The use of andexanet alpha in the Polish setting: An interdisciplinary protocol. Expert consensus statement of the Polish Cardiac Society

Andexanet alfa (AA) is a recombinant inactive analog of human activated factor X (FXa), effectively reversing the effects of its inhibitors - rivaroxaban and apixaban, which are available in Poland. The drug was approved for clinical use registration after the publication of the results of the ANNEXA-4 trial (Andexanet Alfa, a Novel Antidote to the Anticoagulation Effects of FXa Inhibitors 4), in which its efficacy in restoring hemostasis in life-threatening hemorrhages in patients receiving using the aforementioned anticoagulants was demonstrated. Hence, AA is now recommended for patients on apixaban or rivaroxaban therapy with massive and uncontrollable hemorrhages, including hemorrhagic strokes (HS) and gastrointestinal bleeding. Drug-specific chromogenic anti-Xa assays are generally best suited for estimating rivaroxaban and apixaban plasma levels, aside from direct assessment of their concentrations. The absence of anti-Xa activity, determined using these assays, allows us to rule out the presence of clinically relevant plasma concentrations of any FXa inhibitor. On the other hand, the dose of AA should not be modified based on the results of coagulation tests, as it depends solely on the time that elapsed since the last dose of FXa inhibitor and oon the dose and type of FXa inhibitor. AA is administered as an intravenous (i.v.) bolus, followed by an i.v. infusion of the drug. The maximum reversal of anti-Xa activity occurs within two minutes of the end of the bolus treatment, with the continuation of the continuous i.v. infusion allowing the effect to be maintained for up to two hours afterwards. Because anticoagulant activity can reappear after the infusion is completed, it is currently unclear at what point after AA administration FXa inhibitors or heparin should be re-administered. In Poland AA is starting to become available and its urgent need to administer it to patients with severe bleeding on apixaban or rivaroxaban.

The Dilemma after Sealing an Endovascular Aortic Aneurysm - Three Ways Out

INTRODUCTION

Endovascular aneurysm sealing (EVAS) was commercially introduced in 2013. The initial results of EVAS were positive, leading to its widespread use. The mid- and long-term reports showed greater than expected rates of migration, which led to a recall of the device. In the present article, we describe our experience in managing type Ia endoleaks and migration occurring with the Nellix system in three different ways: open repair with Nellix explantation, Nellix-in-Nellix application (NINA technique), and the use of the multibranched Colt device originally dedicated to the treatment of thoracoabdominal aneurysms.

MATERIALS AND METHODS

From February 2014 to June 2021, we performed 20 procedures for failed EVAS or ChEVAS (migration, type Ia endoleak, secondary aneurysm rupture). All patients treated for EVAS failure were male, aged 65 - 79.

RESULTS

Seven Nellix explantations were performed. Three patients were admitted to our hospital with ruptured aneurysms that occurred 3 weeks to 4 years (mean 124 weeks) after EVAS, and another four with type Ia endoleak. In all but one case, removal of the Nellix system was easy. In two patients, tube grafts were implanted and in the remaining five cases, bifurcated grafts were implanted. In four patients, graft legs were anastomosed with the internal iliac arteries. One patient with secondary aneurysm rupture died from multiorgan failure on the 4th postoperative day. In two cases, transient renal failure was noticed in the perioperative period. All patients were admitted to the intensive care unit for 1 to 4 days (mean 2 days). The mean hospital stay was 9 days. All patients stayed in follow-up (3 - 56 months), but no other complications occurred. Eight patients were treated with the NINA technique: five for distal migration of the Nellix and three for failed ChEVAS. Four patients had a NINA procedure performed with three chimneys, three with two and one with one chimney. In one case, two iliac limbs were implanted to avoid kinking of the external iliac arteries. The median hospitalization time after the procedure was 9 days (range 3 - 12). Four patients developed transient acute renal insufficiency in the perioperative period. The follow-up ranged between 4 and 72 months. In one patient, deterioration of preexisting chronic renal insufficiency developed 5 months after the procedure, but dialysis was not required. One patient died from exacerbation of heart failure 7 months after the NINA procedure. The Colt device was implanted in five patients for the treatment of distal migration with type Ia endoleaks. None of the patients developed any signs of spinal cord ischemia. All patients were admitted to the intensive care unit for 1 or 2 days. In two cases, transient acute renal failure was noticed in the perioperative period. The mean hospital stay was 9 days. All patients remained in follow-up (6 - 22 months). In one case, the occlusion of the celiac trunk branch was found in contrast computed tomography 1 month after implantation of the Colt device, but without any symptoms. No other complications occurred.

CONCLUSIONS

Normal strategies for the management of complications for late failure of EVAR, including stent-graft extensions, are not suitable after EVAS; therefore, alternatives are necessary. Conversion to open repair carries an extensive burden on the patient, so it is not recommended for patients with high surgical risk. The use of a Nellix-in-Nellix application to treat late failure of EVAS is not within the instructions for use but could be an effective strategy for a type Ia endoleak with or without migration. The use of this technique has been extremely limited since the Nellix system was recalled from the market. The use of the Colt multibranched device may be an alternative option, but due to the small number of patients, this method needs further evaluation.

Impact of the coronavirus disease 2019 (COVID-19) pandemic on the care of patients with acute and chronic aortic conditions

OBJECTIVES

To evaluate the impact of the coronavirus disease 2019 (COVID-19) pandemic on acute and elective thoracic and abdominal aortic procedures.

METHODS

Forty departments shared their data on acute and elective thoracic and abdominal aortic procedures between January and May 2020 and January and May 2019 in Europe, Asia and the USA. Admission rates as well as delay from onset of symptoms to referral were compared.

RESULTS

No differences in the number of acute thoracic and abdominal aortic procedures were observed between 2020 and the reference period in 2019 [incidence rates ratio (IRR): 0.96, confidence interval (CI) 0.89-1.04; P = 0.39]. Also, no difference in the time interval from acute onset of symptoms to referral was recorded (<12 h 32% vs > 12 h 68% in 2020, < 12 h 34% vs > 12 h 66% in 2019 P = 0.29). Conversely, a decline of 35% in elective procedures was seen (IRR: 0.81, CI 0.76-0.87; P < 0.001) with substantial differences between countries and the most pronounced decline in Italy (-40%, P < 0.001). Interestingly, in Switzerland, an increase in the number of elective cases was observed (+35%, P = 0.02).

CONCLUSIONS

There was no change in the number of acute thoracic and abdominal aortic cases and procedures during the initial wave of the COVID-19 pandemic, whereas the case load of elective operations and procedures decreased significantly. Patients with acute aortic syndromes presented despite COVID-19 and were managed according to current guidelines. Further analysis is required to prove that deferral of elective cases had no impact on premature mortality.

Results of endovascular aortic arch repair using the Relay Branch system

OBJECTIVES

Our goal was to evaluate results of endovascular aortic arch repair using the Relay Branch system.

METHODS

Forty-three patients with thoracic aortic pathology involving the aortic arch have been treated with the Relay Branch system (Terumo Aortic, Sunrise, FL, USA) in 10 centres. We assessed in-hospital mortality, neurological injury, treatment success according to current reporting standards and the need for secondary interventions. In addition, outcome was analysed according to the underlying pathology: non-dissective disease versus residual aortic dissection (RAD) (defined as remaining dissection after previous type A repair, chronic type B aortic dissections).

RESULTS

In-hospital mortality was 9% (0% in patients with RAD). Disabling stroke occurred in 7% (0% in patients with RAD); non-disabling stroke occurred in 19% (7% in patients with RAD). Early type IA and B endoleak formation occurred in 4%. Median follow-up was 16 ± 18 months. During the follow-up period, 23% of the patients died. Aortic-related deaths were low (3% in patients with RAD).

CONCLUSIONS

The results of endovascular aortic arch repair using the Relay Branch system in a selected patient population with regard to technical success are good. In-hospital mortality is acceptable, the number of disabling strokes is low and technical success is high. Non-disabling stroke is a major concern, and every effort has to be taken to reduce this to a minimum. The best outcome is seen in patients with underlying RAD. Finally, more data are needed.

Replacement of infected aortoiliac vascular grafts with bifurcated BioIntegral Surgical No-React® bovine pericardial xenografts

The infection of a vascular prosthesis is potentially fatal, and its effective treatment still remains the greatest challenge for vascular surgeons. We present our initial experience using bovine pericardial vascular prostheses to replace infected aortoiliac vascular grafts. Six consecutive patients with infection of the graft were prospectively included in this study. Infection of the vascular graft was confirmed by clinical symptoms, laboratory tests and the results of computed tomography and positron emission tomography/computed tomography. In all cases, the infected aortoiliac graft was surgically removed and replaced by the bovine-pericardial BioIntegral aortic-bifemoral prosthesis. Technical success was achieved in every case with no in-hospital or 30 days mortality. One patient required revision of distal anastomosis due to recurrent bleeding at day four after surgery. One patient presented with upper gastrointestinal tract bleeding during the postoperative period, which was managed endoscopically. The mean hospital stay was 14 days (range 9-19). The control CT scan performed 2 months after surgery showed significant regression of abscesses and periprosthetic inflammation. Two patients died within 32 months of follow-up: one due to heart attack, the other due to generalized sepsis, which was correlated with the previous infection. Four patients are still in follow-up. The BioIntegral prosthesis is patent in all four cases, with no clinical or ultrasonographic signs of infection. Our brief investigation shows that a bovine pericardial prosthesis may be a valuable option in the treatment of vascular grafts infections.

Prospective study of the E-liac Stent Graft System in patients with common iliac artery aneurysms: 30-Day results

OBJECTIVES

To study the safety and feasibility of the E-liac Stent Graft System® in patients with aorto/iliac aneurysms.

METHODS

A prospective multicentric European registry of patients receiving the E-liac Stent Graft System® was conducted. Endpoints of the study included the technical success as well as periprocedural events and 30-day endoleaks, reinterventions, internal and external iliac artery patency and mortality.

RESULTS

Between July 2014 and June 2016, a total of 45 patients (93% men, mean age 72 years, range 53-90 years) were enrolled at 11 sites in four European countries. Five patients received an isolated iliac treatment. Thirty-seven patients were treated with a combination of an abdominal stent graft and a unilateral E-liac and three in combination with bilateral E-liac. All E-liac Stent Grafts (48) were implanted in the intended position and the internal iliac arteries were successfully bridged. Two patients did not receive clinical success, due to endoleak type Ia of the aortic stent graft. At 30-day follow-up, clinical success rate was 96%. Three successful endovascular reinterventions were performed within the 30-day follow-up: one due to a type Ia endoleak in the common iliac artery, one due to type Ia endoleak of the aortic stent graft, and one due to bilateral lower limb claudication provoked by stent graft limb stenosis. At 30-day, a 100% survival rate and complete absence of pelvic or buttock ischemia/claudication were reported. Primary patency at 30 days was 100% for the internal iliac artery and 98% for the external iliac artery with an assisted patency of 100% in the latter.

CONCLUSIONS

The high clinical success rate, low rates of device-related reinterventions (2%), and excellent patency rate demonstrate the safety and feasibility of the E-liac Stent Graft System. Long-term results are awaited to state efficacy and durability. Clinical Trials.gov. Identifier no. NCT02209194.

Percutaneous thrombin injection to complete SMA pseudoaneurysm exclusion after failing of endograft placement

Visceral aneurysms are potentially life-threatening vascular lesions. Superior mesenteric artery (SMA) pseudoaneurysms are a rare but well-recognized complication of chronic pancreatitis. Open surgical repair of such an aneurysm, especially in patients after previous surgical treatment, might be dangerous and risky. Stent graft implantation makes SMA pseudoaneurysm exclusion possible and therefore avoids a major abdominal operation. Percutaneous direct thrombin injection is also one of the methods of treating aneurysms in this area. We report a first case of percutaneous ultrasound-guided thrombin injection to complete SMA pseudoaneurysm exclusion after an unsuccessful endograft placement. Six-month follow-up did not demonstrate any signs of aneurysm recurrence.

A Series of 15 Patients with Extracranial Carotid Artery Aneurysms: Surgical and Endovascular Treatment

OBJECTIVES

This is a retrospective review of 15 patients with primary and secondary aneurysms of extracranial carotid arteries treated surgically and endoluminally over 20 years in one centre.

PATIENTS AND METHODS

Fifteen aneurysms of extracranial carotid arteries were noticed in the same number of patients: five atherosclerotic, two after previous carotid surgery, six post-traumatic, one inflammatory, one of unknown etiology. All of them were symptomatic.

RESULTS

In the group treated surgically some complications occurred in the perioperative time: one haematoma, two transient neurological deficits, one fatal stroke. In the endovascular group of patients no complications occurred after the treatment. One fatal stroke occurred during operation-the patient died on the 43rd postoperative day due to respiratory insufficiency. Two other deaths occurred during the follow-up: one caused by myocardial infarction 10 years after the aneurysm resection, and the second due to a fatal stroke 3 years after aneurysmorraphy. One patient refused treatment and died 9 months after being diagnosed.

CONCLUSION

Neurological deficits in patients after neck injuries should arouse the suspicion of the presence of a carotid artery aneurysm. Open repair remains the method of choice in treating carotid artery aneurysms but endovascular procedures create the possibility of treating extracranial aneurysms in selected cases when open surgery is not recommended.

[New possibilities in treatment of atherosclerosis--increase of nitric oxide synthesis by L-arginine supplementation]

Diseases such as heart attack, stroke or critical atherosclerotic leg ischaemia are very common in the developed countries. It is estimated that they are the main cause of deaths in the age group over 40 years. Patients with advanced leg ischaemia can be treated surgically. However in distal disseminated occlusions, surgery is technically impossible. In such cases amputation is the treatment of choice, but postoperative death ratio in this group is still high. That is why new ways of atherosclerosis treatment are needed. Progress in vascular biology brings new methods of treatment. Discovering of vasodilatory effect of nitric oxide makes us seek for ways of increasing its endogenous synthesis in endothelium of blood vessels. Studies on angiogenic cytokine application, amplification of NO synthesis expression and other gene engineering techniques are carried out in order to increase the concentration of nitric oxide in endothelium. It has been found that an increase of nitrix oxide synthesis can be achieved by administering L-arginine. Numerous trials suggest that supplementation of this amino acid can be of great therapeutic importance in patients with various atherosclerotic diseases. Clinical effectiveness of L-arginine is comparable to conventional pharmacotherapy. It seems that in the near future L-arginine supplementation may contribute to better results of atherosclerosis treatment.

Increased local vascular endothelial growth factor expression associated with antitumor activity of proteasome inhibitor

Inhibition of the proteasome, a multicatalytic proteinase complex, is an attractive approach to cancer therapy. Here we report that a selective inhibitor of the chymotrypsin-like activity of the proteasome, PSI (N-benzyloxycarbonyl-Ile-Glu(O-t-butyl)-Ala-leucinal) may inhibit growth of solid tumors not only through apoptosis induction, but also indirectly--through inhibition of angiogenesis. Two murine tumors: colon adenocarcinoma (C-26) and Lewis lung carcinoma (3LL) were chosen to study the antitumor effect of PSI. In an in vivo model of local tumor growth, PSI exerted significant antitumor effects against C-26 colon carcinoma, but not against 3LL lung carcinoma. Retardation of tumor growth was observed in mice treated with both 10 nmoles and 100 nmoles doses of PSI and in the latter group prolongation of the survival time of tumor-bearing mice was observed. PSI inhibited angiogenesis in the C-26 growing tumors with no such effect in 3LL tumors. Unexpectedly, that activity was associated with upregulation of vascular endothelial growth factor (VEGF) at the level of mRNA expression and protein production in C-26 tumors treated with PSI. C-26 cells treated with PSI produced increased amounts of VEGF in vitro in a dose- and time-dependent manner. We demonstrated that in C-26 colon adenocarcionoma higher VEGF production may render endothelial cells susceptible to the proapoptotic activity of PSI and is associated with inhibition of tumor growth.

Effects of the combination of a proteasome inhibitor (PSI) and an inhibitor of ubiquitin-ligases (Leu-Ala) on the ultrastructure of human leukemic U937 cells

We have used the dipeptide Leu-Ala in an attempt to prevent the formation of ubiquitin-protein conjugates in U937 cells by inhibition of cellular E3 enzymes (ubiquitin ligases). Proteasome inhibitors induce the formation of perinuclear aggregates of ubiquitinated proteins and proteasomes (aggresomes) in the area of the proteolytic center of the cell. Leu-Ala did not prevent the forrmation of those aggregates under the action of PSI (peptidyl aldehyde, selective inhibitor of the chymotrypsin-like activity of the proteasome), however it induced an accumulation of lipid droplets in treated cells, suggesting a previously unknown involvement of Leu-Ala in lipid metabolism. We conclude, that either Leu-Ala is not able to completely inhibit the cellular E3 enzymes or some of those enzymes are insensitive to this dipeptide, allowing therefore the build-up of ubiquitin-conjugates in the proteolytic centre of the cell.

Effects of proteasome inhibitor PSI on neoplastic and non-transformed cell lines

In this study we compared the sensitivity of different human and murine cell lines varying in the stage of transformation to dose- and time-dependent cytostatic and/or cytotoxic effects of PSI (a selective proteasome inhibitor), measured by a standard MTT assay. It was found that intensively proliferating cell lines were more sensitive to very small doses of PSI after 24 h incubation than the slow proliferating ones. Non-transformed cell lines showed no sensitivity to PSI, as there was no difference in cell viability in comparison with the control group even after 72 h incubation.

Effects of an inhibitor of tripeptidyl peptidase II (Ala-Ala-Phe-chloromethylketone) and its combination with an inhibitor of the chymotrypsin-like activity of the proteasome (PSI) on apoptosis, cell cycle and proteasome activity in U937 cells

AAF-AMC is not a specific TPP II substrate, since it is also hydrolyzed by purified proteasomes. Moreover, AAF-cmk, claimed to be a specific TPP II inhibitor, also inhibits the chymotrypsin-like activity of the proteasome. While AAF-cmk itself is mildly cytostatic to U-937 cells and induces cell cycle block in G1, its combination with PSI does not induce an increase in the cytostatic/cytotoxic effects. This suggests that TPP II is possibly less important for cell metabolism than it was previously believed and it is less probable that it can be able to fully compensate for the loss of the proteasome function.

Lovastatin and simvastatin are modulators of the proteasome

Lovastatin and simvastatin are HMG-CoA reductase inhibitors widely used as antihyperlipidemic drugs, which also display antiproliferative properties. In the present paper, we provide evidence that both lovastatin and simvastatin are modulators of the purified bovine pituitary 20 S proteasome, since they mildly stimulate the chymotrypsin-like activity and inhibit the peptidylglutamylpeptide hydrolyzing activity without interfering with the trypsin-like activity. However, those effects are only observed when the closed ring forms of the drugs are used, while the opened ring form of lovastatin acts as a mild inhibitor of the chymotrypsin like activity. The closed ring form of lovastatin is much more potent as a cytotoxic agent on the Colon-26 (C-26) colon carcinoma cell line than the opened ring form, which is only mildly cytostatic. Moreover, neither the cytotoxic effects nor the effects on 20 S proteasome activities are prevented by mevalonate, which by itself inhibits the trypsin-like activity of the proteasome. Neither the opened ring nor the closed ring form of lovastatin induces an accumulation of ubiquitin-protein conjugates, which is observed after treatment with lactacystin, a selective proteasome inhibitor. In contrast with the opened ring form of lovastatin, the closed ring form induces the disappearance of detectable p27(kip1) from C-26 cells. Altogether, our results indicate that the closed ring form of lovastatin induces cytotoxic effects independent of its HMG-CoA inhibiting activity, however, those effects are mediated by a complex modulation of proteasome activity rather than by inhibition of the 20 S proteasome.