 50 ( 1 ) 38 - 49 2020.01

ISSN 09411291

Visceral artery aneurysms (VAAs) are rare and affect the celiac artery, superior mesenteric artery, and inferior mesenteric artery, and their branches. The natural history of VAAs is not well understood as they are often asymptomatic and found incidentally; however, they carry a risk of rupture that can result in death from hemorrhage in the peritoneal cavity, retroperitoneal space, or gastrointestinal tract. Recent advances in imaging technology and its availability allow us to diagnose all types of VAA. VAAs can be treated by open surgery, laparoscopic surgery, endovascular therapy, or a hybrid approach. However, there are still no specific indications for the treatment of VAAs, and the best strategy depends on the anatomical location of the aneurysm as well as the clinical presentation of the patient. This article reviews the literature on the etiology, clinical features, diagnosis, and anatomic characteristics of each type of VAA and discusses the current options for their treatment and management.

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Peak systolic velocity ratio derived from quantitative vessel analysis for restenosis after femoropopliteal intervention: a multidisciplinary review from Endovascular Asia

Kawarada O., Hozawa K., Zen K., Huang H.L., Kim S.H., Choi D., Park K., Kato K., Kato T., Tsubakimoto Y., Ichihashi S., Fujimura N., Higashimori A., Sato T., Yan B.P.Y., Pang S.Y.C., Wongwanit C., Leong Y.P., Chua B., George R.K., Chen I.C., Lee J.K., Hsu C.H., Pua U., Iwata Y., Miki K., Okada K., Obara H.

Cardiovascular Intervention and Therapeutics (Cardiovascular Intervention and Therapeutics) 35 ( 1 ) 52 - 61 2020.01

ISSN 18684300

With technological improvements in the endovascular armamentarium, there have been tremendous advances in catheter-based femoropopliteal artery intervention during the last decade. However, standardization of the methodology for assessing outcomes has been underappreciated, and unvalidated peak systolic velocity ratios (PSVRs) of 2.0, 2.4, and 2.5 on duplex ultrasonography have been arbitrarily but routinely used for assessing restenosis. Quantitative vessel analysis (QVA) is a widely accepted method to identify restenosis in a broad spectrum of cardiovascular interventions, and PSVR needs to be validated by QVA. This multidisciplinary review is intended to disseminate the importance of QVA and a validated PSVR based on QVA for binary restenosis in contemporary femoropopliteal intervention.

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Incidence, diagnosis and treatment of popliteal artery entrapment syndrome in current vascular practice in Japan

Fujimura N., Hosokawa K., Obara H., Igari K., Akamatsu D., Matsumoto H., Asami A., Shibutani S., Akiyoshi T., Nunokawa M., Harada H., Inoue K., Koya A., Furuyama T., Sagara D., Shintani T., Yamaoka T., Akiyama Y., Inoue Y., Hoshina K.

Cardiovascular Intervention and Therapeutics (Cardiovascular Intervention and Therapeutics) 36 ( 4 ) 506 - 513 2020

ISSN 18684300

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.

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Methicillin-resistant Staphylococcus aureus carriers are vulnerable to bloodstream infection after living donor liver transplantation

Takemura Y., Hibi T., Shinoda M., Obara H., Minagawa T., Kitago M., Yagi H., Abe Y., Matsubara K., Oshima G., Hori S., Hoshino K., Yamada Y., Itano O., Takano Y., Kuroda T., Hasegawa N., Kitagawa Y.

Clinical Transplantation (Clinical Transplantation) 33 ( 12 ) 2019.12

ISSN 09020063

Background: Bloodstream infection (BSI) is a life-threatening complication after living donor liver transplantation (LDLT). We aimed to explore the incidence and predisposing factors of BSI at our institution. Methods: We conducted a retrospective cohort analysis on all consecutive adults with BSI within 6 months after LDLT performed between 2005 and 2016. For antimicrobial prophylaxis, ampicillin/sulbactam, cefotaxime, and micafungin were administered. From 2011, methicillin-resistant Staphylococcus aureus (MRSA) carriers were decolonized using mupirocin ointment and chlorhexidine gluconate soap. Risk factors for BSI were identified by uni- and multivariate logistic regression. Results: Of a total of 106 LDLTs, 42 recipients (40%) suffered BSI. The BSI group demonstrated significantly higher in-hospital mortality rates compared with the non-BSI group (24% vs. 7%, P =.01). We identified MRSA carrier (odds ratio [OR], 19.1; P <.001), ABO incompatibility (OR, 2.9; P =.03), and estimated glomerular filtration rate <30 mL/min/1.73m (OR, 15.8; P =.02) as independent risk factors for BSI. Decolonization treatment for MRSA carriers did not reduce the incidence of all-cause BSI but reduced the frequency of BSI caused by MRSA. Conclusion: To our knowledge, for the first time, MRSA carriers were revealed to be highly vulnerable to BSI after LDLT. 2

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Impact of Stent Graft Design on External Iliac Artery Limb Occlusion Rates After Endovascular Aneurysm Repair: Post-hoc Analysis of a Japanese Multicentre Database

Shintani T., Obara H., Matsubara K., Hayashi K., Hayashi M., Ono S., Shimogawara T., Shibutani S., Watada S., Sekimoto Y., Uchida N., Asami A., Fujii T., Harada H., Fujimura N., Sato Y., Kitagawa Y.

European Journal of Vascular and Endovascular Surgery (European Journal of Vascular and Endovascular Surgery) 58 ( 6 ) 839 - 847 2019.12

ISSN 10785884

Objective/Background: It was hypothesised that a helical stent with expanded polytetrafluoroethylene (ePTFE) grafts could provide a preventive effect for external iliac artery (EIA) limb occlusion following endovascular aortic aneurysm repair (EVAR). Therefore, a post-hoc analysis of a Japanese multicentre database was conducted to assess the impact of the stent graft design on EIA limb occlusion rates. Methods: Patients who underwent EVAR with EIA limb deployment between 2008 and 2016 were evaluated. The stent graft limbs were divided into two groups: group A comprised stent graft limbs made of a helical stent with ePTFE grafts (Excluder; n = 255), and group B comprised stent graft limbs made of a Z stent with polyester grafts (Zenith, Flex and Endurant; n = 173). The main outcome was the incidence of limb occlusion and severe limb stenosis (EIA related limb complications). The risk factors for EIA related limb complications were analysed and the midterm results between groups A and B compared. Fine–Gray generalisation of the proportional hazards model was used after propensity score matching to calculate the hazard ratio (HR). Results: One complication occurred in group A and 10 complications occurred in group B. The risk factors for EIA related limb complications for the entire group were a stent graft limb size ≤10 mm (HR 5.41; p = .01) and inclusion in group B (HR 14.9; p = .009). After propensity matching, group A (n = 159) was matched with group B (n = 159). The cumulative incidence function of EIA related limb complications at five years was 0.66% in group A and 7.8% in group B (HR 8.67; p = .039). Conclusion: Stent graft design can affect limb patency in EIA limb deployment. When EIA limb deployment is necessary for patients with a small EIA, such as Japanese patients, stent graft limbs made of a helical stent with ePTFE should be used to reduce the risk of limb occlusion.

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Achievement of Durable and Complete Remission of Graft-versus-host Disease After Liver Transplantation With Ruxolitinib: A Case Report

Endo Y., Oshima G., Hibi T., Shinoda M., Sakurai M., Koda Y., Izawa Y., Obara H., Kitago M., Yagi H., Abe Y., Matsubara K., Yamada Y., Fukushima A., Yokose T., Mori T., Kuroda T., Kitagawa Y.

Transplantation (Transplantation) 103 ( 11 ) e375 - e377 2019.11

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Type IIIb Endoleak Is Not Extremely Rare and May Be Underdiagnosed after Endovascular Aneurysm Repair

Fujimura N., Ichihashi S., Matsubara K., Shibutani S., Harada H., Obara H., Kichikawa K., Kitagawa Y.

Journal of Vascular and Interventional Radiology (Journal of Vascular and Interventional Radiology) 30 ( 9 ) 1393 - 1399.e1 2019.09

ISSN 10510443

Purpose: To investigate the real incidence of type IIIb endoleaks associated with the Zenith stent graft, currently the most widely used third-generation polyester stent graft, in a Japanese multicenter database. Materials and Methods: Retrospective analysis was conducted of 433 patients who underwent endovascular aneurysm repair (EVAR) of aortoiliac aneurysms with the use of Zenith stent grafts from 2007 to 2016. The mean age of patients was 75.6 y ± 7.8, and 85.2% of patients were men. Mean transverse diameters of abdominal aortic aneurysms and common iliac artery aneurysms were 50.8 mm ± 9.9 and 42.2 mm ± 10.3, respectively. Results: During a mean follow-up period of 41.9 mo, 7 type IIIb endoleaks (1.6%) were identified. Four patients were definitively diagnosed during repeat intervention, and 3 were diagnosed based on postoperative CT images. Three patients were treated surgically, 2 were treated by relining with an additional stent graft, and 2 were conservatively followed with CT imaging. Only 1 of 5 patients who underwent repeat intervention had a preoperative diagnosis of type IIIb endoleak, reflecting the difficulty in its diagnosis. Conclusions: The incidence of type IIIb endoleak in Zenith stent grafts was 1.6% in this study, suggesting that type IIIb endoleaks are not extremely rare. In addition, type IIIb endoleak may be underdiagnosed or misdiagnosed as a different type of endoleak. Type IIIb endoleaks should always be considered in patients with sac expansion after EVAR.

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Comparison of olanexidine versus povidone-iodine for preventing surgical site infection in gastrointestinal surgery: Study protocol for a multicentre, single-blind, randomised controlled clinical trial

Takeuchi M., Obara H., Kawakubo H., Shinoda M., Okabayashi K., Mayanagi S., Irino T., Fukuda K., Nakamura R., Wada N., Kitago M., Yagi H., Abe Y., Oshima G., Hori S., Tsuruta M., Ishida T., Yokose T., Hirukawa K., Isobe Y., Sekimoto Y., Harada H., Maeda Y., Shito M., Kondo T., Sato Y., Kitagawa Y.

BMJ Open (BMJ Open) 9 ( 5 ) 2019.05

Introduction: The prevalence of surgical site infection (SSI) remains higher in gastrointestinal surgery than in other surgeries. Although several guidelines have indicated the efficacy of chlorhexidine and povidone-iodine in reducing the SSI rate, the optimal recommendation has still not been established. Therefore, it is necessary to determine the more effective antiseptic for surgical site preparation. Olanexidine (1.5% olanedine, Otsuka Pharmaceutical Factory, Tokushima, Japan), which is a new antiseptic in Japan, has antimicrobial activity against a wide range of bacteria, including Gram-positive and Gram-negative bacteria. Our study will contribute to determining a new antiseptic for use in gastrointestinal and other surgeries. Methods and analysis: We propose a multicentre, randomised controlled clinical trial for comparing two treatments, that is, 1.5% olanexidine or 10% povidone-iodine, for surgical skin preparation to prevent SSI in clean-contaminated gastrointestinal surgeries with surgical wounds. Patients aged ≥20 years at the time of consent will be included. The primary outcome measure is the 30-day postoperative SSI rate. For the primary analysis, which is aimed at comparing the treatment effects, the adjusted risk ratio and its 95% CI will be estimated using the Mantel-Haenszel method. Ethics and dissemination: The protocol was first approved by the Institutional Review Board of Keio University School of Medicine, followed by the institutional review board of each participating site. Participant recruitment began in June 2018. The final results will be published in international peer-reviewed medical journals.

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