Clinical Implications of Additional Pedal Artery Angioplasty in Critical Limb Ischemia Patients With Infrapopliteal and Pedal Artery Disease

PURPOSE

To evaluate the clinical implications of additional pedal artery angioplasty (PAA) for patients with critical limb ischemia (CLI).

METHODS

Twenty-nine patients (mean age 77.8±8.6 years; 21 men) with CLI (32 limbs) presenting with de novo infrapopliteal and pedal artery (Kawarada type 2/3) disease were reviewed. The need for PAA was based on the existence of sufficient wound blush (WB) around the target wounds after conventional above-the-ankle revascularization. Fourteen patients with insufficient WB in 14 limbs received additional PAA, while 15 patients with sufficient WB in 18 limbs did not. The groups were compared for overall survival, limb salvage, and amputation-free survival within 1 year after the procedure. The wound healing rate, time to wound healing, and freedom from reintervention rate were also evaluated.

RESULT

The success rate of additional PAA was 93% (13/14). All limbs with successful PAA achieved sufficient WB (13/13). Despite insufficient WB before the additional PAA, overall survival (86% vs 73%, p=0.350), limb salvage (93% vs 83%, p=0.400), amputation-free survival (79% vs 53%, p=0.102), and freedom from reintervention (64% vs 73%, p=0.668) rates were similar in both groups. Furthermore, the wound healing rate (93% vs 60%, p=0.05) was higher and time to wound healing (86.0±18.7 vs 152.0±60.2 days, p=0.05) was shorter in the patients who received PAA.

CONCLUSION

Additional PAA might improve the WB and clinical outcomes (especially speed and extent of wound healing) in patients with CLI attributed to infrapopliteal and pedal artery disease.

Insulin-like growth factor-I enhances transforming growth factor-beta-induced extracellular matrix protein production through the P38/activating transcription factor-2 signaling pathway in keloid fibroblasts

Keloids are benign dermal tumors, characterized by invasive growth of fibroblasts and concomitant increased biosynthesis of extracellular matrix components, with unclear etiology. We previously demonstrated that keloid fibroblasts overexpress insulin-like growth factor-I receptor. In investigating the role of insulin-like growth factor-I receptor overexpression, insulin-like growth factor-I and transforming growth factor-beta interaction was examined in relation to extracellular matrix protein production in cultured human and mouse fibroblasts. Western blotting revealed that collagen type I was expressed in keloid and normal fibroblasts, and its expression was increased by transforming growth factor-beta stimulation more significantly in keloid rather than in normal fibroblasts. Insulin-like growth factor-I and transforming growth factor-beta1 costimulation markedly increased extracellular matrix proteins (collagen type I, fibronectin, and plasminogen activator inhibitor-1) compared with cultures with transforming growth factor-beta1 alone. Insulin-like growth factor-I treatment alone had no stimulatory effect. Real-time reverse transcription-polymerase chain reaction confirmed parallel collagen type I messenger RNA level changes. Luciferase assays were conducted to investigate intracellular signaling pathways in this synergistic stimulation using a mouse fibroblast cell line. Transforming growth factor-beta1 (1 or 10 ng per ml) increased the specific signaling activity approximately 10-fold, whereas the increase with insulin-like growth factor-I (100 ng per ml) was less than 2-fold compared with basal activity; however, the combination of transforming growth factor-beta1 and insulin-like growth factor-I resulted in an approximately 25-fold increase. Insulin-like growth factor-I markedly enhanced transforming growth factor-beta-induced phosphorylation of p38 mitogen-activated protein kinase and activating transcription factor-2. Luciferase assay showed that this synergistic effect was attenuated by the p38 mitogen-activated protein kinase specific inhibitor SB203580 or phosphatidylinositol 3-kinase inhibitor wortmannin, but not by the mitogen-activated protein kinase/extracellular-signal-regulated protein kinase kinase inhibitor PD98059. These results indicate that insulin-like growth factor-I enhances transforming growth factor-beta-induced keloid formation through transforming growth factor-beta postreceptor signal cross-talk, mainly via the p38 mitogen-activated protein kinase/activating transcription factor-2 pathway.

Cytokine-dependent gp130 receptor subunit regulates rat modified axial-pattern epigastric flap

We investigated axial-pattern flap survival by modulating the cytokine receptor component, gp130, to elucidate the mechanism of the cytokine receptor modulation subsequently leading to the initiation of local angiogenesis and blood-flow augmentation. Fifty-two male Wistar rats were divided into four groups. The flap size was 8 x 8 cm, with the medial middle branch of the superficial epigastric artery as the only nutrient supply vessel. Group 1 received only a control vehicle, group 2 received leukemia inhibitory factor(LIF), cDNA treated, group 3 received combined treatment of LIF and anti-gp130 antibody, and group 4 was the anti-gp130-treated group. All groups received 0.1 mL phosphate-buffered saline (PBS) via 30-gauge needle injected into the proximal site of the femoral artery after distal sites of the bifurcated femoral artery to epigastric artery and vein were clamped. All clamps were removed after 10 min of incubation of the injected agents. During the first 3 postoperative days, the flap survival was significantly more improved in the anti-gp130-treated and combined-treated groups than in the control (88 +/- 1.5% and 77 +/- 5.3 vs. 45 +/- 7.8, respectively, p <.01). Laser blood flowmetry on day 3 showed a significant increase of blood flow in three different flap sites in anti-gp130-treated and combined-treated groups than in the other groups (p <.001). Microangiography showed remarkable differences between all four groups. The anti-gp130-treated flap showed augmented vessel formation at the base of the pedicle, which elongated the vessel interconnection up to the distal area. Strong gp130 transcripts and vascular endothelial growth factor (VEGF) expression were observed in all groups, as determined using reverse-transcription polymerase chain reaction (RT-PCR). The intensity of VEGF expression was the strongest in the anti-gp130-treated group. Attenuation of the gp130 receptor subunit can improve axial-pattern flap survival along with angiogenesis.

Release of extra-articular ankylosis by coronoidectomy and insertion of a free abdominal flap: case report

INTRODUCTION

It is generally agreed that an effective treatment for extra-articular ankylosis may be coronoidectomy and excision of scar tissue. But these conventional procedures have shown a high rate of recurrence of ankylosis due to heterotopic bone and fibrous tissue formation. OBJECTIVE AND PATIENT: We report a case in whom a coronoid osteotomy and insertion of a free abdominal flap was used to treat ankylosis of the mandible following radiotherapy for maxillary cancer.

RESULTS

This procedure prevented recurrence of ankylosis by heterotopic bone and fibrous tissue formation. In addition, this flap reduced the risk of postoperative infection and promoted primary healing.

CONCLUSION

The procedure, coronoidectomy and insertion of a free flap, was successful because the well-vascularized musculocutaneous flap occupied the dead space, and replaced the shortage of oral mucosa consequently inhibiting the recurrence of extra-articular ankylosis.

Intracellular distribution of Hg2+ applied to epidermis in mice. Analysis of subcellular fractions

To analyze the permeation of Hg2+ in the epidermis as contact dermatitis allergen, the carrier substances from the HgCl2-treated epidermis were isolated. The peak amount of Hg2+ in the epidermis of mouse tail skin was observed at 12 h after the painting. Thereafter, it remained almost stationary. In the analysis of subcellular fractions, the nuclei fraction showed the highest Hg2+ incorporation, while the soluble protein fraction showed the lowest.