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Rigsby DC, Clark TWI, Vance AZ, Chittams J, Cohen R, Mantell MP, Kobrin S, Trerotola SO. Percutaneous Management of Dialysis Access Steal Syndrome: Interventions and Outcomes from a Single Institution's 20-Year Experience. J Vasc Interv Radiol 2024; 35:601-610. [PMID: 38171415 DOI: 10.1016/j.jvir.2023.12.566] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 12/21/2023] [Accepted: 12/23/2023] [Indexed: 01/05/2024] Open
Abstract
PURPOSE To determine safety and effectiveness of percutaneous interventions performed by interventional radiologists at a single institution over 2 decades in patients with dialysis access steal syndrome (DASS). MATERIALS AND METHODS A retrospective review of fistulograms from 2001 to 2021 (N = 11,658) was performed. In total, 286 fistulograms in 212 patients with surgically created dialysis accesses met inclusion criterion of fistulography for suspected DASS. Chart review collected data regarding patient demographics, comorbidities, access characteristics, fistulography findings, intervention(s) performed, and outcomes. Procedures with and without DASS intervention were compared. Odds ratios (ORs), adjusted for age, sex, comorbidities, access characteristics, and multiple within-patient events, were calculated using logistic regression to determine associations between steal intervention status and outcome variables: (a) major adverse events, (b) access preservation, and (c) follow-up surgery. A percutaneously treatable cause of DASS was present in 128 cases (45%). Treatment of DASS lesions was performed in 118 cases. Fifteen embolizations were also performed in patients without DASS lesions. RESULTS Technical success of DASS interventions, defined by the Society of Interventional Radiology (SIR) reporting standards, was 94%; 54% of interventions resulted in DASS symptom improvement at a median follow-up of 15 days. Patients with steal intervention had 60% lower odds of follow-up surgery (OR, 0.4; P = .007). There was no difference in major adverse events (P = .98) or access preservation (P = .13) between groups. CONCLUSIONS In this retrospective cohort study, approximately half of DASS fistulograms revealed a percutaneously treatable cause of steal. Over half of DASS interventions resulted in symptomatic relief. Percutaneous intervention was associated with lower odds of follow-up surgery without compromising access preservation.
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Affiliation(s)
- Devyn C Rigsby
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Timothy W I Clark
- Department of Radiology, Division of Interventional Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ansar Z Vance
- Department of Radiology, Division of Interventional Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jesse Chittams
- Biostatistics Consulting Unit, Office of Nursing Research, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania
| | - Raphael Cohen
- Department of Medicine, Division of Renal, Electrolyte, and Hypertension, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Mark P Mantell
- Department of Surgery, Penn Presbyterian Medical Center, Philadelphia, Pennsylvania
| | - Sidney Kobrin
- Department of Medicine, Division of Renal, Electrolyte, and Hypertension, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Scott O Trerotola
- Department of Radiology, Division of Interventional Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.
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Moawad S, Vance AZ, Cobb RM, Mantell MP, Cohen R, Clark TWI. Radiofrequency guidewire-facilitated recanalization of chronic thoracic central venous occlusions in hemodialysis patients. CVIR Endovasc 2024; 7:10. [PMID: 38214823 PMCID: PMC10786812 DOI: 10.1186/s42155-023-00422-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Accepted: 12/19/2023] [Indexed: 01/13/2024] Open
Abstract
PURPOSE To assess the outcome and safety of radiofrequency (RF) wire recanalization in patients with end-stage renal disease (ESRD) and chronic central venous occlusions (CVO). MATERIALS AND METHODS A retrospective review of ESRD patients who underwent RF-wire recanalization of symptomatic chronic thoracic CVO from January 2017 to August 2022 yielded 20 patients who underwent 21 procedures. All patients had undergone at least one prior unsuccessful attempt at central venous recanalization using conventional catheter-based techniques. Technical success was defined by the ability to cross the CVO using RF-wire recanalization enabling endovascular treatment. Access circuit patency was evaluated based on follow-up imaging and symptomatic improvement. RESULTS Radiofrequency wire recanalization was successful in 17/21 procedures (81%) with all patients (100%) reporting resolution of arm ± facial swelling. Three major complications occurred (14%): two hemothoraces and one hemopericardium. Medial stent diameter was 13 mm (range, 9-14 mm). Mean duration of hospital stay was 2 days ± 3 days. Mean procedure time was 158 ± 46 min with a mean fluoroscopy time of 31.7 ± 16.3 min. Primary unassisted patency at 6 and 12 months was 94 ± 6% and 85 ± 10%, respectively. Additional interventions resulted in significantly increased stent graft patency (P = 0.006). CONCLUSION Radiofrequency wire-enabled recanalization of CVO in symptomatic dialysis patients has a high rate of technical success with resolution of arm and facial swelling and resumed use of the ipsilateral dialysis access. Although a superior safety profile was seen than with needle-based techniques such as sharp recanalization, major complications were not infrequent indicating that this RF-wire procedure should be performed in centers equipped to manage central venous perforations.
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Affiliation(s)
- Sherif Moawad
- Section of Interventional Radiology, Department of Radiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Ansar Z Vance
- Section of Interventional Radiology, Department of Radiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Ryan M Cobb
- Section of Interventional Radiology, Department of Radiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Mark P Mantell
- Division of Vascular Surgery, Department of Surgery, Penn Presbyterian Medical Center, University of Pennsylvania, Philadelphia, PA, USA
| | - Raphael Cohen
- Division of Nephrology, Department of Medicine, Penn Presbyterian Medical Center, University of Pennsylvania, Philadelphia, PA, USA
| | - Timothy W I Clark
- Section of Interventional Radiology, Department of Radiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.
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Babore Y, Vance AZ, Cohen R, Mantell MP, Levin LS, Troiano M, Peacock A, Reddy S, Clark TWI. Association between End-Stage Renal Disease and Major Adverse Limb Events after Peripheral Vascular Intervention. J Vasc Interv Radiol 2024; 35:15-22.e2. [PMID: 37678752 DOI: 10.1016/j.jvir.2023.06.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Revised: 05/30/2023] [Accepted: 06/15/2023] [Indexed: 09/09/2023] Open
Abstract
PURPOSE To examine the effect of end-stage renal disease (ESRD) on the likelihood of major adverse limb events (MALEs) in patients with Rutherford Category 4-6 critical limb ischemia (CLI) who underwent percutaneous vascular intervention (PVI). MATERIALS AND METHODS Two contemporaneous cohorts of patients who underwent PVI for symptomatic CLI from 2012 to 2022, differing in ESRD status, were matched using propensity score methods. This database identified 628 patients who underwent 1,297 lower extremity revascularization procedures; propensity score matching yielded 147 patients (180 limbs, 90 limbs in each group). Kaplan-Meier and Cox proportional hazard analyses were used to assess the effect of ESRD status on MALEs, stratified into major amputation (further stratified into above-knee amputation and below-knee amputation [BKA]) and reintervention (PVI or bypass). RESULTS After PVI, 31.3% of patients in the matched cohorts experienced a MALE (45.7% ESRD vs 18.2% non-ESRD), and 15.6% experienced a major amputation (27.1% ESRD vs 5.2% non-ESRD). Cox proportional hazards analysis revealed that ESRD was an independent predictor of MALE (hazard ratio [HR], 3.15; 95% CI, 1.58-6.29; P = .001), major amputation (HR, 7.00; 95% CI, 2.06-23.79; P = .002), and BKA (HR, 7.56; 95% CI, 1.71-33.50; P = .008). CONCLUSIONS ESRD is strongly predictive of MALE and major amputation risk, specifically BKA, in patients undergoing PVI for Rutherford Category 4-6 CLI. These patients warrant closer follow-up, and new methods may become necessary to predict and further reduce their amputation risk.
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Affiliation(s)
- Yonatan Babore
- Division of Interventional Radiology, Department of Radiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ansar Z Vance
- Division of Interventional Radiology, Department of Radiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Raphael Cohen
- Division of Nephrology, Department of Medicine, Penn Presbyterian Medical Center, Philadelphia, Pennsylvania
| | - Mark P Mantell
- Division of Vascular Surgery, Department of Surgery, Penn Presbyterian Medical Center, Philadelphia, Pennsylvania
| | - L Scott Levin
- Departments of Orthopedics and Plastic Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Michael Troiano
- Division of Foot and Ankle Surgery, Department of Orthopedics, Penn Presbyterian Medical Center, Philadelphia, Pennsylvania
| | - Andrew Peacock
- Division of Foot and Ankle Surgery, Department of Orthopedics, Penn Presbyterian Medical Center, Philadelphia, Pennsylvania
| | - Shilpa Reddy
- Division of Interventional Radiology, Department of Radiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Timothy W I Clark
- Division of Interventional Radiology, Department of Radiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania.
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Stoecker JB, Li X, Clark TWI, Mantell MP, Trerotola SO, Vance AZ. Dialysis Access-Associated Steal Syndrome and Management. Cardiovasc Intervent Radiol 2023; 46:1168-1181. [PMID: 37225970 DOI: 10.1007/s00270-023-03462-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Accepted: 05/01/2023] [Indexed: 05/26/2023]
Abstract
Dialysis-associated steal syndrome (DASS) occurs in 1-8% of hemodialysis patients with arteriovenous (AV) access. Major risk factors include use of the brachial artery for access creation, female sex, diabetes, and age > 60 years. DASS carries severe patient morbidity including tissue or limb loss if not recognized and managed promptly, as well as increased mortality. Diagnosis of DASS requires a directed history and physical exam supported by non-invasive testing. Prior to definitive therapy, detailed arteriography, fistulography, and flow measurements are performed to delineate underlying etiologies and guide management. To optimize success, DASS treatment should be individualized according to access location, underlying vascular disease, flow dynamics, and provider expertise. Possible causes of DASS include extremity inflow or outflow arterial occlusive disease, high AV access flow rate, and reversal of distal extremity arterial blood flow; DASS may also exist without any of the prior features. Depending on the DASS etiology, various endovascular and/or surgical interventions should be considered. Regardless, in the majority of patients presenting with DASS, access preservation can be achieved.
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Affiliation(s)
- Jordan B Stoecker
- Division of Vascular Surgery, Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Xin Li
- Division of Interventional Radiology, Department of Radiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Timothy W I Clark
- Division of Interventional Radiology, Department of Radiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
- Penn Presbyterian Medical Center, 4 Wright Saunders Building, 51 N. 39th Street, Philadelphia, PA, 19104, USA
| | - Mark P Mantell
- Division of Vascular Surgery, Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Scott O Trerotola
- Division of Interventional Radiology, Department of Radiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Ansar Z Vance
- Division of Interventional Radiology, Department of Radiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.
- Penn Presbyterian Medical Center, 4 Wright Saunders Building, 51 N. 39th Street, Philadelphia, PA, 19104, USA.
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Ramadan OI, Dember LM, Wang GJ, Ng JH, Mantell MP, Neuman MD. Association between anaesthesia type and arteriovenous fistula maturation. BJA Open 2022; 3:100031. [PMID: 36267664 PMCID: PMC9581339 DOI: 10.1016/j.bjao.2022.100031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
BACKGROUND Whereas general anaesthesia is commonly used for haemodialysis fistula creation, regional or local anaesthesia has been posited to lead to better fistula maturation outcomes. We sought to measure the association between anaesthesia type and arteriovenous fistula maturation. METHODS We performed a secondary analysis of data from the Hemodialysis Fistula Maturation study, a multicentre prospective cohort study of advanced chronic kidney disease patients who underwent single-stage upper extremity fistula creation between 2010 and 2013. We evaluated the relationship between anaesthesia type and unassisted (without maturation-facilitating interventions) or overall (unassisted or assisted) fistula maturation using multivariable logistic regression. RESULTS Among 602 participants, 336 (55.8%) received regional/local anaesthesia and 266 (44.2%) received general anaesthesia. Unassisted maturation occurred in 164/309 patients (53.1%) after regional/local vs 91/226 patients (40.3%) after general anaesthesia (P=0.003). After adjustment for patient factors and fistula type, regional/local anaesthesia was associated with greater odds of unassisted maturation than general anaesthesia (odds ratio 1.72, 95% confidence interval 1.24-2.39; P=0.001). However, after further adjustment for clinical centre fixed effects, odds of unassisted maturation did not differ by anaesthesia type (odds ratio 1.03, 95% confidence interval 0.78-1.36; P=0.830). Similar findings were observed for overall maturation and composite endpoints accounting for potential survivorship bias. CONCLUSIONS Regional/local anaesthesia was associated with increased odds of fistula maturation when adjusting for patient factors and fistula type. However, this association did not persist after adjusting for centre fixed effects. Future research is needed to better understand the relationship between anaesthesia type and centre factors to optimise outcomes after fistula surgery.
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Affiliation(s)
- Omar I. Ramadan
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
| | - Laura M. Dember
- Renal-Electrolyte and Hypertension Division, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Department of Biostatistics and University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Grace J. Wang
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
| | - Jia Hwei Ng
- Division of Kidney Diseases and Hypertension, Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Great Neck, NY, USA
| | - Mark P. Mantell
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Mark D. Neuman
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
- Department of Anesthesiology and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
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Ramadan OI, Dember LM, Ng JH, Mantell MP, Wang GJ, Neuman MD. Association Between Anesthesia Type and Arteriovenous Fistula Maturation: Secondary Analysis of a Multicenter Prospective Cohort Study. J Am Coll Surg 2021. [DOI: 10.1016/j.jamcollsurg.2021.07.647] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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7
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Shamimi-Noori S, Mantell MP, Vance AZ, Trerotola SO, Clark TWI. Response to Letter to the Editor. J Vasc Interv Radiol 2020; 31:2160. [PMID: 33261749 DOI: 10.1016/j.jvir.2020.08.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Accepted: 08/16/2020] [Indexed: 11/26/2022] Open
Affiliation(s)
- Susan Shamimi-Noori
- Section of Interventional Radiology, Department of Radiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Mark P Mantell
- Division of Vascular Surgery, Department of Surgery, Penn Presbyterian Medical Center, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ansar Z Vance
- Section of Interventional Radiology, Department of Radiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Scott O Trerotola
- Section of Interventional Radiology, Department of Radiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Timothy W I Clark
- Section of Interventional Radiology, Department of Radiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
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Barrette LX, Vance AZ, Mantell MP, Kratz KM, Redmond JW, Clark TWI. Safety and Efficacy of Arterial Closure Devices Following Antegrade Femoral Access: A Case–Control Study. Vasc Endovascular Surg 2020; 54:612-617. [DOI: 10.1177/1538574420941298] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Purpose: Vascular closure device (VCD) use following antegrade femoral access may present unique challenges relative to retrograde access. We retrospectively compared safety and efficacy of these devices between antegrade and retrograde patient cohorts undergoing percutaneous intervention. Materials and Methods: Over a 5-year period, a consecutive series of 107 limbs in 84 patients underwent VCD arteriotomy closure following percutaneous revascularization using an antegrade approach (VCD-A). Device deployment success rates, time to ambulation, and complication rates were compared to a contemporaneous control group of 401 limbs in 305 patients who underwent closure following retrograde access (VCD-R) during revascularization or embolization procedures. Results: Closure was attempted in VCD-A using 53 StarClose, 35 Perclose, and 19 Angio-Seal devices. Hemostasis (without supplemental manual compression) was achieved in 86/107 (80.4%) limbs. Closure was attempted in VCD-R using 215 StarClose, 119 Perclose, and 67 Angio-Seal devices with hemostasis in 357/401 (89.0%) limbs. Device deployment failure occurred in 7/107 (6.5%) of VCD-A and 20/401 (5.0%) of VCD-R ( P = .52), independent of specific device type. Femoral pseudoaneurysm developed in 1/107 and 1/401 of VCD-A and VCD-R ( P = .31), and minor hematoma developed in 3/107 and 8/401 of the VCD-A and VCD-R ( P = .61). Mean time to ambulation was 204.1 minutes in VCD-A and 204.8 minutes in VCD-R ( P = .97). Conclusion: Antegrade femoral closure was associated with high rates of technical success and low complications, similar to retrograde closure. Time to ambulation was the same in both groups despite higher heparin doses in the antegrade patients.
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Affiliation(s)
- Louis-Xavier Barrette
- Section of Interventional Radiology, Department of Radiology, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA, USA
| | - Ansar Z. Vance
- Section of Interventional Radiology, Department of Radiology, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA, USA
- Section of Interventional Radiology, Penn Presbyterian Medical Center, Philadelphia, PA, USA
| | - Mark P. Mantell
- Division of Vascular Surgery, Department of Surgery, Penn Presbyterian Medical Center, Philadelphia, PA, USA
| | - Kathleen M. Kratz
- Section of Interventional Radiology, Penn Presbyterian Medical Center, Philadelphia, PA, USA
| | - Jonas W. Redmond
- Section of Interventional Radiology, Department of Radiology, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA, USA
| | - Timothy W. I. Clark
- Section of Interventional Radiology, Department of Radiology, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA, USA
- Section of Interventional Radiology, Penn Presbyterian Medical Center, Philadelphia, PA, USA
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Shamimi-Noori S, Sheng M, Mantell MP, Vance AZ, Cohen R, Trerotola SO, Reddy SN, Nadolski GJ, Stavropoulos SW, Clark TWI. Diagnosis and Treatment of Nonmaturing Fistulae for Hemodialysis Access via Transradial Approach: A Case-Control Study. J Vasc Interv Radiol 2020; 31:993-999.e1. [PMID: 32376177 DOI: 10.1016/j.jvir.2020.01.023] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2019] [Revised: 01/23/2020] [Accepted: 01/24/2020] [Indexed: 10/24/2022] Open
Abstract
PURPOSE To compare outcomes of transradial access for endovascular treatment of nonmaturing hemodialysis fistulae compared to brachial arteriography followed by unidirectional or bidirectional fistula access for intervention. MATERIALS AND METHODS In this institutional review board-approved, retrospective, case-control study, 56 consecutive patients with nonmaturing arteriovenous fistulae underwent percutaneous intervention between 2015 and 2018. The transradial group (n = 28) underwent radial artery access for diagnostic fistulography and intervention. The control group (n = 28) underwent retrograde brachial artery access for fistulography followed by unidirectional/bidirectional fistula access for intervention. Both groups had similar demographics, fistula characteristics, and stenosis locations. RESULTS Fewer punctures were required in the transradial group compared to controls (1.2 vs 2.4, P < .0001), and procedure time was shorter (64.9 vs 91.3 minutes, P = .0016). Anatomic, technical, and clinical success rates trended higher in the transradial group compared to controls (93% vs 86%, 96% vs 89%, and 82% vs 64%, respectively). Nonmaturation resulting in fistula abandonment was lower in the transradial group (3.7% vs 25%, P = .025). Primary unassisted patency at 3, 6, and 12 months was 77.1% ± 8.2%, 73.1% ± 8.7%, and 53.3% ± 10.6% in the transradial group, respectively, and 63.0% ± 9.3%, 55.6% ± 9.6%, and 48.1% ± 9.6% in the control group, respectively (P = .76). Primary assisted patency at 12 months was 92.3% ± 5.3% in the transradial group compared to 61.8% ± 9.6% at 12 months in the control group (P = .021). No major complications occurred. Minor complications were lower in the transradial group than in the control group (14% vs 39%, P = .068). CONCLUSIONS Treatment of nonmaturing fistulae via a transradial approach was safe, improved midterm patency, and was associated with lower rates of fistula abandonment.
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Affiliation(s)
- Susan Shamimi-Noori
- Department of Radiology, Section of Interventional Radiology, University of Pennsylvania Perelman School of Medicine, 51 N 39th St., Philadelphia, PA, 19104
| | - Mike Sheng
- Department of Radiology, Section of Interventional Radiology, University of Pennsylvania Perelman School of Medicine, 51 N 39th St., Philadelphia, PA, 19104
| | - Mark P Mantell
- Department of Surgery, Division of Vascular Surgery, Penn Presbyterian Medical Center, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ansar Z Vance
- Department of Radiology, Section of Interventional Radiology, University of Pennsylvania Perelman School of Medicine, 51 N 39th St., Philadelphia, PA, 19104
| | - Raphael Cohen
- Department of Medicine, Division of Nephrology, Penn Presbyterian Medical Center, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Scott O Trerotola
- Department of Radiology, Section of Interventional Radiology, University of Pennsylvania Perelman School of Medicine, 51 N 39th St., Philadelphia, PA, 19104
| | - Shilpa N Reddy
- Department of Radiology, Section of Interventional Radiology, University of Pennsylvania Perelman School of Medicine, 51 N 39th St., Philadelphia, PA, 19104
| | - Gregory J Nadolski
- Department of Radiology, Section of Interventional Radiology, University of Pennsylvania Perelman School of Medicine, 51 N 39th St., Philadelphia, PA, 19104
| | - S William Stavropoulos
- Department of Radiology, Section of Interventional Radiology, University of Pennsylvania Perelman School of Medicine, 51 N 39th St., Philadelphia, PA, 19104
| | - Timothy W I Clark
- Department of Radiology, Section of Interventional Radiology, University of Pennsylvania Perelman School of Medicine, 51 N 39th St., Philadelphia, PA, 19104.
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10
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Chen JX, Levin LS, Mantell MP, Redmond JW, Clark TWI. Endovascular Therapy for Below-the-Elbow Arterial Disease: An Initial Single-Center Experience. J Endovasc Ther 2019; 26:505-511. [PMID: 31179815 DOI: 10.1177/1526602819854167] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Purpose: To evaluate the technical success, clinical success, and complication rates of endovascular revascularization for below-the-elbow (BTE) peripheral artery disease. Materials and Methods: A retrospective review was performed of 19 patients (mean age 63 years; 12 men) with critical hand ischemia (CHI) who underwent 25 interventions in 19 arms between October 2010 and June 2017. Access was attained using 4-F or 5-F sheaths via antegrade brachial, retrograde radial, or fistula/graft access routes depending on the target vessel. A 0.018-inch hydrophilic microwire was used for intimal or subintimal recanalization. Angioplasty was performed over a 0.014-inch guidewire using low-profile balloons. The primary endpoint of the study was technical success, defined as successful lesion crossing/dilation, with residual stenosis <30%. Clinical success referred to improvement in pain and/or steal symptoms. Results: Technical success was achieved in 88% (22 of 25 procedures), with no significant difference in outcome associated with indications or baseline vessel disease. Complications occurred in 6 cases, of which 5 were minor and 1 was major. Clinical success was achieved in 12 of 14 patients with available follow-up; 5 of 7 patients with ulcers experienced wound healing. Conclusion: Endovascular revascularization for BTE occlusive disease is an effective and safe strategy for treating CHI.
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Affiliation(s)
- James X Chen
- 1 Division of Interventional Radiology, Department of Radiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.,2 Vascular and Interventional Specialists, Charlotte Radiology, Charlotte, NC, USA
| | - L Scott Levin
- 3 Department of Orthopedic Surgery and Division of Plastic Surgery, Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Mark P Mantell
- 4 Division of Vascular Surgery, Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Jonas W Redmond
- 1 Division of Interventional Radiology, Department of Radiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Timothy W I Clark
- 1 Division of Interventional Radiology, Department of Radiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
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11
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Bai HX, Davis AJO, Mantell MP, Troiano MA, Brandis AW, Redmond JRB, Clark TWI. Prediction of Limb Salvage Following Percutaneous Vascular Intervention Using a Composite Tibial Artery Perfusion Score. Cardiovasc Intervent Radiol 2019; 42:1080-1087. [PMID: 31001667 DOI: 10.1007/s00270-019-02223-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2018] [Accepted: 04/11/2019] [Indexed: 11/25/2022]
Abstract
PURPOSE To assess a novel tibial artery perfusion score (TPS) for predicting limb salvage in critical limb ischemia (CLI) patients undergoing percutaneous vascular intervention (PVI). PATIENTS AND METHODS A consecutive cohort of 115 CLI patients undergoing PVI in 144 limbs from 2011 to 2016 was analyzed. TPS comprised a 27-point scale based on: (1) patent tibial vessels following PVI, (2) severity of calcification of the tibial arteries, (3) presence of an intact pedal arch following intervention, (4) whether or not revascularization was direct or indirect based on the target angiosome, (5) presence of angiosome blush at the completion of index intervention. Limbs were stratified into (1) High [21-27 points], (2) Medium [13-20 points], and (3) Low [0-12 points] TPS. Predictive value of TPS was evaluated using logistic regression and Cox proportional hazards models. RESULTS The median follow-up was 15.7 months (range 0.4-69.9 months). Limb salvage in High, Medium, and Low TPS groups was 90.6%, 85.9%, and 55.6%, respectively, as freedom from the composite outcome: (1) limb complication resulting in death, (2) tibial bypass surgery, (3) above-the-knee amputation, or (4) below-the-knee amputation in patients without supratibial disease at the time of PVI. TPS was significantly associated with limb salvage defined as freedom from both the composite outcome and major amputation. CONCLUSIONS Based on this preliminary investigation, TPS was associated with limb salvage in CLI limbs, particularly in high-risk limbs. Further validation in a prospective cohort may identify patients with high-risk limbs in need of closer surveillance and earlier reintervention. LEVEL OF EVIDENCE Level IV, case series.
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Affiliation(s)
- Harrison X Bai
- Section of Interventional Radiology, Department of Radiology, Penn Presbyterian Medical Center, Perelman School of Medicine, University of Pennsylvania, 39th and Market Streets, Philadelphia, PA, 19104, USA
| | - Andrew J O Davis
- Section of Interventional Radiology, Department of Radiology, Penn Presbyterian Medical Center, Perelman School of Medicine, University of Pennsylvania, 39th and Market Streets, Philadelphia, PA, 19104, USA
| | - Mark P Mantell
- Division of Vascular Surgery, Department of Surgery, Penn Presbyterian Medical Center, University of Pennsylvania, 39th and Market Streets, Philadelphia, PA, 19104, USA
| | - Michael A Troiano
- Department of Podiatry, Penn Presbyterian Medical Center, University of Pennsylvania, 39th and Market Streets, Philadelphia, PA, 19104, USA
| | - Aaron W Brandis
- Section of Interventional Radiology, Department of Radiology, Penn Presbyterian Medical Center, Perelman School of Medicine, University of Pennsylvania, 39th and Market Streets, Philadelphia, PA, 19104, USA
| | - Jonas R B Redmond
- Section of Interventional Radiology, Department of Radiology, Penn Presbyterian Medical Center, Perelman School of Medicine, University of Pennsylvania, 39th and Market Streets, Philadelphia, PA, 19104, USA
| | - Timothy W I Clark
- Section of Interventional Radiology, Department of Radiology, Penn Presbyterian Medical Center, Perelman School of Medicine, University of Pennsylvania, 39th and Market Streets, Philadelphia, PA, 19104, USA.
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Clark TW, Redmond JW, Mantell MP, Nadolski GJ, Mondschein JI, Dowd MF, Dagli MS, Sudheendra D, Shlansky-Goldberg RD, Cohen RD. Initial Clinical Experience: Symmetric-Tip Dialysis Catheter with Helical Flow Characteristics Improves Patient Outcomes. J Vasc Interv Radiol 2015; 26:1501-8. [DOI: 10.1016/j.jvir.2015.06.033] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2015] [Revised: 06/26/2015] [Accepted: 06/29/2015] [Indexed: 11/17/2022] Open
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Yan Y, Clark TWI, Mondschein JI, Shlansky-Goldberg RD, Dagli MS, Soulen MC, Stavropoulos SW, Sudheendra D, Mantell MP, Cohen RD, Kobrin S, Chittams JL, Trerotola SO. Outcomes of percutaneous interventions in transposed hemodialysis fistulas compared with nontransposed fistulas and grafts. J Vasc Interv Radiol 2014; 24:1765-72; quiz 1773. [PMID: 24409470 DOI: 10.1016/j.jvir.2013.08.025] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
PURPOSE To compare postpercutaneous intervention outcomes of autogenous venous-transposition arteriovenous fistulas (AVFs) versus those of autogenous nontransposed AVFs (nAVFs) and prosthetic arteriovenous grafts (AVGs). MATERIALS AND METHODS A total of 591 hemodialysis accesses (195 transposed AVFs [tAVFs], 205 nAVFs, 191 AVGs) in 522 patients (278 male; mean age, 57 y; range, 15–91 y) underwent percutaneous transluminal angioplasty (PTA) and/or mechanical thrombectomy (ie, declotting). Access characteristics, surgical history, percutaneous interventions, postinterventional primary and secondary access patency, and follow-up data were collected. Cox proportional-hazards regression analyses, Fisher exact tests, and χ2 tests were performed. RESULTS Mean follow-up period was 32 months. Mean access ages at initial percutaneous intervention were 260 days (tAVF), 206 days (nAVF), and 176 days (AVG; P < .01). One-year postinterventional primary patency (PIPP) rates were 25% (tAVF), 24% (nAVF), and 14% (AVG). One-year postinterventional secondary patency (PISP) rates were 77% (tAVF), 61% (nAVF), and 63% (AVG). Median PIPP durations were 138 days (tAVF), 121 days (nAVF), and 79 days (AVG; P = .0001). Median PISP durations were 1,076 days (tAVF), 783 days (nAVF), and 750 days (AVG; P = .019). Total interventions needed to maintain PISP were 2.4 (tAVF), 1.3 (nAVF), and 3.2 (AVG) per patient-year (P < .001), which included 1.9, 1.2, and 1.4 PTAs (P < .01) and 0.45, 0.15, and 1.8 declotting procedures, respectively (P < .001). CONCLUSIONS Based on the number of percutaneous interventions needed to maintain PISP, these results confirm the current Dialysis Outcomes Quality Initiative access preference of nAVFs before tAVFs before AVGs. tAVFs offered superior postinterventional outcomes than AVGs. With additional interventions, tAVFs could even outperform nAVFs in terms of PISP.
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Yurkovic A, Cohen RD, Mantell MP, Kobrin S, Soulen MC, Chittams J, Trerotola SO. Outcomes of Thrombectomy Procedures Performed in Hemodialysis Grafts with Early Failure. J Vasc Interv Radiol 2011; 22:317-24. [DOI: 10.1016/j.jvir.2010.11.021] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2010] [Revised: 10/11/2010] [Accepted: 11/13/2010] [Indexed: 11/26/2022] Open
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Ziegler TR, Mantell MP, Chow JC, Rombeau JL, Smith RJ. Intestinal adaptation after extensive small bowel resection: differential changes in growth and insulin-like growth factor system messenger ribonucleic acids in jejunum and ileum. Endocrinology 1998; 139:3119-26. [PMID: 9645684 DOI: 10.1210/endo.139.7.6097] [Citation(s) in RCA: 44] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The distal small bowel exhibits greater adaptive growth than proximal segments after partial small intestine resection. To explore this process, we evaluated adaptive cellularity, intestinal insulin-like growth factor (IGF) system messenger RNA (mRNA) transcripts, and effects of recombinant IGF-I treatment in jejunum and ileum of adult rats. Gastrostomy-fed animals underwent 80% jejuno-ileal resection or intestinal transection and reanastomosis without resection, followed by infusion of human recombinant IGF-I (2.4 mg/kgXday) or vehicle. After 7 days, resected rats demonstrated modest adaptive growth in jejunum and marked cell proliferation in ileum. Resection increased IGF-I mRNA in both jejunum (183%) and ileum (249%) and up-regulated IGFBP-4 mRNA levels in both tissues. IGFBP-3 mRNA fell significantly in ileum after resection. IGF-I infusion modestly increased ileal cellularity after resection, but had no effect in jejunum. IGF-I markedly increased IGFBP-3 mRNA levels in jejunum after both transection and resection. These data confirm that bowel resection induces greater adaptive growth in ileum than jejunum. IGF-I administration modestly increases ileal, but not jejunal, growth after resection. Increased levels of intestinal IGF-I and IGFBP-4 mRNA suggest roles for IGF-I and IGFBP-4 in mediating small bowel adaptation. Higher levels of jejunal IGFBP-3 mRNA may be related to limited jejunal vs. ileal growth after extensive jejuno-ileal resection.
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Affiliation(s)
- T R Ziegler
- Department of Medicine, Emory University School of Medicine, Atlanta, Georgia 30322, USA
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Ziegler TR, Mantell MP, Chow JC, Rombeau JL, Smith RJ. Gut adaptation and the insulin-like growth factor system: regulation by glutamine and IGF-I administration. Am J Physiol 1996; 271:G866-75. [PMID: 8944702 DOI: 10.1152/ajpgi.1996.271.5.g866] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Intestinal adaptation after extensive small bowel resection in rats is augmented by the provision of diets supplemented with the amino acid glutamine (Gln) or by administration of insulin-like growth factor-I (IGF-I). The goal of this study was to investigate potential synergistic effects of Gln and IGF-I on postresection ileal hyperplasia. Rats underwent 80% small bowel resection (SBR) and then were fed low-Gln or L-Gln-enriched diets and subcutaneously given recombinant human IGF-I or vehicle for 7 days. Gln and IGF-I each significantly enhanced adaptive ileal hyperplasia (DNA content) compared with rats receiving vehicle and low-Gln diet. Ileal DNA content was highest when IGF-I was administered together with Gln supplementation. Combined IGF-I plus Gln synergistically increased ileal weight and protein content. This was associated with higher plasma concentrations of IGF-I and Gln than observed when IGF-I or Gln was given individually. Ileal IGF-I mRNA expression rose nearly twofold during gut adaptation after SBR; this response was augmented with IGF-I administration but was unaltered by Gln feeding. In contrast, dietary Gln, but not IGF-I therapy, prevented a decrease in hepatic IGF-I mRNA induced by SBR. We conclude that parenteral IGF-I and enteral Gln have both individual and synergistic effects on ileal adaptation after massive small intestinal resection. These findings support the concept that specific gut-trophic nutrients and growth factors may be combined to enhance intestinal adaptation and possibly reduce the severity of short bowel syndrome after intestinal resection.
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Affiliation(s)
- T R Ziegler
- Joslin Research Laboratory, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts 02215, USA
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Mantell MP, Ziegler TR, Adamson WT, Roth JA, Zhang W, Frankel W, Bain A, Chow JC, Smith RJ, Rombeau JL. Resection-induced colonic adaptation is augmented by IGF-I and associated with upregulation of colonic IGF-I mRNA. Am J Physiol 1995; 269:G974-80. [PMID: 8572229 DOI: 10.1152/ajpgi.1995.269.6.g974] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
The effects of exogenous insulin-like growth factor-I (IGF-I) on colonic adaptation were examined in male Sprague-Dawley rats (n = 60, 225-275 mg) after either a 60% small bowel and cecal resection (RX) or mid-small bowel transection with reanastomosis (TX). Animals received a 7-day treatment with either IGF-I (2.4 mg.kg-1.day-1) or vehicle (V; 0.1 mol/l acetic acid). Body weight decreased significantly after resection (-25.6 +/- 4.0 g; P < 0.05 vs. TX/V). IGF-I treatment significantly reduced weight loss after resection (-12.4 +/- 3.8 g; P < 0.01 vs. RX/V) and induced significant weight gain after transection (15.6 +/- 4.0 g; P < 0.05 vs. TX/V). Plasma IGF-I decreased with resection (526 +/- 41 TX/V vs. 344 +/- 17 ng/ml RX/V; P < 0.01). IGF-I treatment significantly increased plasma IGF-I levels (805 +/- 100 ng/ml TX/IGF, 677 +/- 56 ng/ml RX/IGF). After resection, IGF-I treatment significantly increased colonic mucosal weight, DNA, protein content, and crypt depth when compared with resection alone (P < 0.05). Colonic water absorption, measured by an in vivo [3H]polyethylene glycol assay, was significantly increased by IGF-I treatment in resected animals (399 +/- 23 RX/IGF vs. 306 +/- 32 microliter.cm-1.h-1 RX/V; P < 0.05). Resection resulted in increased steady-state colonic IGF-I mRNA (182% of TX/V; P < 0.01) without significantly affecting IGF-I receptor mRNA expression. Regulation of IGF binding protein (BP)-3 and -4 was discoordinate, with IGFBP-3 mRNA tending to decrease with resection (67% of TX/V; P is not significant) and IGFBP-4 increasing significantly (191% of TX/V; P < 0.05). An important role for IGF-I in colonic adaptation after massive intestinal resection is indicated by 1) significantly enhanced colonic mucosal growth and water absorption with IGF-I treatment and 2) postresection upregulation of colonic IGF-I mRNA and alteration of IGFBP-3 and IGFBP-4 mRNA expression.
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Affiliation(s)
- M P Mantell
- Department of Surgery, University of Pennsylvania Hospital, Philadelphia 19104, USA
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Zhang W, Frankel WL, Adamson WT, Roth JA, Mantell MP, Bain A, Ziegler TR, Smith RJ, Rombeau JL. Insulin-like growth factor-I improves mucosal structure and function in transplanted rat small intestine. Transplantation 1995; 59:755-61. [PMID: 7533956 DOI: 10.1097/00007890-199503150-00020] [Citation(s) in RCA: 43] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
The transplanted small intestine develops significant mucosal atrophy, impaired nutrient and water absorption, and increased bacterial translocation to mesenteric lymph nodes in rats maintained on elemental diets or total parenteral nutrition. This study determined the effects of administration of an peptide growth factor (insulin-like growth factor-I[IGF-I]) on the mucosal structure and barrier function of rat small bowel isografts. Thirty-six adult Lewis rats underwent either resection of the distal 60% of the small bowel and proximal colon followed by a 40-cm orthotopic jejunal isograft or proximal small bowel transection and distal small bowel resection to leave an analogous length of small intestine in control animals. All rats received an isocaloric, isonitrogenous, polymeric diet (200 kcal/kg/day, 2 gN/kg/day) by gastrostomy and were infused with either IGF-I (2.4 mg/kg/day) or vehicle by osmotic pumps subcutaneously. After 10 days of treatment, jejunal crypt cell production, mucosal morphometric indices, glucose and water absorption, body weight, and bacterial translocation to mesenteric lymph nodes (MLN) were measured. Jejunal mRNA content for IGF-I, IGF-I receptor, and IGF-binding proteins 3 and 4 (IGFBP-3,4) were determined by Northern blotting. Crypt cell production, villus height, crypt depth, and villus surface area were significantly increased in control and transplanted jejunum of rats infused with IGF-I when compared to animals given vehicle alone. Additionally, jejunal glucose absorption and water absorption were significantly improved in both IGF-I groups when compared with their respective vehicle controls. IGF-I infusion increased body weight in transplanted and control animals and markedly reduced bacterial translocation to MLN after small bowel transplantation. Jejunal levels of IGF-I mRNA were significantly increased in transplanted animals when compared to transected controls. IGF-I treatment significantly increased IGFBP-3 tissue mRNA levels in both transected and transplanted animals. These results demonstrate that IGF-I administration, after small bowel transplantation, improves mucosal structure and absorptive function and reduces bacterial translocation to MLN. IGF-I may have important effects in transplanted small bowel both as an endogenous and administered growth factor.
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Affiliation(s)
- W Zhang
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia 19104
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Zhang W, Frankel WL, Roth J, Mantell MP, Bain A, Klurfeld DM, Rombeau JL. Insulin-like growth factor-I improves mucosal structure and function in small bowel transplantation in the rat. Transplant Proc 1994; 26:1458-9. [PMID: 8029988] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Affiliation(s)
- W Zhang
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia 19104
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