Crossing of infrainguinal peripheral arterial chronic total occlusion with a blunt microdissection catheter

PURPOSE

Crossing of lower-extremity arterial chronic total occlusion (CTO) can be challenging. Use of the Viance peripheral CTO crossing device (Covidien) in the superficial femoral (SFA), popliteal, and below-the knee (BTK) arterial locations has received limited study.

METHODS

Fifty-eight patients from the Excellence in Peripheral Artery Disease (XLPAD) registry (NCT01904851) were treated between April 2010 and November 2013 with the Viance device. The procedural and 30-day clinical outcomes were collected.

RESULTS

Mean age was 65.5 ± 8.7 years and 55.1% had diabetes mellitus. Most lesions (n = 58) were TASC classification type C (n = 16; 27.6%) and D (n = 16; 27.6%), with mean lesion length 140.0 ± 71.0 mm; 93.1% of lesions were de novo and 81.0% were severely calcified. Technical success (crossing without the use of a reentry device) was achieved in 87.9% of cases and procedural success was obtained in 86.2%; 51.7% of lesions received stents, with the remaining treated with balloon angioplasty and/or atherectomy. Average fluoroscopy time was 39.1 ± 21.2 min, with 187.8 ± 72.0 mL of contrast and 210.0 ± 212.0 Gy cm² radiation dose-area product. There was 1 periprocedural complication (access-site hematoma treated conservatively without blood transfusion). At 30 days post procedure, there was significant improvement in ankle-brachial index (0.72 ± 0.30 to 0.84 ± 0.16; P=.01) and Rutherford class (3.33 ± 0.81 to 1.54 ± 1.47; P<.001). Clinically-indicated target vessel revascularization, surgical intervention or amputation at 30 days was 5.2%.

CONCLUSION

Use of Viance to cross infrainguinal arterial CTO was associated with high success, low complication rates, and significant symptom improvement.

Quantitative measurement of the nanoparticle size and number concentration from liquid suspensions by atomic force microscopy

Microscopy techniques are indispensable to the nanoanalytical toolbox and can provide accurate information on the number size distribution and number concentration of nanoparticles (NPs) at low concentrations (ca. ppt to ppb range) and small sizes (ca. <20 nm). However, the high capabilities of microscopy techniques are limited by the traditional sample preparation based on drying a small volume of suspension of NPs on a microscopy substrate. This method is limited by low recovery of NPs (ca. <10%), formation of aggregates during the drying process, and thus, the complete misrepresentation of the NP suspensions under consideration. This paper presents a validated quantitative sampling technique for atomic force microscopy (AFM) that overcomes the above-mentioned shortcomings and allows full recovery and representativeness of the NPs under consideration by forcing the NPs into the substrate via ultracentrifugation and strongly attaches the NPs to the substrate by surface functionalization of the substrate or by adding cations to the NP suspension. The high efficiency of the analysis is demonstrated by the uniformity of the NP distribution on the substrate (that is low variability between the number of NPs counted on different images on different areas of the substrate), the high recovery of the NPs up to 71%) and the good correlation (R > 0.95) between the mass and number concentrations. Therefore, for the first time, we developed a validated quantitative sampling technique that enables the use of the full capabilities of microscopy tools to quantitatively and accurately determine the number size distribution and number concentration of NPs at environmentally relevant low concentrations (i.e. 0.34-100 ppb). This approach is of high environmental relevance and can be applied widely in environmental nanoscience and nanotoxicology for (i) measuring the number concentration dose in nanotoxicological studies and (ii) accurately measuring the number size distribution of NPs; both are key requirements for the implementation of the European Commission recommendation for definition of nanomaterials.

Haemostatic effect of ecliptaalba on albino rabbits

Ecliptaalba (Bhringraj) is an important traditional Indian medicinal plant reported to have antipyretic, anti-inflammatory, antihistaminic, hepatoprotective and anthelmintic effect well documented in literature. In the present study ethanolic leaf extract of eclipta alba (EEEA) was evaluated for its haemostatic activity by their ability to affect the screening test or modify the experimentally induced prolongation of test time on the basis of its folklore claim in normal, aspirin and heparin treated rabbits. The parameters recorded were BT, CT, PT and APTT & platelet count in all the three groups. The study was carried out in 3 parts in different doses 200,400,600 & 800mg/kg. Part-A-study of the haemostatic effect of Ethanolic extract of E. alba (EEEA) in graded doses on normal rabbits. Part-B-study of EEEA in aspirin treated rabbits. Part-C-study of EEEA in heparin treated rabbits. Tranexamic acid was used as the standard drug. Statistical analysis was performed using one way ANOVA & student t test. In normal rabbits EEEA high doses 800mg/k & 600mg/kg exhibited significant reduction in BT & CT (p<0.01). The same doses were found to decrease the aspirin induced increase in BT & heparin induced increase in CT in a significant manner (p<0.01). As decrease in CT might be due to liberation of some active principles from leaves of Ecliptaalba which demonstrated to have anti-haemorrhagic activity against snake bite not affecting any coagulation factor. No significant effect on PT, APPT and platelet count was observed. EEEA exhibited definite haemostatic effect in the above 3 sets of study. Phytochemical analysis and isolation of active principle is essential to carry on beneficial effects from laboratory bench to bedside of patients.

Release and capture of bioactive oxidized phospholipids and oxidized cholesteryl esters during percutaneous coronary and peripheral arterial interventions in humans

OBJECTIVES

This study sought to assess whether oxidized lipids are released downstream from obstructive plaques after percutaneous coronary and peripheral interventions using distal protection devices.

BACKGROUND

Oxidation of lipoproteins generates multiple bioactive oxidized lipids that affect atherothrombosis and endothelial function. Direct evidence of their role during therapeutic procedures, which may result in no-reflow phenomenon, myocardial infarction, and stroke, is lacking.

METHODS

The presence of specific oxidized lipids was assessed in embolized material captured by distal protection filter devices during uncomplicated saphenous vein graft, carotid, renal, and superficial femoral artery interventions. The presence of oxidized phospholipids (OxPL) and oxidized cholesteryl esters (OxCE) was evaluated in 24 filters using liquid chromatography, tandem mass spectrometry, enzyme-linked immunosorbent assays, and immunostaining.

RESULTS

Phosphatidylcholine-containing OxPL, including (1-palmitoyl-2-[9-oxo-nonanoyl] PC), representing a major phosphatidylcholine-OxPL molecule quantitated within plaque material, [1-palmitoyl-2-(5-oxo-valeroyl)-sn-glycero-3-phosphocholine], and 1-palmitoyl-2-glutaroyl-sn-glycero-3-phosphocholine, were identified in the extracted lipid portion from all vascular beds. Several species of OxCE, such as keto, hydroperoxide, hydroxy, and epoxy cholesteryl ester derivatives from cholesteryl linoleate and cholesteryl arachidonate, were also present. The presence of OxPL was confirmed using enzyme-linked immunoassays and immunohistochemistry of captured material.

CONCLUSIONS

This study documents the direct release and capture of OxPL and OxCE during percutaneous interventions from multiple arterial beds in humans. Entrance of bioactive oxidized lipids into the microcirculation may mediate adverse clinical outcomes during therapeutic procedures.

Massive pericardial effusion as the only manifestation of primary hypothyroidism

Small pericardial effusion (PE) is not an infrequent manifestation in primary hypothyroidism. But massive PE with or without cardiac tamponade is rare and often associated with severe form of the disease. Here we report an eight-year-old boy who was admitted with massive PE that required repeated pericardiocentesis. Detailed examinations failed to identify the etiology initially. Five months later, child was readmitted with massive PE with impending cardiac tamponade. Primary hypothyroidism was diagnosed based on the clinical and laboratory finding and was thought to be the underlying etiology of previously encountered undiagnosed massive PE. Beside pericardiocentesis, child was treated with thyroid hormone replacement. Condition gradually improved without further recurrence of PE till date. Therefore, irrespective of the presence of clinical signs, primary hypothyroidism should be suspected in every patient presenting with massive PE to prevent recurrence as well as its serious complications like cardiac tamponade.

Perception of medical students about pharmacology and scope of improvement

Pharmacology is a subject taught in the medical curriculum in India over a period of one and half years along with pathology, microbiology and forensic medicine. The present study was planned to know the opinion of medical students regarding pharmacology and to assess the proposed teaching schedule and methods of teaching pharmacology. The study was conducted in a private medical college in eastern India among the medical undergraduate students in 5th semester. Total 74 students participated in the study. A pre-designed, pre-tested, semi-structured questionnaire was given to the students and data was collected after one hour. Collected data was compiled, tabulated and analyzed in SPSS (version 16.0). The subject was perceived as interesting and useful by majority of students and most of them were in opinion to integrate pharmacology with the clinical subjects. Lecture in whole class was the most preferred teaching method according to the students and teaching with chalk and board they preferred most. Rational use of medicine, clinical trial, pediatric and geriatric pharmacology are the important topics the students felt to be included in the curriculum. Regular assessment of teaching methods by the students and taking suggestions from the students about improving the teaching method and redesigning the curriculum can help a lot in improving the learning capacity of the medical students and that will give benefit for the society as a whole.

Laparoscopic and thoracoscopic gastric pull-up for pure esophageal atresia in early infancy

In the developing countries, the babies with pure esophageal atresia undergo an esophagostomy and feeding gastrostomy at birth. It assists in early discharge from hospital. Esophageal substitution in these babies around six months is recommended. We report the first laparoscopic and thoracoscopic gastric pull up in early infancy from India.

Abstract 2040: Indication switching of the FDA-approved anticancer tyrosine kinase inhibitors to treat metabolic diseases

Drug switching is a unique way to identify and extend new indications for approved drugs in drug discovery & development. Tyrosine kinase inhibitors (TKIs) are used in biologically targeted cancer therapy and so far 12 TKIs have been approved by FDA. We hypothesize that these TKIs act on other molecular targets in addition to tyrosine kinases and may manage metabolic diseases given that there is a complex network of kinases that work together to regulate a number of important cellular processes. Employing a comprehensive docking method with our established chemical-protein interactome (CPI) and 11 FDA-approved TKIs, we have discovered301 PDB-deposited proteins corresponding to 353 ligand binding pockets among a total of 1,780 PDB-deposited human protein entries. Notably, sorafenib, dasatinib and crizotinib had a CPI binding score (ZZ_score) of -1.2903, -1.0278 and -1.5384 against histone deacetylase 7A, respectively. In addition, those TKIs achieved high ZZ scores against B-Raf, PPAR and VDR, suggesting a high binding affinity of sorafenib, dasatinib and crizotinib with these proteins. Our preliminary studies have showed that the acetylated-lysine in α-tublin and oncogenic Akt and Raf-signaling was inhibited significantly in human multiple melanoma cells by these TKIs. Interestingly, dasatinib increased VDRE and HDLR luciferase reporter activity in the human lung adenocarcinoma A-549 cells, and dasatinib and crizotinib induced autophage by activated LC3 in vitro. Furthermore, the erlotinib and sorafenib decreased glucose levels in Wistar STZ-D rats. These TKIs are predicted to act on a series of therapeutics targets associated with metabolic diseases (such as PPAR and Sirt1). Collectively, FDA-approved TKIs may be switched to become a “magic bullet” concurrently targeting tyrosine kinase, HDAC, PPAR, VDR and B-Raf, shedding a light for future anti-metabolic disorder and anticancer drug discovery & development. Further validation of additional “hot targets” besides tyrosine kinase such as HDAC, B-Raf, PPAR, Sirt1, Akt and VDR, and in vivo evaluation of anti-metabolic disorder by TKIs are undergoing at our laboratory. These findings suggest that drug switching may represent a new and effective approach to expanding the application of existing drugs.

Citation Format: Jiazhi Sun, Lun Yang, Minghua Li, Zhixin Wang, Amy Haynes, Qian Wang, Isaac Raplee, Jean Melchisedek, Anand Prasad, Kevin B. Sneed, Lin He, Shufeng Zhou. Indication switching of the FDA-approved anticancer tyrosine kinase inhibitors to treat metabolic diseases. [abstract]. In: Proceedings of the 104th Annual Meeting of the American Association for Cancer Research; 2013 Apr 6-10; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2013;73(8 Suppl):Abstract nr 2040. doi:10.1158/1538-7445.AM2013-2040

The use of the Trellis-6 thrombectomy device in the management of acute limb ischemia due to native vessel occlusion: challenges, tips, and limitations

The role of endovascular therapy is expanding in the treatment of acute limb ischemia (ALI). In addition to catheter-based thrombolysis, there are multiple devices which allow for clot disruption and aspiration. The Trellis catheter system provides mechanical agitation of thrombus coupled with chemical thrombolysis. We present two cases of native arterial occlusions in which the Trellis catheter was used for thrombolysis. Procedural tips and challenges associated with the use of this device in native vessels are discussed.

Cardiovascular effects of 1 year of progressive endurance exercise training in patients with heart failure with preserved ejection fraction

BACKGROUND

Heart failure with preserved ejection fraction (HFpEF) is a disease of the elderly with cardiovascular stiffening and reduced exercise capacity. Exercise training appears to improve exercise capacity and cardiovascular function in heart failure with reduced ejection fraction. However, it is unclear whether exercise training could improve cardiovascular stiffness, exercise capacity, and ventricular-arterial coupling in HFpEF.

METHODS

Eleven HFpEF patients and 13 healthy controls underwent invasive measurements with right heart catheterization to define Starling and left ventricular (LV) pressure-volume curves; secondary functional outcomes included Doppler echocardiography, arterial stiffness, cardiopulmonary exercise testing with cardiac output measurement, and ventricular-arterial coupling assessed by the dynamic Starling mechanism. Seven of 11 HFpEF patients (74.9 ± 6 years; 3 men/4 women) completed 1 year of endurance training followed by repeat measurements. Pulmonary capillary wedge pressures and LV end-diastolic volumes were measured at baseline during decreased and increased cardiac filling. LV compliance was assessed by the slope of the pressure-volume curve. Beat-to-beat LV end-diastolic pressure (estimated from pulmonary arterial diastolic pressure) and stroke volume index were obtained, and spectral transfer function analysis was used to assess the dynamic Starling mechanism.

RESULTS

Before training, HFpEF patients had reduced exercise capacity, distensibility and dynamic Starling mechanism but similar LV compliance and end-diastolic volumes compared to controls albeit with elevated filling pressure and increased wall stress. One year of training had little effect on LV compliance and volumes, arterial stiffness, exercise capacity or ventricular-arterial coupling.

CONCLUSION

Contrary to our hypothesis, 1 year of endurance training failed to impart favorable effects on cardiovascular stiffness or function in HFpEF.

Differential expression of oxidation-specific epitopes and apolipoprotein(a) in progressing and ruptured human coronary and carotid atherosclerotic lesions

The relationships between oxidation-specific epitopes (OSE) and lipoprotein (a) [Lp(a)] and progressive atherosclerosis and plaque rupture have not been determined. Coronary artery sections from sudden death victims and carotid endarterectomy specimens were immunostained for apoB-100, oxidized phospholipids (OxPL), apo(a), malondialdehyde-lysine (MDA), and MDA-related epitopes detected by antibody IK17 and macrophage markers. The presence of OxPL captured in carotid and saphenous vein graft distal protection devices was determined with LC-MS/MS. In coronary arteries, OSE and apo(a) were absent in normal coronary arteries and minimally present in early lesions. As lesions progressed, apoB and MDA epitopes did not increase, whereas macrophage, apo(a), OxPL, and IK17 epitopes increased proportionally, but they differed according to plaque type and plaque components. Apo(a) epitopes were present throughout early and late lesions, especially in macrophages and the necrotic core. IK17 and OxPL epitopes were strongest in late lesions in macrophage-rich areas, lipid pools, and the necrotic core, and they were most specifically associated with unstable and ruptured plaques. Specific OxPL were present in distal protection devices. Human atherosclerotic lesions manifest a differential expression of OSEs and apo(a) as they progress, rupture, and become clinically symptomatic. These findings provide a rationale for targeting OSE for biotheranostic applications in humans.

Successful management of lower extremity distal embolization following percutaneous atherectomy with the JetStream G3 device

There has been a resurgence of atherectomy as a strategy to treat peripheral atherosclerosis. Distal embolization occurs frequently during peripheral endovascular interventions but is of particular concern during atherectomy. We describe a case of distal embolization following atherectomy with the Pathway JetStream system successfully managed with aspiration thrombectomy and infrapopliteal angioplasty. A detailed review of the incidence, treatment, and prevention of DE in this context are presented.

Proposed Mayo Clinic criteria for the diagnosis of Tako-Tsubo cardiomyopathy and long-term prognosis

Tako-Tsubo cardiomyopathy (TTC) is a reversible cardiomyopathy with a clinical presentation indistinguishable from myocardial infarction. TTC is estimated to represent 1%-2% of patients presenting with acute myocardial infarction. It most commonly occurs in postmenopausal women and is frequently precipitated by a stressful event. Chest pain and dyspnea are the typical presenting symptoms. Transient ST-segment elevation on ECG and a small rise in cardiac biomarkers are common. Characteristic wall motion abnormalities extend beyond the territory of a single epicardial coronary artery in the absence of obstructive coronary lesions. Supportive treatment leads to spontaneous rapid recovery in nearly all patients. The prognosis is excellent, and recurrence occurs in < 10% of patients. In this article, we review the clinical features of TTC that form the basis of the Mayo Clinic diagnostic criteria, as well as the long-term prognosis for this type of cardiomyopathy.

Distinguishing dynamics using recurrence-time statistics

The probability densities of the mean recurrence time, which is the average time needed for a system to recur to a previously visited neighborhood, are investigated in various dynamical regimes and are found to be in agreement with those of the finite-time Lyapunov exponents. The important advantages of the former ones are that they are easy to estimate and that comparable short time series are sufficient. Asymmetric distributions with exponential tails are observed for intermittency and crisis-induced intermittency, while for typical chaos, the distribution has a Gaussian shape. Further, the shape of the distribution distinguishes intermittent strange nonchaotic attractors from those appearing through fractalization and tori collision mechanisms. Furthermore, statistics performed on the peaks in the frequency distribution of recurrence times unveil scaling behavior in agreement with that obtained from the spectral distribution function defined as the number of peaks in the Fourier spectrum greater than a predefined value. The results of the present recurrence statistics are of relevance in classifying different dynamics and providing important insights into the dynamics of a system when only one realization of this system is available. The practical use of this approach for experimental data is shown on experimental electrochemical time series.