Preservation of hypogastric artery blood flow during endovascular aneurysm repair of an abdominal aortic aneurysm with bilateral common and internal iliac artery involvement: utilization of off-the-shelf stent-graft components

A 72-year-old male presented with a 7.4-cm abdominal aortic aneurysm with bilateral common and internal iliac involvement. To maintain pelvic perfusion, preservation of the patient's left hypogastric artery (HA) was pursued. Two weeks after right HA embolization, endovascular repair of the patient's aneurysms was performed using a branched endograft approach. A 22-mm main body bifurcated endograft was unsheathed and the proximal covered stent was removed. The contralateral gate was preloaded with a wire and catheter. The device was resheathed and placed in the left common iliac artery. The preloaded wire in the contralateral gate was snared from the right side, establishing through-and-through femoral access. A contralateral femoral sheath was advanced up and over the aortic bifurcation from the right side into the contralateral gate of the bifurcated endograft. The repair was bridged to the left HA using a balloon-expandable stent-graft, followed by standard endovascular abdominal aortic aneurysm repair. Completion angiography demonstrated exclusion of patient's aneurysms, without evidence of endoleak, and maintenance of pelvic blood flow through the left HA. The patient recovered without complication and was discharged home on postoperative day 4. This technique illustrates the technical feasibility of using a preloaded commercially available endograft to preserve HA blood flow and maintain pelvic perfusion during endovascular aortic aneurysm repair.

Endovascular Management of Aortic Arch Vessel Occlusion

A 56-year-old female presented with pain in her bilateral upper extremities. Angiogram demonstrated occlusion of her left subclavian and innominate arteries (IAs). The patient’s left subclavian occlusion was successfully treated with percutaneous mechanical thrombectomy, angioplasty, and stenting. One month later, endovascular revascularization of the IA was performed. Initially the lesion could not be directly transversed from neither an antegrade nor a retrograde approach. Wires were passed from the brachial and femoral arteries into the right common carotid artery where the femoral wire was snared and brought out through the right brachial access. Over this through-and-through wire access, angioplasty and stenting of the IA was performed with an excellent angiographic result. In follow-up, the patient remained free of upper extremity symptoms. Occlusive lesions of the aortic arch vessels can be successfully managed with antegrade and retrograde endovascular techniques.

Noninterruption of Warfarin Therapy is Safe and Does not Compromise Outcome in Patients Undergoing Endovenous Laser Therapy (EVLT)

Objective: To assess the need for cessation of oral anticoagulation with warfarin for patients undergoing endovenous laser therapy (EVLT). Methods: Between September 2004 and July 2010, 518 patients underwent 770 EVLT procedures on the lower extremity, at our institution. Of these patients, 5 underwent a total of 12 separate lower extremity EVLT procedures for the treatment of symptomatic reflux without interruption of warfarin therapy. Results: No bleeding complications were observed during the procedure or in early follow-up. None of the patients developed a deep venous thrombosis. Complete ablation of the target vessel was observed in all patients on follow-up Duplex ultrasounds at 1 and 8 weeks postintervention. Conclusion: Endovenous laser therapy can be safely performed and does not compromise target vessel ablation in patients receiving oral anticoagulation warfarin therapy. Warfarin therapy should not be routinely interrupted in patients undergoing this procedure.

North Carolina all-terrain vehicle (ATV) safety legislation: an assessment of the short-term impact on ATV-related morbidity and mortality

OBJECTIVE

All-terrain vehicle (ATV)-related morbidity and mortality has increased in the US, and states have attempted to combat this trend with ATV-specific safety legislation. The objective of this study was to examine the short-term changes in ATV-related injuries and deaths following the enactment of legislation regulating the operation and sale of ATVs in North Carolina.

STUDY DESIGN AND DATA COLLECTION

The study is a retrospective analysis comparing ATV collisions during the six month pre and post period of the effective date of legislation. Demographics, medical outcomes, passenger seat position, helmet use, and alcohol use were analyzed.

DATA

Subjects were identified through the North Carolina Trauma Registry and data from the Office of the Chief Medical Examiner.

FINDINGS

A total of 102 (51 in both pre- and post-legislation) subjects required medical treatment or were declared dead secondary to ATV collisions in North Carolina. Children under the age of eight years, who were forbidden from using ATVs under the new legislation, had significantly fewer total medical evaluations and deaths in the post-legislative time period. There was no association between legislative time period and ATV-related passenger, helmet, or alcohol use.

CONCLUSIONS

In the six months following the enactment of North Carolina's ATV bill, children under the age of eight years were seriously injured or died less often due to ATV-related crashes. No other significant changes in ATV riding patterns were seen between the two time periods, and the morbidity and mortality of all ATV riders did not change.

LIMITATIONS

The examined data sets do not include data from all North Carolina hospitals.

Endovascular repair of a Kommerell's diverticulum in a patient with a left-sided aortic arch and right-sided descending thoracic aorta

Thoracic aortic anomalies are rare and may be associated with pathologic vascular conditions necessitating intervention. We present a case of a patient with a left aortic arch, right descending thoracic aorta, and a Kommerell's diverticulum giving rise to an aberrant right subclavian artery. The Kommerell's diverticulum was successfully managed with a right carotid to subclavian artery bypass and thoracic endograft exclusion.

Red blood cell transfusion within the first 24 hours of admission is associated with increased mortality in the pediatric trauma population: a retrospective cohort study

BACKGROUND

Allogeneic red blood cell transfusion is associated with increased morbidity and mortality in adult trauma patients. Although studies have suggested that the adoption of a more restrictive transfusion strategy may be safely applied to critically ill adult and all-cause critically ill pediatric patients, recent developments in our understanding of the negative consequences of red blood cell transfusion have focused almost entirely on adult populations, while the applicability of these findings to the pediatric population remains poorly defined. The object of this study was to evaluate the effect of red blood cell transfusion within the first 24 hours following admission on mortality in pediatric trauma patients treated at our institution.

RESULTS

Age, race, and mechanism of injury did not differ between transfused and non-transfused groups, although there were significantly more female patients in the transfusion group (51 vs. 37%; p < 0.01). Shock index (pulse/systolic blood pressure), injury severity score, and new injury severity score were all significantly higher in the transfused group (1.21 vs. 0.96, 26 vs. 10, and 33 vs. 13 respectively; all p </= 0.01). Patients who received a red blood cell transfusion experienced a higher mortality compared to the non-transfused group (29% vs. 3%; p < 0.001). When attempting to control for injury severity, goodness-of-fit analysis revealed a poor fit for the statistical model preventing reliable conclusions about the contribution of red blood cell transfusion as an independent predictor of mortality.

CONCLUSION

Red blood cell transfusion within the first 24 hours following admission is associated with an increase in mortality in pediatric trauma patients. The potential contribution of red blood cell transfusion as an independent predictor of hospital mortality could not be assessed from our single-institution trauma registry. A review of state-wide or national trauma databases may be necessary to obtain adequate statistical confidence.

Surgical bypass procedures to facilitate endovascular repair of aortic arch pathology

Thoracic aortic aneurysms and other thoracic aortic lesions may become life-threatening conditions if they remain untreated. Conventional open surgical reconstruction with placement of an interposition graft is regarded as a definitive form of treatment, but is associated with considerable operative morbidity and mortality. Thoracic aortic lesions involving the aortic arch require more complex surgical interventions necessitating cardiopulmonary bypass, and hypothermic circulatory arrest. Outcomes from this form of treatment have a reported early stroke and death rate of up to 25%. Thoracic endovascular aortic repair is a less invasive alternative for the treatment of many thoracic aortic lesions. The application of a thoracic endoprosthesis may be limited by the extent of involvement of the proximal thoracic aorta as coverage of arch vessel ostia may be necessary to obtain adequate proximal endograft fixation and aneurysm exclusion. In an effort to overcome proximal landing zone limitations imposed by arch vessel involvement, hybrid surgical-endovascular reconstructive and debranching bypass procedures have been performed to create a proximal landing zone of adequate length. Although these adjunctive techniques incorporate invasive surgical procedures, it is believed that minimizing the procedural invasiveness, by avoiding aortic cross-clamping and/or hypothermic circulatory arrest, morbidity and mortality outcomes can be improved especially in high-risk patients. Several surgical approaches and techniques have been described for various levels of aortic arch involvement with encouraging early and mid-term results, although the long-term durability of these hybrid surgical-endovascular procedures remains to be defined.

Nonfocused enhanced CT evaluation of acute appendicitis increases length of stay in the emergency department but does not increase perforation rate

Nonfocused enhanced CT (NFECT) using intravenous and oral contrast is highly sensitive and specific for the diagnosis of acute appendicitis but requires additional time for transit of oral contrast and imaging interpretation. The aim of this study was to review our use of NFECT for the evaluation of acute appendicitis. Over a 2-year period, 295 adult patients presented to our emergency department and were diagnosed with acute appendicitis. Of these patients, 240 (81%) had undergone some form of cross-sectional imaging of the abdomen, and the majority (n = 193 [65%]) had NFECT scans performed during their evaluation. Fifty-five (19%) patients did not undergo cross-sectional radiographic evaluation (nonimaging group). Compared with the nonimaging group, patients who underwent NFECT were older (37 vs 32 years; P = 0.015) and more likely to be female (49% vs 20%; P < 0.001). Length of stay in the emergency department was significantly greater for patients who underwent NFECT (606 vs 321 minutes; P < 0.001), but there was no significant difference in the rate of acute appendiceal perforation (15% vs 9%; P = 0.297). In conclusion, use of NFECT for the diagnosis of acute appendicitis nearly doubles the patient's time in the emergency department with no significant increase in the acute perforation rate.

Nonfocused Enhanced CT Evaluation of Acute Appendicitis Increases Length of Stay in the Emergency Department but Does Not Increase Perforation Rate

Nonfocused enhanced CT (NFECT) using intravenous and oral contrast is highly sensitive and specific for the diagnosis of acute appendicitis but requires additional time for transit of oral contrast and imaging interpretation. The aim of this study was to review our use of NFECT for the evaluation of acute appendicitis. Over a 2-year period, 295 adult patients presented to our emergency department and were diagnosed with acute appendicitis. Of these patients, 240 (81%) had undergone some form of cross-sectional imaging of the abdomen, and the majority (n = 193 [65%]) had NFECT scans performed during their evaluation. Fifty-five (19%) patients did not undergo cross-sectional radiographic evaluation (nonimaging group). Compared with the nonimaging group, patients who underwent NFECT were older (37 vs 32 years; P = 0.015) and more likely to be female (49% vs 20%; P < 0.001). Length of stay in the emergency department was significantly greater for patients who underwent NFECT (606 vs 321 minutes; P < 0.001), but there was no significant difference in the rate of acute appendiceal perforation (15% vs 9%; P = 0.297). In conclusion, use of NFECT for the diagnosis of acute appendicitis nearly doubles the patient's time in the emergency department with no significant increase in the acute perforation rate.

Endograft Malapposition in the Distal Aortic Arch Resulting in Functional Coarctation

The application of thoracic endografts to thoracic aortic injuries is often limited by the available diameters of these devices. Abdominal aortic endografts have been successfully used in the thoracic aorta to overcome sizing limitations. A case is presented of a patient who underwent endovascular exclusion of a thoracic aortic transection with an abdominal aortic endograft iliac limb. The repair was complicated by endograft malapposition to the lesser curvature of the aortic arch and the development of a functional coarctation. The endovascular repair was successfully salvaged through the use of a balloon-expandable stent to improve endograft apposition to the vessel wall.

Thoracic endovascular aortic repair of traumatic injuries involving the descending thoracic aorta

Acute traumatic thoracic aortic transection is a devastating injury that often occurs in the context of multiple associated traumatic injuries. Patients who survive the initial trauma and present to the hospital experience progressive hospital mortality and remain at risk for rupture of the contained injury. Conventional open surgical repair is regarded as a definitive form of treatment with long-term durability. Unfortunately, the stress subjected upon the multitrauma patient during the operative intervention is believed to contribute to considerable operative morbidity and mortality. Despite advancements in the management and treatment of this condition, hospital and operative mortality remains high. Thoracic endovascular aortic repair (TEVAR) has emerged as a viable alterative to conventional open repair for the treatment of these injuries. This less invasive form of therapy allows for a rapid stabilization of the aortic disruption without subjecting the patient to the physiologic stress of a major operative intervention. This may potentially translate into reductions in associated operative mortality and morbidity for this condition. This review highlights some of the anatomic and technical considerations regarding endovascular repair of traumatic thoracic aortic injuries, and reviews reported outcomes.

Aortoesophageal fistula after thoracic endovascular aortic repair and transthoracic embolization

Endografts are more commonly being used to treat thoracic aortic aneurysms and other vascular lesions. Endoleaks are a potential complication of this treatment modality and can be associated with aneurysmal sac expansion and rupture. This case report presents a patient who developed a type IA endoleak after endograft repair of a descending thoracic aneurysm. The endoleak was successfully treated through computed tomographic-guided transthoracic embolization, although the patient experienced lower extremity paraparesis postprocedurally. The patient's endovascular repair was complicated by the development of an aortoesophageal fistula and endograft infection necessitating operative débridement and endograft explantation.

Endovascular Repair of a Thoracic Aortic Injury in a Burn Patient

Mortality in burn patients who sustain concomitant mechanical traumatic injuries at the time of thermal injury is greater than in patients who sustain isolated injuries. Invasive interventions to treat these mechanical traumatic injuries may be a source of added mortality and contribute to an injury-induced state of immunosuppression. Less-invasive interventions may minimize morbidity and mortality and allow for improved recovery from thermal injury. A case is presented of a patient who sustained 20% TBSA electrical burns and an acute thoracic aortic injury near the diaphragmatic hiatus. Abdominal aortic stent-graft components were used to successfully exclude the patient's thoracic aortic injury. The patient made a successful recovery from his burns and sustained no infectious complications. This case report highlights the potential advantages of endovascular therapy for the treatment of aortic trauma in patients who sustain concomitant burn injuries.

Intestinal ischemia-reperfusion injury alters purinergic receptor expression in clinically relevant extraintestinal organs

BACKGROUND

Intestinal ischemia-reperfusion (IIR) injury is known to initiate the systemic inflammatory response syndrome, which often progresses to multiple organ failure. We investigated changes in purinoceptor expression in clinically relevant extra-intestinal organs following IIR injury.

MATERIALS AND METHODS

Anesthetized adult male BalbC mice were randomized to sham laparotomy (control, n = 5), or 15 min of superior mesenteric artery occlusion. Experimental ischemia was followed by a period of reperfusion [1 min (n = 6) or 1 h (n = 6)]. Mice were then sacrificed and lung, kidney, and intestinal tissues were harvested. Following RNA extraction, purinoceptor mRNA expression for P2Y2, A3, P2X7, A2b, P2Y4, and P2Y6 was analyzed using real-time RT-PCR.

RESULTS

Significant differences in purinoceptor expression were observed in the lungs and kidneys of mice exposed to IIR injury when compared to controls. Pulmonary P2Y2 receptor expression was increased in the 1 h IIR group when compared to control, while pulmonary A3 receptor expression was incrementally elevated following IIR injury. In the kidney, P2Y2 receptor expression was increased in the 1 h IIR group compared to both 1 min IIR and control, and A3 receptor expression was decreased in the 1 h IIR group compared to the 1 min IIR group. No significant changes were observed in the intestinal purinoceptor profiles.

CONCLUSION

Purinoceptor expression is altered in the murine lung and kidney, but not intestine following experimental IIR injury. These findings may implicate extracellular nucleotides and purinoceptors as possible mediators of the extra-intestinal organ dysfunction associated with IIR injury.

Endovascular Exclusion of an External Carotid Artery Pseudoaneurysm Using a Covered Stent

Aneurysmal lesions of the external carotid artery are extremely rare. A case is presented of a 3.8 cm right external carotid artery pseudoaneurysm treated by transluminal exclusion using an endovascular stent-graft. Following stent-graft placement, complete occlusion of the aneurysmal sac and main vessel lumen patency was successfully demonstrated. This report demonstrates the technical feasibility of utilizing stent-grafts to treat aneurysmal lesions involving the external carotid artery.

Metformin-associated lactic acidosis in a burn patient

Hyperglycemia commonly is observed as part of the hypermetabolic response to severe burn injury. In routine burn care, physicians use interventions to address and reduce the complications of this stress-induced hyperglycemia. Metformin (1,1-dimethylbiguanide), an orally administered hyperglycemic medication, has been used previously to modulate the stress-induced hyperglycemic response in nondiabetic burn patients. The use of this medication in nonburn diabetic patients has been associated with the development of lactic acidosis. We present an acute burn patient who developed lactic acidosis while receiving metformin for management of his diabetes.

Coverage of the left subclavian artery during thoracic endovascular aortic repair

BACKGROUND

Thoracic aortic stent grafts require proximal and distal landing zones of adequate length to effectively exclude thoracic aortic lesions. The origins of the left subclavian artery and other aortic arch branch vessels often impose limitations on the proximal landing zone, thereby disallowing endovascular repair of more proximal thoracic lesions.

METHODS

Between October 2000 and November 2005, 112 patients received stent grafts to treat lesions involving the thoracic aorta. The proximal aspect of the stent graft partially or totally occluded the origin of at least one great vessel in 28 patients (25%). The proximal attachment site was in zone 0 in one patient (3.6%), zone 1 in three patients (10.7%), and zone 2 in 24 patients (85.7%). Patients with proximal implantation in zones 0 or 1 underwent debranching procedures of the supra-aortic vessels before stent graft repair. In one patient who underwent zone 1 deployment, the left subclavian artery was revascularized before stent graft deployment. Among patients who underwent zone 2 deployment with partial or complete occlusion of the left subclavian artery, none underwent prior revascularization. Patients were assessed postoperatively and at follow-up for development of neurologic symptoms as well as symptoms of left upper extremity claudication or ischemia.

RESULTS

Mean follow-up was 7.3 months. Among the 24 patients with zone 2 implantation, 10 (42%) had partial left subclavian artery coverage at the time of their primary procedure. A total of 19 patients experienced complete cessation of antegrade flow through the origin of the left subclavian artery without revascularization at the time of the initial endograft repair as a result of a secondary procedure or as a consequence of left subclavian artery thrombosis. Left upper extremity symptoms developed in three (15.8%) patients that did not warrant intervention, and rest pain developed in one (5.3%), which was treated with the deployment of a left subclavian artery stent. Two primary (type IA and type III) endoleaks (7.1%) and one secondary endoleak (type IA) (3.6%) were observed in patients who underwent zone 2 deployment. Three cerebrovascular accidents were observed. Thoracic aortic lesions were successfully excluded in all patients who underwent supra-aortic debranching procedures.

CONCLUSION

Intentional coverage of the origin of the left subclavian artery to obtain an adequate proximal landing zone during endovascular repair of thoracic aortic lesions is well tolerated and may be managed expectantly, with some exceptions.

Multiple Hepatic Artery Aneurysms: Use of Transcatheter Embolization for Rupture

Aneurysmal disease of the hepatic artery is a rare and potentially life-threatening entity. Aneurysms occur anywhere along the hepatic artery and its branches, but they have a predilection for occurring as a solitary lesion of the common or right hepatic artery. Diffuse intrahepatic hepatic artery aneurysm is the rarest form and is especially challenging. Treatment of these lesions has been described in only a few case reports. We present a patient with ruptured intrahepatic hepatic artery aneurysms treated by percutaneous transcatheter embolization.

Endovascular repair of lesions involving the descending thoracic aorta

BACKGROUND

Vascular lesions involving the thoracic aorta are often life-threatening conditions that carry significant morbidity and mortality with traditional open surgical repair. Preliminary results suggest that endovascular therapy is an effective and possibly advantageous treatment for diseases of the descending thoracic aorta.

METHODS

Between October 2000 and May 2004, 50 consecutive patients underwent endovascular stent-grafting of lesions involving the descending thoracic aorta. Attempted stent-graft deployment was performed electively in 39 patients and emergently in 11. The pathology of electively treated aortic lesions included degenerative/atherosclerotic aneurysms (n = 24), pseudoaneurysms (n = 11), aortic dissections (n = 2), and penetrating ulcers (n = 2). Emergently treated aortic lesions were for acute rupture due to infectious (mycotic) aneurysms (n = 4), atherosclerotic/degenerative aneurysms (n = 3), acute type B dissections (n = 2), and acute transections (n = 2). Devices used include Talent (n = 45), AneuRx aortic cuffs (n = 2), custom-fabricated Gianturco-Dacron grafts (n = 2), and a modified Cook-Zenith abdominal aortic graft (n = 1). Follow-up was performed at 1-month, 6-months, 1-year, and annually thereafter.

RESULTS

Primary technical success, defined as successful deployment and exclusion of the lesion without evidence of type I or type III endoleak, was achieved in 48 (96%) of 50 patients. In one patient, the procedure was terminated due to inability to access the iliac vessels. In another patient, a type III endoleak was observed at the completion of the primary procedure that required deployment of an additional stent-graft component 2 months later. Of the 49 patients who received endografts, seven underwent secondary procedures to correct endoleaks, with five of these seven requiring the deployment of additional endovascular stent-graft components. Major complications included four in-hospital deaths, with three of these occurring in patients treated emergently. Additionally, respiratory failure (n = 6), multisystem organ failure (n = 2), cerebrovascular accident (n = 2), retroperitoneal hematoma (n = 2), acute renal insufficiency (n = 1), and pulmonary embolus (n = 1) were also observed. The overall endoleak rate was 20%, with five primary (< or = 30 days) and five secondary (> 30 days) endoleaks observed. Five of the endoleaks were treated with the deployment of one or more additional endovascular stent-graft components. Two of the endoleaks were treated with endovascular balloon remolding. Mean follow-up was 271 days. There were no aneurysm ruptures or aneurysm-related deaths.

CONCLUSIONS

Endovascular treatment of vascular lesions involving the descending thoracic aorta can be safely performed with low morbidity in high-risk patients. Endovascular repair may become an attractive alternative for the treatment of a wide range of pathology along this vascular territory.

Bacterial endospores and their significance in stress resistance

In terms of resistance to extreme environmental stresses, the bacterial spore represents a pinnacle of evolution. Spores are highly resistant to a wide variety of physical stresses such as: wet and dry heat, UV and gamma radiation, oxidizing agents, chemicals, and extremes of both vacuum and ultrahigh hydrostatic pressure. Some of the molecular mechanisms underlying spore resistance properties have been elucidated in the laboratory, and involve both: (i) protection of vital spore macromolecules during dormancy, and (ii) repair of damaged macromolecules during germination. Our group has recently become interested in testing if the laboratory model of spore UV resistance is relevant to spore persistence in the environment. We have constructed a number of Bacillus subtilis strains which are defective in various DNA repair systems and spore structural components. Using spores of these strains, we have been exploring: (i) the types of damage induced in DNA by the UV-B and UV-A components of sunlight; (ii) the relative contribution of the major spore DNA repair systems to spore solar radiation resistance; and (iii) the role of spore structural components such as the spore coats and dipicolinic acid (DPA) in attenuation of the lethal and mutagenic effects of solar UV. The current data are reviewed with the ultimate goal of obtaining a complete model describing spore persistence and longevity in the terrestrial solar UV radiation environment.

Role of the spore coat layers in Bacillus subtilis spore resistance to hydrogen peroxide, artificial UV-C, UV-B, and solar UV radiation

Spores of Bacillus subtilis possess a thick protein coat that consists of an electron-dense outer coat layer and a lamellalike inner coat layer. The spore coat has been shown to confer resistance to lysozyme and other sporicidal substances. In this study, spore coat-defective mutants of B. subtilis (containing the gerE36 and/or cotE::cat mutation) were used to study the relative contributions of spore coat layers to spore resistance to hydrogen peroxide (H(2)O(2)) and various artificial and solar UV treatments. Spores of strains carrying mutations in gerE and/or cotE were very sensitive to lysozyme and to 5% H(2)O(2), as were chemically decoated spores of the wild-type parental strain. Spores of all coat-defective strains were as resistant to 254-nm UV-C radiation as wild-type spores were. Spores possessing the gerE36 mutation were significantly more sensitive to artificial UV-B and solar UV radiation than wild-type spores were. In contrast, spores of strains possessing the cotE::cat mutation were significantly more resistant to all of the UV treatments used than wild-type spores were. Spores of strains carrying both the gerE36 and cotE::cat mutations behaved like gerE36 mutant spores. Our results indicate that the spore coat, particularly the inner coat layer, plays a role in spore resistance to environmentally relevant UV wavelengths.