Percutaneous Axillary Artery Access for Peripheral and Complex Endovascular Interventions: Clinical Outcomes and Cost Benefits

OBJECTIVES

The aim of this study was to determine the safety, efficacy, and applicability of percutaneous axillary artery (pAxA) access in patients requiring upper extremity large sheath access during complex aortic, cardiac, and peripheral endovascular procedures. We also take this opportunity to address the potential cost-benefits offered by pAxA access compared to open upper extremity access.

METHODS

A total of 26 consecutive patients, between June 2018 and October 2020, underwent endovascular intervention, requiring upper extremity access (UEA). Ultrasound-guided, percutaneous access of the axillary artery was used in all 26 patients with off-label use of pre-close technique with Perclose ProGlide closure devices. Access sites accommodated sheath sizes that ranged from 6 to 14 French (F). End points were technical success and access site-related complications including isolated neuropathies, hematoma, distal embolization, access-site thrombosis, and post-operative bleeding requiring secondary interventions. Technical success was defined as successful arterial closure intraoperatively with no evidence of stenosis, occlusion, or persistent bleeding, requiring additional intervention.

RESULTS

Of the 26 patients requiring pAxA access, 15 underwent complex endovascular aortic aneurysm repairs (EVAR) with branched, fenestrated, snorkel, or parallel endografts, 6 underwent peripheral vascular interventions, and 5 underwent cardiac interventions. Fifty-three percent accommodated sheath sizes of 12F or higher. Technical success was achieved in 100% of cases with no major perioperative access complications requiring additional open or endovascular procedures. In our series, we had one post-operative mortality secondary to myocardial infarction in a patient with significant coronary artery disease.

CONCLUSIONS

Our data again demonstrated the proposed safety and efficacy attributable to pAxA access, while extending its application to wide spectrum of endovascular interventions which included peripheral or coronary vascular in addition to complex EVAR.

Genetic and pharmacologic modulation of cementogenesis via pyrophosphate regulators

Pyrophosphate (PP_i) serves as a potent and physiologically important regulator of mineralization, with systemic and local concentrations determined by several key regulators, including: tissue-nonspecific alkaline phosphatase (ALPL gene; TNAP protein), the progressive ankylosis protein (ANKH; ANK), and ectonucleotide pyrophosphatase/phosphodiesterase 1 (ENPP1; ENPP1). Results to date have indicated important roles for PP_i in cementum formation, and we addressed several gaps in knowledge by employing genetically edited mouse models where PP_i metabolism was disrupted and pharmacologically modulating PP_i in a PP_i-deficient mouse model. We demonstrate that acellular cementum growth is inversely proportional to PP_i levels, with reduced cementum in Alpl KO (increased PP_i levels) mice and excess cementum in Ank KO mice (decreased PP_i levels). Moreover, simultaneous ablation of Alpl and Ank results in reestablishment of functional cementum in dKO mice. Additional reduction of PP_i by dual deletion of Ank and Enpp1 does not further increase cementogenesis, and PDL space is maintained in part through bone modeling/remodeling by osteoclasts. Our results provide insights into cementum formation and expand our knowledge of how PP_i regulates cementum. We also demonstrate for the first time that pharmacologic manipulation of PP_i through an ENPP1-Fc fusion protein can regulate cementum growth, supporting therapeutic interventions targeting PP_i metabolism.

Carotid Artery Angioplasty and Stenting for Atherosclerotic Plaque with Mobile Intimal Flap

Atherosclerotic carotid stenosis associated with a mobile carotid plaque (MCP) is a relatively rare entity, observed in less than 1 in 2,000 carotid ultrasound examinations. As such, the natural history of this lesion and risk for neurological thromboembolic complications are not well defined. Small case reports have described treatment varying from medical management with anticoagulation, to carotid endarterectomy, and more recently, carotid stenting. We present two patients with carotid stenosis associated with a MCP. A distinct MCP component that varied with the cardiac cycle was clearly delineated on ultrasound in both patients. Intravascular ultrasound (IVUS) at the time of carotid stenting confirmed the MCP. Successful carotid angioplasty and stenting was performed in both patients with resolution of the MCP documented on IVUS and follow-up duplex ultrasound. Although the definitive treatment method remains uncertain, carotid stenting is a viable option for treatment in patients with MCPs.

Endovascular Repair of Concomitant Celiac and Splenic Artery Aneurysms Using a Combination of Coil Embolization and Aortic Cuff Stent Graft

Large celiac artery aneurysms are associated with a high rupture and mortality risk. Traditionally, open surgical repair has been the mainstay of treatment. Endovascular alternatives have been increasingly described, ranging from coil embolization to exclusion with covered stent grafts. Certain features such as a short wide neck, small vessel diameters, and severe vessel tortuosity can limit these two options. We describe a 75-year-old man with a splenic and celiac trunk aneurysm that was treated using a combination of coil embolization to occlude the outflow artery and aneurysm sac, followed by an aortic stent graft cuff to block the inflow. This resulted in successful exclusion of the splenic and celiac artery aneurysms while preserving flow to both the spleen and liver through collateral pathways.

Bidirectional multiplexing of heralded single photons from a silicon chip

We demonstrate integrated spatial multiplexing of heralded single photons generated from a single 96 μm long silicon photonic crystal waveguide in a bidirectional pump configuration. By using a low-loss fiber-coupled opto-ceramic switch, the multiplexing technique enhances the brightness of the single photon source by 51.2±4.0% while maintaining the coincidence-to-accidental ratio. Compared with the demonstration of multiplexing two individual sources, the bidirectional pump scheme represents a twofold reduction in the footprint of nonlinear devices for future large-scale integration of on-chip single photon sources. The 51.2±4.0% gain will make any quantum operation requiring n photons 1.5(n) times faster.

Ultracompact all-optical XOR logic gate in a slow-light silicon photonic crystal waveguide

We demonstrate an ultracompact, chip-based, all-optical exclusive-OR (XOR) logic gate via slow-light enhanced four-wave mixing (FWM) in a silicon photonic crystal waveguide (PhCWG). We achieve error-free operation (<10⁻⁹) for 40 Gbit/s differential phase-shift keying (DPSK) signals with a 2.8 dB power penalty. Slowing the light to vg = c/32 enables a FWM conversion efficiency, η, of -30 dB for a 396 μm device. The nonlinear FWM process is enhanced by 20 dB compared to a relatively fast mode of vg = c/5. The XOR operation requires ≈ 41 mW, corresponding to a switching energy of 1 pJ/bit. We compare the slow-light PhCWG device performance with experimentally demonstrated XOR DPSK logic gates in other platforms and discuss scaling the device operation to higher bit-rates. The ultracompact structure suggests the potential for device integration.

All-optical XOR logic gate for 40Gb/s DPSK signals via FWM in a silicon nanowire

We demonstrate an all-optical XOR logic function for 40Gb/s differential phase-shift keyed (DPSK) data signals in the C-band, based on four-wave mixing (FWM) in a silicon nanowire. Error-free operation with a system penalty of ~3.0dB and ~4.3dB at 10⁻⁹ BER is achieved.

Photonic chip based transmitter optimization and receiver demultiplexing of a 1.28 Tbit/s OTDM signal

We demonstrate chip-based Tbaud optical signal processing for all-optical performance monitoring, switching and demultiplexing based on the instantaneous Kerr nonlinearity in a dispersion-engineered As(2)S(3) planar waveguide. At the Tbaud transmitter, we use a THz bandwidth radio-frequency spectrum analyzer to perform all-optical performance monitoring and to optimize the optical time division multiplexing stages as well as mitigate impairments, for example, dispersion. At the Tbaud receiver, we demonstrate error-free demultiplexing of a 1.28 Tbit/s single wavelength, return-to-zero signal to 10 Gbit/s via four-wave mixing with negligible system penalty (< 0.5 dB). Excellent performance, including high four-wave mixing conversion efficiency and no indication of an error-floor, was achieved. Our results establish the feasibility of Tbaud signal processing using compact nonlinear planar waveguides for Tbit/s Ethernet applications.

Simultaneous multi-impairment monitoring of 640 Gb/s signals using photonic chip based RF spectrum analyzer

We report the first demonstration of simultaneous multi-impairment monitoring at ultrahigh bitrates using a THz bandwidth photonic-chip-based radio-frequency (RF) spectrum analyzer. Our approach employs a 7 cm long, highly nonlinear (gamma approximately 9900 /W/km), dispersion engineered chalcogenide planar waveguide to capture the RF spectrum of an ultrafast 640 Gb/s signal, based on cross-phase modulation, from which we numerically retrieve the autocorrelation waveform. The relationship between the retrieved autocorrelation trace and signal impairments is exploited to simultaneously monitor dispersion, in-band optical signal to noise ratio (OSNR) and timing jitter from a single measurement. This novel approach also offers very high OSNR measurement dynamic range (> 30 dB) and is scalable to terabit data rates.

Terahertz bandwidth RF spectrum analysis of femtosecond pulses using a chalcogenide chip

We report the first demonstration of the use of an RF spectrum analyser with multi-terahertz bandwidth to measure the properties of femtosecond optical pulses. A low distortion and broad measurement bandwidth of 2.78 THz (nearly two orders of magnitude greater than conventional opto-electronic analyzers) was achieved by using a 6 cm long As(2)S(3) chalcogenide waveguide designed for high Kerr nonlinearity and near zero dispersion. Measurements of pulses as short as 260 fs produced from a soliton-effect compressor reveal features not evident from the pulse's optical spectrum. We also applied an inverse Fourier transform numerically to the captured data to re-construct a time-domain waveform that resembled pulse measurement obtained from intensity autocorrelation.

Lymphosarcoma in a boar

A 14-month-old Yorkshire boar was examined. In the abdomen, two big tumour masses were found in the intestines. In addition, pale nodules occurred in the liver, kidneys, in and upon the spleen, in the wall of the heart and in the testicles. By immunohistochemistry tumour cells were positive for CD3, but negative for B-lymphocyte antigen and CD79. From these findings it was concluded that the boar was suffering from multicentric lymphosarcoma probably of T-cell origin.

CD56+/CD4+ lymphomas and leukemias are morphologically, immunophenotypically, cytogenetically, and clinically diverse

CD56, a neural adhesion molecule, is a marker of natural killer (NK) lymphocytes as well as a subgroup of CD8+ T cells. Normal lymphocytes with a CD56/CD4 phenotype are scarce. Physiologic increases may occur in patients with immunosuppression, chronic inflammation, and autoimmune disorders. We report 4 cases of lymphomas/leukemias with the unusual CD56/CD4 phenotype. Two were of T-cell and 2 of true NK-cell origin. The T-cell lymphomas had large granular lymphocyte morphologic features and splenomegaly. One patients had a benign course; the other died within months of the leukemia diagnosis. The 2 NK cell lymphomas had blastic morphologic features, initially involved skin, and had a very aggressive clinical course; 1 patient died of acute leukemia, and 1 had recurrence after bone marrow transplantation. Cytogenetic analyses did not show a consistent pattern of abnormalities. The NK lymphoma with acute leukemia had a t(2;5) but was CD30- and anaplastic lymphoma kinase negative. Although CD56+/CD4+ lymphomas/leukemias are a heterogeneous group, there may be a distinct subgroup of NK lymphoblastoid lymphomas of the skin, judging from our cases, as well as those previously reported.

Platelet washing to prevent recurrent febrile reactions to leucocyte-reduced transfusions

Symptoms of fever and/or rigours after transfusion continue to occur commonly in patients receiving platelets leucocyte-reduced after storage. A cohort of 24 consecutive patients who had experienced severe or repeated febrile nonhaemolytic reactions to post-storage leucocyte-reduced platelet transfusions were treated with saline-washed, post-storage leucocyte-reduced platelets. The frequency of reactions declined from 20% of transfusions (n = 191) to 0.6% (n = 331) after instituting saline-washed, post-storage leucocyte-reduced platelet transfusions. These results support the hypothesis that substances present in the supernatant of stored platelet concentrates mediate febrile nonhaemolytic transfusion reactions, and provide one strategy for preventing their occurrence.

Clonal analysis of gliomas

In malignant gliomas, the characteristically heterogeneous features and frequent diffuse spread within the brain have raised the question of whether malignant gliomas arise monoclonally from a single precursor cell or polyclonally from multiple transformed cells forming confluent clones. Although monoclonality has been shown in surgically resected tissues, these may not include the full spectrum of patterns seen on autopsy material. Little is known about the clonality of low-grade gliomas from which malignant gliomas may sometimes arise. We sought to investigate the clonality of low-grade and malignant gliomas by using and comparing surgical and autopsy material with a Polymerase chain reaction (PCR)-based assay for nonrandom X chromosome inactivation. For that, purpose, archival surgical and autopsy material from 15 female patients (group A) (age 4 to 73 years; median, 45) with malignant gliomas (12 glioblastomas, one gliosarcoma, one anaplastic oligoastrocytoma, one gliomatosis cerebri), surgical material only from 21 female patients (group S) (age 6 to 78 years; median, 60) with low-grade and malignant gliomas (four low-grade astrocytomas, three oligoastrocytomas, two anaplastic astrocytomas, one gemistocytic astrocytoma, four oligodendrogliomas, seven glioblastomas) were analyzed. In group A, representative areas (mean = 5/patient; median = 7) were microdissected from tissue sections and assayed by PCR amplification of a highly polymorphic microsatellite marker locus of the human androgen receptor gene (HUMARA) in the presence of alpha32P with and without predigestion with a methylation-sensitive restriction enzyme (HhaI). Products were resolved by denaturing gel electrophoresis and autoradiographed. In group S, selected tumor areas were used for the assay. Each patient's normal brain tissue was used for control. The band intensity of alleles were measured by densitometric scanning. In group A, 13 of 15 cases were informative (heterozygous). The same pattern of nonrandom X chromosome inactivation was present in all areas of solid dense and moderate tumor infiltration in eight including all components of the gliosarcoma. Two of eight also showed focal loss of heterozygosity (LOH). One of 13 presented global LOH. Two of 13 showed microsatellite instability, one of which in a patient with Turcot syndrome, the other in gliomatosis cerebri. Opposite skewing patterns were seen in distant areas of gliomatosis cerebri consistent with oligoclonal derivation. Clonality remained indeterminate in one glioblastoma and in the anaplastic oligoastrocytoma because of skewed lyonization in the normal control. In group S, 19 of 21 cases were informative. Fifteen of 19 were monoclonal (four low-grade astrocytomas, one anaplastic astrocytoma, one gemistocytic astrocytoma, two oligodendrogliomas, one oligoastrocytoma, six glioblastomas). Four of 19 were indeterminate. We conclude that (1) Low-grade and malignant gliomas are usually monoclonal tumors, and extensively infiltrating tumors must result from migration of tumor cells (2) Gliomatosis cerebri may initiate as an oligoclonal process or result from collision gliomas (3) Biphasic gliomas likely arise from a single precursor cell. (4) LOH at the HUMARA locus is probably related to partial or complete deletion of an X-chromosome, which occurs in malignant gliomas during clonal evolution.

An anonymous genomic clone that detects a frequent RFLP adjacent to the D4S10 (G8) marker and Huntington's disease

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A distributed microcomputer-controlled system for data acquisition and power spectral analysis of EEG

A relatively powerful and inexpensive microcomputer-based system for the spectral analysis of the EEG is presented. High resolution and speed is achieved with the use of recently available large-scale integrated circuit technology with enhanced functionality (INTEL Math co-processors 8087) which can perform transcendental functions rapidly. The versatility of the system is achieved with a hardware organization that has distributed data acquisition capability performed by the use of a microprocessor-based analog to digital converter with large resident memory (Cyborg ISAAC-2000). Compiled BASIC programs and assembly language subroutines perform on-line or off-line the fast Fourier transform and spectral analysis of the EEG which is stored as soft as well as hard copy. Some results obtained from test application of the entire system in animal studies are presented.

The ontogeny of fetal lamb electrocortical activity: a power spectral analysis

With the use of a relatively inexpensive microcomputer-based system for power spectral analysis, we have been able to provide quantitative information on maturational changes in electrocorticogram waveforms in the third-trimester fetal lamb. Twenty-six electrocorticogram recordings were obtained from nine fetal lambs, with gestational ages ranging from 114 to 139 days' gestation. The transition from disorganized to cyclic electrocorticogram activity (high-voltage slow activity and low-voltage fast activity) occurred at approximately 115 to 120 days' gestation. However, quantitative changes in waveform characteristics of the electrocorticogram continued throughout the rest of gestation. These maturational changes occurred primarily in the low-voltage fast activity periods, with a decrease in power density in the delta (0.3 to 3 Hz) band and an increase in the maximum frequencies detected in the beta (15 to 30 Hz) band. There were no significant changes in the power spectrum of the high-voltage slow activity periods as a function of gestational age.