Komori, Kimihiro

Sugimachi, Keizo

Yonemitsu, Yoshikazu

Elsevier - Publisher Connector 

JOURNAL OF VASCULAR SURGERY
Volume 29, Number 2
not influence the cost to the extent anticipated, or
even significantly. We agree with Dr Wang that
stents can be deployed safely on an outpatient
basis, and this is our current practice. We did not
begin our program with that premise, however. On
the other hand, the length of stay for direct surgi-
cal reconstruction has decreased significanfiy dur-
ing the last few years. Therefore, these cost data do
not fully reflect the ongoing efforts to streamline
both procedures. Although we admit that the cost
data published in this manuscript are not perfect,
they are our best attempt at presenting the data
with appropriate cohort comparisons.
6. These cost data were obtained directly from thc
accounting office on the basis of accurate patient
admission statistics and were not underestimated.
They are accurate. The discussant to whom Dr
Wang refers was speculating and was not an
informed panel expert.
7. As admitted in the manuscript, the cost per patient
encounter was higher for surgical reconstruction as
compared with angioplasty with or without stenting.
However, we believe that the cost estimates derived
on a per-limb-treated basis are the best method of
comparison and provide a perspective not common-
ly offered in the interventional radiology literature.
That is to say, on the basis of these data, direct sur-
gical reconstruction offered better value per limb
treated in terms of clinical improvement and long-
term patency rates. Although Dr Wang and other
interventional radiologists might contend that this
endpoint is unfair because angioplasty was done
more for unilateral disease and bypass grafting was
done more for bilateral disease, the per procedure or
per patient perspective found in much of the radiol-
ogy literature is unfair in the other direction.
8. It is well recognized that procedural and physician
charges for angioplasty and stenting are rising as a
result of more sophisticated imaging and instru-
mentation and that those for surgical bypass graft-
ing are falling because of drastic reimbursement
trends. The results of the prospective, randomized
trial that Dr Wang suggests, if it includes cost of
reintervention and is performed on those patients
with more extensive aortoiliac disease than normal-
ly treated with angioplasty, might surprise him and
his colleagues. We too would welcome it, but until
such a trial shows otherwise, we believe that our
data reflect a true picture of comparative costs for
these procedures when applied to patients with
severe forms of aortoiliac occlusive disease.
Jeffrey L. Ballard, MD
Associate Professor of Surgery
Division ofVascular Surgery
Lorna Linda University Medical Center
Lorna Linda, Calif
Letters to the Editors 389
REFERENCES
1. Ballard JL, Bergan JJ, Singh P, Yonemoto H, Killeen JD.
Aortoiliac stent deployment versus surgical reconstruction:
analysis of outcome and cost. J Vasc Surg 1998;28:94-103.
2. Ballard JL, Taylor FC, Sparks SR, Killeen JD. Stenting with-
out thrombolysis for aortoiliac occlusive disease: experience
in 14 high-risk patients. Ann Vasc Surg 1995;9:453-8.
3. Deiparine MK, Ballard JL, Taylor FC, Chase DR. Endovascular
stent infection. J Vasc Surg 1996;23:529-33.
4. Ballard JL, Sparks SR, Taylor FC, Bergan JJ, Smith DC, Bunt
TT, Killeen JD. Complications of iliac artery stent deploy-
ment. J Vasc Surg 1996;24:545-55.
5. Wilson SE, Wolf GL, Cross AP, Veterans Administration
Cooperative Study No 199. Percutaneous transluminal
angioplasty versus operation for peripheral arteriosclerosis:
report of a prospective randomized trial in a selected group
of patients. J Vasc Surg 1989;9:1-9.
6. Holm J, ArtVidsson B, Jivegard L, et al. Chronic lower limb
ischaemia. A prospective randomised controlled study com-
paring the I-year results ofvascular surgery and percutaneous
transluminal angioplasty (PTA). Eur J Vasc Surg 1991;5:
517-22.
24/41/94660
Regarding "Detection of active cytomegalovirus
infection in inflammatory aortic aneurysms with
RNA polymerase chain reaction"
To the Editors
In addition to Dr Tanaka's reply (J Vasc Surg
1998:27:587-8), we would like to provide some addition-
al comments to the critique by Dr Satta and colleagues l
regarding possible cytomegalovirus pathogenesis in
human aortic diseases. We want to avoid misunderstand-
ing because it is slightly complex.
First, we should emphasize that we suggested
cytomegalovirus as a possible pathogen of so-called
inflammatory abdominal aortic aneurysms (IAAAs)2 but
not of conventional atherosclerotic abdominal aortic
aneurysms (AAAs).3,4 Cytomegalovirus transcripts could
be detected only in IAAAs but not in AAAB. Thus, we
concluded that cytomegalovirus transcripts might play a
role in the sustained chronic inflammatory reaction and
massive adventitial fibrosis of IAAAs but did not clearly
suggest the pathologic nature of AAAB.
Second, I am afraid that the authors might have con-
fused the status of cytomegalovirus infection in such aortic
diseases because the analytical technique that they used does
not seem to be appropriate for this purpose. The process of
infection ofhuman Herpesviridae is not fully elucidated, but
numerous studies suggest that at least four types of condi-
tions seem to exist in cytomegalovirus infection (Table I).
The following conditions are suggested: type 1, lytic infec-
tion associated with cytomegalic inclusion body that leads
to the death ofthe host cell; type 2, persistent infection with
virus production that does not lead to cell death; type 3,
latent infection that expresses some viral genes without viral
production; and type 4, postinfection with viral genome and
without viral gene expression. Clearly, type 1 infection can
390 Letters to the Editors
Table 1. Types of conditions in cytomegalovirus infections
JOURNAL OF VASCULAR SURGERY
February 1999
Type 1 lytic Type 2 persistent Type 3 latent Type 4
Infection type infection infection infection postinfection
Viral genome (DNA) + + + +
Viral transcript (RNA) + + +
Viral virion production + +
Inclusion body + ±
Host cell lysis +
be seen in the immunocompromised host, as a result of
AIDS, or in the organ transplant recipient, and type 4 infec-
tion is common (eg, normal human vascular tree). Thus,
these types should be excluded.
As we already described in previous studies,3,4
cytomegalovirus-derived cytopathic findings, histopatho-
logically, cannot be seen in lAAAs. We suggested that
cytomegalovirus infection in IAAAs is a type 3 latent infec-
tion (partially activated infection) and that in MAs or ordi-
nary atherosclerosis is a type 4 just postinfection (complete-
ly inactivated). The electromicroscopy that the authors used
in their study is used to detect the particle of virion. Thus,
this technique is for type 1 or type 2 infection but is not
appropriate to obtain the evidence oftype 3 latent infection.
Next, the authors tried immunohistochemistry and failed to
detect the cytomegalovirus antigen in MAs in their study, I
and we used the more sensitive RT-polymerase chain reac-
tion method and in situ hybridization and could detect viral
gene transcripts in IAAAs, but we also failed to detect them
in AAAs.3-S Therefore, these results between the two
groups are clearly reasonable. Recently, Kondo et al6
demonstrated that cytomegalovirus expresses sense and
antisense immediate early transcript in the latent state of
infection. This result suggests that antisense transcript par-
tially inhibits the translation ofmessenger RNA to proteins,
and it may be possible that this results in reducing the sen-
sitivity ofimmunohisto-chemistry but not affecting the sen-
sitivity of messenger RNA detection methods.
We concluded that a type 3 cytomegalovirus latent
infection is still worthwhile being studied as a candidate of
specific pathogens of inflammatory aortic diseases.
Yoshikazu Yonemitsu, MD, PhD*
Kimihiro Komori, MD, PhD
Keizo Sugimachi, MD, PhD, FACS
Department of Surgery II
Faculty of Medicine
Kyushu University
Fukuoka, Japan
Ion Transport Unit
National Heart and Lung Institute
Imperial College School of Medicine
Emmanuel Kaye Building
London, United Kingdom
REFERENCES
1. Satta J, Mosorin M, Piiiikk6 P, Juvonen T. Regarding
"Detection of active cytomegalovirus infection in inflamma-
tory aortic aneurysms with RNA polymerase chain reaction."
J Vasc Surg 1998;27:587.
2. Walker DI, Bloor K, Williams G, Gillie 1. Inflammatory
aneurysms of the abdominal aorta. Br J Surg 1972;59:609-14.
3. Yonemitsu Y, Nakagawa K, Tanaka S, Mori R, Sugimachi K,
Sueishi K. In situ detection of frequent and active infection of
human cytomegalovirus in inflammatory abdominal aortic
aneurysms: possible pathogenic role in sustained chronic
inflammatory reaction. Lab Invest 1996;74:723-36.
4. Tanaka S, Komori K, Okadome K, Sugimachi K, Mori R.
Detection of active cytomegalovirus infection in inflammato-
ry aortic aneurysms with RNA polymerase chain reaction. J
Vasc Surg 1994;20:235-43.
5. Yonemitsu Y. Viruses and vascular disease. Nature Med
1998;4:253-4.
6. Kondo K, Xu J, Mocarski E. Human cytomegalovirus latent
gene expression in granulocyte-macrophage progenitors in
culture and in healthy seropositive individuals. Proc Nat!
Acad Sci USA 1996;93:11137-42.
24/41/94661


Regarding “Detection of active cytomegalovirus infection in inflammatory aortic aneurysms with RNA polymerase chain reaction” 

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Regarding “Detection of active cytomegalovirus infection in inflammatory aortic aneurysms with RNA polymerase chain reaction”

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