Regionalization of Emergent Vascular Surgery for Patients With Ruptured AAA Improves Outcomes.

PubMed

Warner, Courtney J; Roddy, Sean P; Chang, Benjamin B; Kreienberg, Paul B; Sternbach, Yaron; Taggert, John B; Ozsvath, Kathleen J; Stain, Steven C; Darling, R Clement

2016-09-01

Safe and efficient endovascular aneurysm repair (EVAR) for ruptured abdominal aortic aneurysm (r-AAA) requires advanced infrastructure and surgical expertise not available at all US hospitals. The objective was to assess the impact of regionalizing r-AAA care to centers equipped for both open surgical repair (r-OSR) and EVAR (r-EVAR) by vascular surgeons. A retrospective review of all patients with r-AAA undergoing open or endovascular repair in a 12-hospital region. Patient demographics, transfer status, type of repair, and intraoperative variables were recorded. Outcomes included perioperative morbidity and mortality. Four hundred fifty-one patients with r-AAA were treated from 2002 to 2015. Three hundred twenty-one patients (71%) presented initially to community hospitals (CHs) and 130 (29%) presented to the tertiary medical center (MC). Of the 321 patients presenting to CH, 133 (41%) were treated locally (131 OSR; 2 EVAR) and 188 (59%) were transferred to the MC. In total, 318 patients were treated at the MC (122 OSR; 196 EVAR). At the MC, r-EVAR was associated with a lower mortality rate than r-OSR (20% vs 37%, P = 0.001). Transfer did not influence r-EVAR mortality (20% in r-EVAR presenting to MC vs 20% in r-EVAR transferred, P > 0.2). Overall, r-AAA mortality at the MC was 20% lower than CH (27% vs 46%, P < 0.001). Regionalization of r-AAA repair to centers equipped for both r-EVAR and r-OSR decreased mortality by approximately 20%. Transfer did not impact the mortality of r-EVAR at the tertiary center. Care of r-AAA in the US should be centralized to centers equipped with available technology and vascular surgeons.

Total laparorobotic repair of abdominal aortic aneurysm with sac exclusion obliteration and aortobifemoral bypass.

PubMed

Wu, Timothy; Prema, Jateen; Zagaja, Gregory; Shalhav, Arieh; Bassiouny, Hisham S

2009-01-01

A 65-year-old man with coronary artery disease, hypertension, and peripheral vascular disease was found to have an asymptomatic abdominal aortic aneurysm (AAA) of 5.5 cm on surveillance for his peripheral vascular disease. Cardiac stress testing demonstrated no evidence of myocardial ischemia, and he opted to undergo open repair of his aneurysm. Laparorobotic repair of the infrarenal AAA using the da Vinci robotic system was performed with an aortobifemoral bypass. We describe a novel technique for AAA exclusion using a cerclage method, which greatly facilitates repair of infrarenal AAAs using laparorobotic techniques. Laparorobotic repair of infrarenal AAA can be greatly facilitated by AAA sac exclusion and obliteration without the need to ligate all lumbar arteries or to open the aneurysm. This virtually avoids blood loss from the sac and minimizes the possibility for open conversion as a result of poor visualization. Minimally invasive aortic intervention for aneurysmal disease using laparascopic methods has been reported in the literature. Problems associated with this technique include a prolonged learning curve and difficulty completing intracorporeal anastomoses. Robotic surgery provides an advantage over laparoscopic surgery in its ability to provide greater degrees of freedom in a relatively small field of view along with superior high-definition, three-dimensional visualization. To date, there have been no known reports of using robotic surgery in the United States as a sole method for repair of AAA. We report our technique of combining robotic surgery with a novel procedure for sac exclusion and obliteration to successfully repair AAA without the need for opening the aneurysm sac and endoaneurysmorrhaphy.

Distinct myeloid cell subsets promote meningeal remodeling and vascular repair after mild traumatic brain injury.

PubMed

Russo, Matthew V; Latour, Lawrence L; McGavern, Dorian B

2018-05-01

Mild traumatic brain injury (mTBI) can cause meningeal vascular injury and cell death that spreads into the brain parenchyma and triggers local inflammation and recruitment of peripheral immune cells. The factors that dictate meningeal recovery after mTBI are unknown at present. Here we demonstrated that most patients who had experienced mTBI resolved meningeal vascular damage within 2-3 weeks, although injury persisted for months in a subset of patients. To understand the recovery process, we studied a mouse model of mTBI and found extensive meningeal remodeling that was temporally reliant on infiltrating myeloid cells with divergent functions. Inflammatory myelomonocytic cells scavenged dead cells in the lesion core, whereas wound-healing macrophages proliferated along the lesion perimeter and promoted angiogenesis through the clearance of fibrin and production of the matrix metalloproteinase MMP-2. Notably, a secondary injury experienced during the acute inflammatory phase aborted this repair program and enhanced inflammation, but a secondary injury experienced during the wound-healing phase did not. Our findings demonstrate that meningeal vasculature can undergo regeneration after mTBI that is dependent on distinct myeloid cell subsets.

Abdominal aortic aneurysm repair in New Zealand: a validation of the Australasian Vascular Audit.

PubMed

Khashram, Manar; Thomson, Ian A; Jones, Gregory T; Roake, Justin A

2017-05-01

In New Zealand (NZ), there are two major sources of operative data for abdominal aortic aneurysm (AAA) repair: the Australasian Vascular Audit (AVA) and the National Minimum Data Set (NMDS). Since the introduction of the AVA in NZ, there has not been any attempt at the validation of outcome data. The aims of this study were to report the outcomes of AAA repair and validate the AAA data captured by AVA using the NMDS. AAA procedures performed in NZ from January 2010 to December 2014 were extracted from the AVA and NMDS. Patients identified from the AVA had their survival status matched to the NMDS. Only primary AAA procedures were included for the analysis, with re-interventions and graft infections excluded. Demographical, risk factors and outcome data were used for validation. The number of patients undergoing primary AAA procedure from AVA and NMDS was 1713 and 2078, respectively. The AVA inpatient mortality for elective and rupture AAA was 1.6 and 32.2%, respectively. The NMDS 30-day mortality from AAA was 2.5 and 31.5%. Overall, 1604 patients were available for matching, and the NMDS correctly reported 98.1% of endovascular aneurysm repair and 94.2% of elective AAA repairs; however, there were major differences in comorbidity reporting between the data sets. Both data sets were incomplete, but combining administrative (NMDS) and clinical (AVA) data sets provided a more accurate assessment of mortality figures. More than 80% of AAA repairs are captured by AVA, but further work to improve compliance and comorbidity documentation is required. © 2016 Royal Australasian College of Surgeons.

Obesity is not an independent risk factor for adverse perioperative and long-term clinical outcomes following open AAA repair or EVAR.

PubMed

Park, Brian; Dargon, Phong; Binette, Christopher; Babic, Bruna; Thomas, Tina; Divinagracia, Thomas; Dahn, Michael S; Menzoian, James O

2011-10-01

Moderate (body mass index [BMI] ≥30) and morbid obesity (BMI ≥35) is increasing at an alarming rate in vascular surgery patients. The objective of this study was to determine the impact of obesity on perioperative and long-term clinical outcomes following open abdominal aortic aneurysm (AAA) repair or endovascular aneurysm repair (EVAR). This review includes patients that underwent open AAA repair (n = 403) or EVAR (n = 223) from 1999 to 2009. Specific patient characteristics such as comorbid diseases, medications, and body mass index (BMI) were assessed. Specific perioperative outcomes such as length of stay, myocardial infarctions, and mortality were reviewed. In addition, long-term outcomes such as rates of reintervention, permanent renal dysfunction, and mortality beyond 30 days were also assessed. The incidence of obesity in open AAA patients was 25.3% (documented incidence 1.5%) and for EVAR was 24.6% (documented incidence 4%). Moderate and morbid obesity was associated with longer intensive care unit (ICU) admissions for both open AAA or EVAR patients (P < .05). However, no significant differences in perioperative outcomes in terms of overall length of stay, myocardial infarction, acute renal failure, wound infections, or mortality were noted between obese and nonobese patients underoing open AAA repair or EVAR (P > .05). Similarly, moderate and morbid obesity was not associated with significant differences in rates of reintervention, permanent renal dysfunction, and mortality beyond 30 days for patients undergoing open AAA repair or EVAR (P > .05). The results of this study indicate that moderate and morbid obesity are not independently associated with adverse perioperative and long-term clinical outcomes for patients undergoing open AAA repair or EVAR. Therefore, either open AAA repair or EVAR can be accomplished safely in moderately obese and morbidly obese patients.

Generation of Functional Blood Vessels from a Single c-kit+ Adult Vascular Endothelial Stem Cell

PubMed Central

Fang, Shentong; Wei, Jing; Pentinmikko, Nalle; Leinonen, Hannele; Salven, Petri

2012-01-01

In adults, the growth of blood vessels, a process known as angiogenesis, is essential for organ growth and repair. In many disorders including cancer, angiogenesis becomes excessive. The cellular origin of new vascular endothelial cells (ECs) during blood vessel growth in angiogenic situations has remained unknown. Here, we provide evidence for adult vascular endothelial stem cells (VESCs) that reside in the blood vessel wall endothelium. VESCs constitute a small subpopulation within CD117+ (c-kit+) ECs capable of undergoing clonal expansion while other ECs have a very limited proliferative capacity. Isolated VESCs can produce tens of millions of endothelial daughter cells in vitro. A single transplanted c-kit-expressing VESC by the phenotype lin−CD31+CD105+Sca1+CD117+ can generate in vivo functional blood vessels that connect to host circulation. VESCs also have long-term self-renewal capacity, a defining functional property of adult stem cells. To provide functional verification on the role of c-kit in VESCs, we show that a genetic deficit in endothelial c-kit expression markedly decreases total colony-forming VESCs. In vivo, c-kit expression deficit resulted in impaired EC proliferation and angiogenesis and retardation of tumor growth. Isolated VESCs could be used in cell-based therapies for cardiovascular repair to restore tissue vascularization after ischemic events. VESCs also provide a novel cellular target to block pathological angiogenesis and cancer growth. PMID:23091420

Variations in Abdominal Aortic Aneurysm Care: A Report From the International Consortium of Vascular Registries

PubMed Central

Sedrakyan, Art; Mao, Jialin; Venermo, Maarit; Faizer, Rumi; Debus, Sebastian; Behrendt, Christian-Alexander; Scali, Salvatore; Altreuther, Martin; Schermerhorn, Marc; Beiles, Barry; Szeberin, Zoltan; Eldrup, Nikolaj; Danielsson, Gudmundur; Thomson, Ian; Wigger, Pius; Björck, Martin; Cronenwett, Jack L.; Mani, Kevin

2016-01-01

Background: This project by the ICVR (International Consortium of Vascular Registries), a collaboration of 11 vascular surgical quality registries, was designed to evaluate international variation in the contemporary management of abdominal aortic aneurysm (AAA) with relation to recommended treatment guidelines from the Society for Vascular Surgery and the European Society for Vascular Surgery. Methods: Registry data for open and endovascular AAA repair (EVAR) during 2010 to 2013 were collected from 11 countries. Variations in patient selection and treatment were compared across countries and across centers within countries. Results: Among 51 153 patients, 86% were treated for intact AAA (iAAA) and 14% for ruptured AAA. Women constituted 18% of the entire cohort (range, 12% in Switzerland–21% in the United States; P<0.01). Intact AAAs were repaired at diameters smaller than recommended by guidelines in 31% of men (<5.5 cm; range, 6% in Iceland–41% in Germany; P<0.01) and 12% of women with iAAA (<5 cm; range, 0% in Iceland–16% in the United States; P<0.01). Overall, use of EVAR for iAAA varied from 28% in Hungary to 79% in the United States (P<0.01) and for ruptured AAA from 5% in Denmark to 52% in the United States (P<0.01). In addition to the between-country variations, significant variations were present between centers in each country in terms of EVAR use and rate of small AAA repair. Countries that more frequently treated small AAAs tended to use EVAR more frequently (trend: correlation coefficient, 0.51; P=0.14). Octogenarians made up 23% of all patients, ranging from 12% in Hungary to 29% in Australia (P<0.01). In countries with a fee-for-service reimbursement system (Australia, Germany, Switzerland, and the United States), the proportions of small AAA (33%) and octogenarians undergoing iAAA repair (25%) were higher compared with countries with a population-based reimbursement model (small AAA repair, 16%; octogenarians, 18%; P<0.01). In general, center-level variation within countries in the management of AAA was as important as variation between countries. Conclusions: Despite homogeneous guidelines from professional societies, significant variation exists in the management of AAA, most notably for iAAA diameter at repair, use of EVAR, and the treatment of elderly patients. ICVR provides an opportunity to study treatment variation across countries and to encourage optimal practice by sharing these results. PMID:27784712

Survival affects decision making for fenestrated and branched endovascular aortic repair.

PubMed

Beach, Jocelyn M; Rajeswaran, Jeevanantham; Parodi, F Ezequiel; Kuramochi, Yuki; Brier, Corey; Blackstone, Eugene; Eagleton, Matthew J

2018-03-01

Repair options for complex abdominal and thoracoabdominal aortic aneurysms (TAAAs) are evolving with increased experience and availability of less invasive endovascular techniques. Identifying risk factors for mortality after fenestrated and branched endovascular aortic repair (F/B-EVAR) could improve patient selection and facilitate decision making regarding who may benefit from prophylactic F/B-EVAR. We evaluated 1091 patients in a prospective investigational device exemption trial who underwent F/B-EVAR from August 2001 to June 2015 for complex aortic aneurysms (CAAs). Multivariable analysis of risk factors for death was performed using a nonproportional hazards model and a nonparametric analysis using random survival forest technology. Operative mortality after F/B-EVAR was low (3.7%), with high CAA-related survival at 30 day and 5 years (96.8% and 94.0%, respectively). All-cause 5-year survival, however, was 46.2% and older age, heart failure, chronic obstructive pulmonary disease, renal disease, anemia, and coagulation disorders were risk factors. Risk was highest for those undergoing type I/II TAAA repairs and those with larger aneurysms. Patients with multiple comorbidities and those undergoing type I or II TAAA repair are at greatest risk of mortality; however, in this high-risk population, F/B-EVAR offers greater survival compared with that reported for the natural history of untreated aneurysms. Operative and early mortality is lower than the best-reported open repair outcomes, even in this high-risk population, suggesting a potential benefit in extending the use of F/B-EVAR to low-to-average risk CAA patients. Copyright © 2017 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.

Concomitant Abdominoplasty and Laparoscopic Umbilical Hernia Repair.

PubMed

van Schalkwyk, Constant P; Dusseldorp, Joseph R; Liang, Derek G; Keshava, Anil; Gilmore, Andrew J; Merten, Steve

2018-04-20

Umbilical hernia is a common finding in patients undergoing abdominoplasty, especially those who are post-partum with rectus divarication. Concurrent surgical treatment of the umbilical hernia at abdominoplasty presents a "vascular challenge" due to the disruption of dermal blood supply to the umbilicus, leaving the stalk as the sole axis of perfusion. To date, there have been no surgical techniques described to adequately address large umbilical herniae during abdominoplasty. To present an effective and safe technique that can address large umbilical herniae during abdominoplasty. A prospective series of 10 consecutive patients, undergoing concurrent abdominoplasty and laparoscopic umbilical hernia repair between 2014 and 2017 were included in the study. All procedures were performed by the same general surgeon and plastic surgeon at the Macquarie University Hospital in North Ryde, NSW, Australia. Data was collected with approval of our ethics committee. At 12-month follow-up there were no instances of umbilical necrosis, wound complications, seroma or recurrent hernia. The mean body mass index was 23.8 kg/m2 (range, 16.1-30.1 kg/m2). Rectus divarication ranged from 35-80 mm (mean, 53.5 mm). Umbilical hernia repair took a mean of 25.9 minutes to complete (range, 18-35 minutes). We present a technique that avoids incision of the rectus fascia minimizes dissection of the umbilical stalk and is able to provide a gold standard hernia repair with mesh. This procedure is particularly suited to post-partum patients with large herniae (>3-4 cm diameter) and wide rectus divarication, where mesh repair with adequate overlap is the recommended treatment.

Biomaterial-mediated strategies targeting vascularization for bone repair.

PubMed

García, José R; García, Andrés J

2016-04-01

Repair of non-healing bone defects through tissue engineering strategies remains a challenging feat in the clinic due to the aversive microenvironment surrounding the injured tissue. The vascular damage that occurs following a bone injury causes extreme ischemia and a loss of circulating cells that contribute to regeneration. Tissue-engineered constructs aimed at regenerating the injured bone suffer from complications based on the slow progression of endogenous vascular repair and often fail at bridging the bone defect. To that end, various strategies have been explored to increase blood vessel regeneration within defects to facilitate both tissue-engineered and natural repair processes. Developments that induce robust vascularization will need to consolidate various parameters including optimization of embedded therapeutics, scaffold characteristics, and successful integration between the construct and the biological tissue. This review provides an overview of current strategies as well as new developments in engineering biomaterials to induce reparation of a functional vascular supply in the context of bone repair.

Outcomes for Symptomatic Abdominal Aortic Aneurysms in the American College of Surgeons National Surgical Quality Improvement Program (NSQIP)

PubMed Central

Soden, Peter A.; Zettervall, Sara L.; Ultee, Klaas H.J.; Darling, Jeremy D.; Buck, Dominique B.; Hile, Chantel N.; Hamdan, Allen D.; Schermerhorn, Marc L.

2016-01-01

Introduction Historically symptomatic AAAs were found to have intermediate mortality compared to asymptomatic and ruptured AAAs but, with wider EVAR use, a more recent study suggested mortality of symptomatic aneurysms were similar to asymptomatic AAAs. These prior studies were limited by small numbers. The purpose of this study is to evaluate the mortality and morbidity associated with symptomatic AAA repair in a large contemporary population. Methods All patients undergoing infrarenal AAA repair were identified in the 2011–2013 ACS-NSQIP, Vascular Surgery targeted module. We excluded acute conversions to open repair and those for whom the surgical indication was embolization, dissection, thrombosis, or not documented. We compared 30-day mortality and major adverse events (MAE) for asymptomatic, symptomatic, and ruptured AAA repair, stratified by EVAR and open repair, with univariate analysis and multivariable logistic regression. Results 5502 infrarenal AAAs were identified, 4495 asymptomatic (830 open repair, 3665 [82%] EVAR), 455 symptomatic (143 open, 312 [69%] EVAR), and 552 ruptured aneurysms (263 open, 289 [52%] EVAR). Aneurysm diameter was similar between asymptomatic and symptomatic AAAs, when stratified by procedure type, but larger for ruptured aneurysms (EVAR symptomatic 5.8cm ±1.6 vs. ruptured 7.5cm ±2.0, P<.001; open repair symptomatic 6.4cm ±1.9 vs. ruptured 8.0cm ±1.9, P<.001). The proportion of females was similar in symptomatic and ruptured AAA (27% vs. 23%, P=.14, respectively), but lower in asymptomatic AAA (20%, P<.001). Symptomatic AAAs had intermediate 30-day mortality compared to asymptomatic and ruptured aneurysms after both EVAR (asymptomatic 1.4% vs. symptomatic 3.8%, P=.001; symptomatic vs. 22% ruptured, P<.001) and open repair (asymptomatic 4.3% vs. symptomatic 7.7% , P=.08; symptomatic vs. 57% ruptured, P<.001). After adjustment for age, gender, repair type, dialysis dependence, and history of severe COPD, patients undergoing repair of symptomatic AAAs were twice as likely to die within 30-days compared to those with asymptomatic aneurysms (OR 2.1, 95%CI 1.3–3.5). When stratified by repair type the effect size and direction of the odds ratios were similar (EVAR OR 2.4, CI 1.2–4.7; open repair OR 1.8, CI 0.86–3.9), although not significant for open repair. Patients with ruptured aneurysms had a sevenfold increased risk of 30-day mortality compared to symptomatic patients (OR 6.5, CI 4.1–10.6). Conclusion Patients with symptomatic AAAs had a two-fold increased risk of perioperative mortality, compared to asymptomatic aneurysms undergoing repair. Furthermore, patients with ruptured aneurysms have a seven-fold increased risk of mortality compared to symptomatic aneurysms. PMID:27146791

Patients with end-stage renal disease have poor outcomes after endovascular abdominal aortic aneurysm repair.

PubMed

Komshian, Sevan; Farber, Alik; Patel, Virendra I; Goodney, Philip P; Schermerhorn, Marc L; Blazick, Elizabeth A; Jones, Douglas W; Rybin, Denis; Doros, Gheorghe; Siracuse, Jeffrey J

2018-06-23

Although endovascular repair of abdominal aortic aneurysms (AAAs) has been demonstrated to have favorable outcomes, not all cohorts of patients with AAA fare equally well. Our goal was to investigate perioperative and 1-year outcomes in patients with end-stage renal disease (ESRD) on dialysis, who have traditionally fared worse after vascular interventions, to assess how ESRD affects outcomes in a large modern cohort of endovascular aneurysm repair (EVAR) patients. The Vascular Quality Initiative database was queried for all patients undergoing EVAR from 2010 to 2017. ESRD patients were compared with patients not on dialysis. Propensity-matched scoring and multivariable analysis were used to isolate the effects of ESRD. Of 28,683 EVARs identified, there were 321 (1.12%) patients with ESRD on dialysis. Patients with ESRD had no difference in presenting AAA size (57.5 ± 12.7 mm vs 56.7 ± 17.2 mm; P = .44); however, they had more urgent/emergent repairs (20.6% vs 13.6%; P = .002) than those without ESRD. ESRD patients were more often younger, nonwhite, and nonobese and less likely to have commercial insurance (P < .05). ESRD patients more often had hypertension, coronary artery disease, congestive heart failure, previous lower extremity bypass, aneurysm repair, and carotid interventions (P < .05). There was no difference in the rate of concomitant procedures. Matching based on demographics, comorbidities, and operative details showed that ESRD patients had longer hospital length of stay (4.8 ± 9.4 days vs 4.1 ± 12.6 days; P = .026) and higher 30-day mortality (7% vs 2.4%; P < .001). There was no difference in cardiac, pulmonary, lower extremity, bowel, and stroke complications or return to the operating room. On multivariable analysis, ESRD was associated with 30-day mortality (odds ratio, 4.1; 95% confidence interval, 2.6-6.7; P < .001). Of the 24,750 elective EVARs, 1.04% had ESRD on dialysis. Matched data for elective EVAR show increased postoperative length of stay, hospital mortality, and 30-day mortality for ESRD patients on dialysis compared with those who are not. There was no association with postoperative myocardial infarction or pulmonary complications. At 1 year, patients with ESRD on dialysis had worse survival (78% vs 94%; P < .001), and ESRD was associated with higher mortality (hazard ratio, 3.3; 95% confidence interval, 2.5-4.2; P < .001). Among patients undergoing EVAR, ESRD is independently associated with higher perioperative and 1-year mortality despite not being associated with higher postoperative complications. This should be taken into account during informed consent for EVAR and risk-benefit considerations in this high-risk population, particularly for elective repair. Copyright © 2018 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.

Detection of patent ductus arteriosus with intraoperative transesophageal echocardiography in a patient undergoing closure of coronary artery to pulmonary artery fistula.

PubMed

Miyata, Yuka; Hayashi, Yukio

2017-01-01

Coronary artery to pulmonary artery fistula is an unusual vascular anomaly, and the shunt ratio of this fistula is usually small. We report anesthetic management of a 55-year-old female with annuloaortic ectasia, aortic valve regurgitation, and coronary artery to pulmonary artery fistula undergoing radical repair. We calculated the left-to-right shunt ratio after placement of a pulmonary artery catheter and found that the ratio was unexpectedly high. Thus, we explored the presence of another shunt by intraoperative transesophageal echocardiography and found patent ductus arteriosus undiagnosed before operation. A combination of a pulmonary artery catheter and transesophageal echocardiography is useful to explore the presence of another shunt, such as patent ductus arteriosus during anesthesia.

Using a multimedia presentation to improve patient understanding and satisfaction with informed consent for minimally invasive vascular procedures.

PubMed

Bowers, N; Eisenberg, E; Montbriand, J; Jaskolka, J; Roche-Nagle, G

2017-02-01

As vascular procedures become more complex, patient understanding of their treatment(s) can become more difficult. We wished to evaluate the utility of multimedia presentations (MPs) to improve patient understanding of their vascular interventions. Patients undergoing endovascular aneurysm repair (EVAR), peripheral angioplasty, Hickman catheter and peripherally inserted central catheter (PICC) insertion were randomized into a control group receiving traditional verbal consent, and a MP group that were shown a two minute simplified video of their procedure on an iPad™ computer in addition to the traditional verbal consent. After obtaining consent, all patients completed a questionnaire assessing their comprehension of the procedure, and satisfaction with the consent process. Satisfaction was rated on a 5 point Likert scale with 5 being 'very helpful' in understanding the procedure. Ninety-three patients were recruited for this study, 62% of which were male. The intervention significantly increased total comprehension in all procedure types controlling for procedure type (multimedia vs. control; F = 9.14, P = .003). A second ANOVA showed there was a significant main effect by intervention (F = 44.06, p < .000) with those in the intervention group showing higher overall satisfaction scores after controlling for surgery type. This study suggests that patients find the use of MP during the consent process to be helpful in patient understanding and that there is improved satisfaction. Given the rapid rate of innovation in vascular interventions, increased regular use of MPs to help patients understand their procedures would be beneficial in the care of patients undergoing vascular interventions. Copyright © 2015 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland. Published by Elsevier Ltd. All rights reserved.

Management of war-related vascular injuries: experience from the second gulf war.

PubMed

Jawas, Ali; Abbas, Alaa K; Nazzal, Munier; Albader, Marzoog; Abu-Zidan, Fikri M

2013-07-01

To study the biomechanism, pattern of injury, management, and outcome of major vascular injuries treated at Mubarak Al-Kabeer Teaching Hospital, Kuwait during the Second Gulf War. This is a descriptive retrospective study. War-related injured patients who had major vascular injuries and were treated at Mubarak Al-Kabeer Teaching Hospital from August 1990 to September 1991 were studied. Studied variables included age, gender, anatomical site of vascular injury, mechanism of injury, associated injuries, type of vascular repair, and clinical outcome. 36 patients having a mean (SD) age of 29.8 (10.2) years were studied. 32 (89%) were males and 21 (58%) were civilians. Majority of injuries were caused by bullets (47.2%) and blast injuries (47.2%). Eight patients (22%) presented with shock.There were 31 arterial injuries, common and superficial femoral artery injuries were most common (10/31). Arterial repair included interposition saphenous vein graft in seven patients, thrombectomy with end-to-end / lateral repair in twelve patients, vein patch in two patients, and arterial ligation in four patients. Six patients had arterial ligation as part of primary amputation. 3/21 (14.3%) patients had secondary amputation after attempted arterial vascular repair of an extremity. There were a total of 17 venous injuries, 13 managed by lateral suture repair and 4 by ligation. The median (range) hospital stay was 8 (1-76) days. 5 patients died (14%). Major vascular injuries occurred in 10% of hospitalized war-related injured patients. Our secondary amputation rate of extremities was 14%. The presence of a vascular surgeon within a military surgical team is highly recommended. Basic principles and techniques of vascular repair remain an essential part of training general surgeons because it may be needed in unexpected wars.

Promoting Endochondral Bone Repair Using Human Osteoarthritic Articular Chondrocytes.

PubMed

Bahney, Chelsea S; Jacobs, Linsey; Tamai, Robert; Hu, Diane; Luan, Tammy F; Wang, Miqi; Reddy, Sanjay; Park, Michelle; Limburg, Sonja; Kim, Hubert T; Marcucio, Ralph; Kuo, Alfred C

2016-03-01

Current tissue engineering strategies to heal critical-size bone defects through direct bone formation are limited by incomplete integration of grafts with host bone and incomplete graft vascularization. An alternative strategy for bone regeneration is the use of cartilage grafts that form bone through endochondral ossification. Endochondral cartilages stimulate angiogenesis and are remodeled into bone, but are found in very small quantities in growth plates and healing fractures. We sought to develop engineered endochondral cartilage grafts using osteoarthritic (OA) articular chondrocytes as a cell source. Such chondrocytes often undergo hypertrophy, which is a characteristic of endochondral cartilages. We compared the ability of unmodified human OA (hOA) cartilage and cartilage grafts formed in vitro from hOA chondrocytes to undergo endochondral ossification in mice. Scaffold-free engineered chondrocyte grafts were generated by pelleting chondrocytes, followed by culture with transforming growth factor-β1 (TGF-β1) and bone morphogenetic protein 4. Samples derived from either primary or passaged chondrocytes were implanted subcutaneously into immunocompromised mice. Grafts derived from passaged chondrocytes from three patients were implanted into critical-size tibial defects in mice. Bone formation was assessed with histology after 4 weeks of implantation. The composition of tibial repair tissue was quantified with histomorphometry. Engineered cartilage grafts generated from passaged OA chondrocytes underwent endochondral ossification after implantation either subcutaneously or in bone. Cartilage grafts integrated with host bone at 15 out of 16 junctions. Grafts variably remodeled into woven bone, with the proportion of bony repair tissue in tibial defects ranging from 22% to 85% (average 48%). Bony repair tissue bridged the tibial defects in half of the animals. In contrast, unmodified OA cartilage and engineered grafts formed from primary chondrocytes did not undergo endochondral ossification in vivo. hOA chondrocytes can adopt an endochondral phenotype after passaging and TGF-β superfamily treatment. Engineered endochondral cartilage grafts can integrate with host bone, undergo ossification, and heal critical-size long-bone defects in a mouse model. However, additional methods to further enhance ossification of these grafts are required before the clinical translation of this approach.

Comparison of three contemporary risk scores for mortality following elective abdominal aortic aneurysm repair.

PubMed

Grant, S W; Hickey, G L; Carlson, E D; McCollum, C N

2014-07-01

A number of contemporary risk prediction models for mortality following elective abdominal aortic aneurysm (AAA) repair have been developed. Before a model is used either in clinical practice or to risk-adjust surgical outcome data it is important that its performance is assessed in external validation studies. The British Aneurysm Repair (BAR) score, Medicare, and Vascular Governance North West (VGNW) models were validated using an independent prospectively collected sample of multicentre clinical audit data. Consecutive, data on 1,124 patients undergoing elective AAA repair at 17 hospitals in the north-west of England and Wales between April 2011 and March 2013 were analysed. The outcome measure was in-hospital mortality. Model calibration (observed to expected ratio with chi-square test, calibration plots, calibration intercept and slope) and discrimination (area under receiver operating characteristic curve [AUC]) were assessed in the overall cohort and procedural subgroups. The mean age of the population was 74.4 years (SD 7.7); 193 (17.2%) patients were women and the majority of patients (759, 67.5%) underwent endovascular aneurysm repair. All three models demonstrated good calibration in the overall cohort and procedural subgroups. Overall discrimination was excellent for the BAR score (AUC 0.83, 95% confidence interval [CI] 0.76-0.89), and acceptable for the Medicare and VGNW models, with AUCs of 0.78 (95% CI 0.70-0.86) and 0.75 (95% CI 0.65-0.84) respectively. Only the BAR score demonstrated good discrimination in procedural subgroups. All three models demonstrated good calibration and discrimination for the prediction of in-hospital mortality following elective AAA repair and are potentially useful. The BAR score has a number of advantages, which include being developed on the most contemporaneous data, excellent overall discrimination, and good performance in procedural subgroups. Regular model validations and recalibration will be essential. Copyright © 2014 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.

The roles of vascular endothelial growth factor in bone repair and regeneration

PubMed Central

Hu, Kai; Olsen, Bjorn R.

2016-01-01

Vascular endothelial growth factor-A (VEGF) is one of the most important growth factors for regulation of vascular development and angiogenesis. Since bone is a highly vascularized organ and angiogenesis plays an important role in osteogenesis, VEGF also influences skeletal development and postnatal bone repair. Compromised bone repair and regeneration in many patients can be attributed to impaired blood supply; thus, modulation of VEGF levels in bones represents a potential strategy for treating compromised bone repair and improving bone regeneration. This review (i) summarizes the roles of VEGF at different stages of bone repair, including the phases of inflammation, endochondral ossification, intramembranous ossification during callus formation and bone remodeling; (ii) discusses different mechanisms underlying the effects of VEGF on osteoblast function, including paracrine, autocrine and intracrine signaling during bone repair; (iii) summarizes the role of VEGF in the bone regenerative procedure, distraction osteogenesis; and (iv) reviews evidence for the effects of VEGF in the context of repair and regeneration techniques involving the use of scaffolds, skeletal stem cells and growth factors. PMID:27353702

The Clinical Impact of Cardiology Consultation Prior to Major Vascular Surgery.

PubMed

Davis, Frank M; Park, Yeo June; Grey, Scott F; Boniakowski, Anna E; Mansour, M Ashraf; Jain, Krishna M; Nypaver, Timothy; Grossman, Michael; Gurm, Hitinder; Henke, Peter K

2018-01-01

To understand statewide variation in preoperative cardiology consultation prior to major vascular surgery and to determine whether consultation was associated with differences in perioperative myocardial infarction (poMI). Medical consultation prior to major vascular surgery is obtained to reduce perioperative risk. Despite perceived benefit of preoperative consultation, evidence is lacking specifically for major vascular surgery on the effect of preoperative cardiac consultation. Patient and clinical data were obtained from a statewide vascular surgery registry between January 2012 and December 2014. Patients were risk stratified by revised cardiac risk index category and compared poMI between patients who did or did not receive a preoperative cardiology consultation. We then used logistic regression analysis to compare the rate of poMI across hospitals grouped into quartiles by rate of preoperative cardiology consultation. Our study population comprised 5191 patients undergoing open peripheral arterial bypass (n = 3037), open abdominal aortic aneurysm repair (n = 332), or endovascular aneurysm repair (n = 1822) at 29 hospitals. At the patient level, after risk-stratification by revised cardiac risk index category, there was no association between cardiac consultation and poMI. At the hospital level, preoperative cardiac consultation varied substantially between hospitals (6.9%-87.5%, P <0.001). High preoperative consulting hospitals (rate >66%) had a reduction in poMI (OR, 0.52; confidence interval: 0.28-0.98; P <0.05) compared with all other hospitals. These hospitals also had a statistically greater consultation rate with a variety of medical specialties. Preoperative cardiology consultation for vascular surgery varies greatly between institutions, and does not appear to impact poMI at the patient level. However, reduction of poMI was noted at the hospitals with the highest rate of preoperative cardiology consultation as well as a variety of medical services, suggesting that other hospital culture effects play a role.

Integrated Fellowship in Vascular Surgery and Intervention Radiology

PubMed Central

Messina, Louis M.; Schneider, Darren B.; Chuter, Timothy A. M.; Reilly, Linda M.; Kerlan, Robert K.; LaBerge, Jeane M.; Wilson, Mark W.; Ring, Ernest J.; Gordon, Roy L.

2002-01-01

Objective To evaluate an integrated fellowship in vascular surgery and interventional radiology initiated to train vascular surgeons in endovascular techniques and to train radiology fellows in clinical aspects of vascular diseases. Summary Background Data The rapid evolution of endovascular techniques for the treatment of vascular diseases requires that vascular surgeons develop proficiency in these techniques and that interventional radiologists develop proficiency in the clinical evaluation and management of patients who are best treated with endovascular techniques. In response to this need the authors initiated an integrated fellowship in vascular surgery and interventional radiology and now report their interim results. Methods Since 1999 vascular fellows and radiology fellows performed an identical year-long fellowship in interventional radiology. During the fellowship, vascular surgery and radiology fellows perform both vascular and nonvascular interventional procedures. Both vascular surgery and radiology-based fellows spend one quarter of the year on the vascular service performing endovascular aortic aneurysm repairs and acquiring clinical experience in the vascular surgery inpatient and outpatient services. Vascular surgery fellows then complete an additional year-long fellowship in vascular surgery. To evaluate the type and number of interventional radiology procedures, the authors analyzed records of cases performed by all interventional radiology and vascular surgery fellows from a prospectively maintained database. The attitudes of vascular surgery and interventional radiology faculty and fellows toward the integrated fellowship were surveyed using a formal questionnaire. Results During the fellowship each fellow performed an average of 1,201 procedures, including 808 vascular procedures (236 diagnostic angiograms, 70 arterial interventions, 59 diagnostic venograms, 475 venous interventions, and 43 hemodialysis graft interventions) and 393 nonvascular procedures. On average fellows performed 20 endovascular aortic aneurysm repairs per year. There was no significant difference between the vascular surgery and radiology fellows in either the spectrum or number of cases performed. Eighty-eight percent (23/26) of the questionnaires were completed and returned. Both interventional radiologists and vascular surgeons strongly supported the integrated fellowship model and favored continuation of the integrated program. Vascular surgery and interventional radiology faculty members wanted additional training in clinical vascular surgery for the radiology-based fellows. With the exception of the radiology fellows there was uniform agreement that vascular surgery fellows benefit from training in nonvascular aspects of interventional radiology. Conclusions Integration of vascular surgery and interventional radiology fellowships is feasible and is mutually beneficial to both disciplines. Furthermore, the integrated fellowship provides exceptional training for vascular surgery and interventional radiology fellows in all catheter-based techniques that far exceeds the minimum requirements for credentialing suggested by various professional societies. There is a clear need for cooperation and active involvement on the parts of the American Board of Radiology and the American Board of Surgery and its Vascular Board to create hybrid training programs that meet mutually agreed-on criteria that document sufficient acquisition of both the cognitive and technical skills required to manage patients undergoing endovascular procedures safely and effectively. PMID:12368668

Is Conventional Open Repair for Abdominal Aortic Aneurysm Feasible in Nonagenarians?

PubMed

Uehara, Kyokun; Matsuda, Hitoshi; Inoue, Yosuke; Omura, Atsushi; Seike, Yoshimasa; Sasaki, Hiroaki; Kobayashi, Junjiro

2017-09-25

Background : Although endovascular repair for abdominal aortic aneurysm has been found to be beneficial in very elderly patients, some patients have contraindications to this procedure. For nonagenarians, the results of open repair remain unclear. The purpose of this study was to compare the outcomes of open vs. endovascular repair for abdominal aortic aneurysm in nonagenarian patients. Methods and Results : Fourteen patients undergoing open surgical repair and 24 undergoing endovascular repair for abdominal aortic aneurysm were evaluated. There was no significant difference in early mortality between the open and endovascular groups (0% vs. 4.1%, p=0.16). The open repair group required much longer hospital stays (26.4 vs. 10.6 days, respectively, p=0.003). Finally, 12 patients (86%) undergoing open repair vs. 21 (88%) undergoing endovascular repair returned home (p=0.49). During a mean follow-up period of 23.4±23.5 months, cumulative estimated 1- and 3-year survival rates were 90.0% and 48.0%, respectively in the open repair group and 90.6% and 54.9%, respectively in the endovascular repair group (p=0.51). Conclusion : Although endovascular repair for abdominal aortic aneurysm was superior in terms of recovery, the results of conventional open repair were acceptable even in nonagenarian patients. Open repair remains an alternative for patients with contraindications to endovascular repair.

NAMPT and NAMPT-controlled NAD Metabolism in Vascular Repair.

PubMed

Wang, Pei; Li, Wen-Lin; Liu, Jian-Min; Miao, Chao-Yu

2016-06-01

Vascular repair plays important roles in postischemic remodeling and rehabilitation in cardiovascular and cerebrovascular disease, such as stroke and myocardial infarction. Nicotinamide adenine dinucleotide (NAD), a well-known coenzyme involved in electron transport chain for generation of adenosine triphosphate, has emerged as an important controller regulating various biological signaling pathways. Nicotinamide phosphoribosyltransferase (NAMPT) is the rate-limiting enzyme for NAD biosynthesis in mammals. NAMPT may also act in a nonenzymatic manner, presumably mediated by unknown receptor(s). Rapidly accumulating data in the past decade show that NAMPT and NAMPT-controlled NAD metabolism regulate fundamental biological functions in endothelial cells, vascular smooth muscle cells, and endothelial progenitor cells. The NAD-consuming proteins, including sirtuins, poly-ADP-ribose polymerases (PARPs), and CD38, may contribute to the regulatory effects of NAMPT-NAD axis in these cells and vascular repair. This review discusses the current data regarding NAMPT and NAMPT-controlled NAD metabolism in vascular repair and the clinical potential translational application of NAMPT-related products in treatment of cardiovascular and cerebrovascular disease.

Improved repair of bone defects with prevascularized tissue-engineered bones constructed in a perfusion bioreactor.

PubMed

Li, De-Qiang; Li, Ming; Liu, Pei-Lai; Zhang, Yuan-Kai; Lu, Jian-Xi; Li, Jian-Min

2014-10-01

Vascularization of tissue-engineered bones is critical to achieving satisfactory repair of bone defects. The authors investigated the use of prevascularized tissue-engineered bone for repairing bone defects. The new bone was greater in the prevascularized group than in the non-vascularized group, indicating that prevascularized tissue-engineered bone improves the repair of bone defects. [Orthopedics. 2014; 37(10):685-690.]. Copyright 2014, SLACK Incorporated.

Lead, Follow, or Get out of the Way-How Bold Young Surgeons Brought Vascular Surgery into Clinical Practice from the Korean War Battlefield.

PubMed

Baker, Michael S

2016-05-01

The maturation of vascular surgery into widespread clinical practice was accelerated by events that took place in Korea during the conflict of 1950-1953. Early research and anecdotal clinical trials were just then resulting in publication of cases of the successful vascular repairs and replacements. Noncrushing vascular clamps were being developed and limited manufacture begun. The stage was set for a major advance in the treatment of arterial injury, just as war commenced in Korea, which provided a clinical laboratory. When the war on the Korean Peninsula erupted in June 1950, the policy of the Army Medical department was to ligate all arterial injuries unless a simple transverse or end-to-end anastomosis could be performed, and repair was "contrary to policy and orders." Despite pressure and threats of "courts martial for vascular repairs" from the senior military medicine leaders-clinical experiments in arterial repair were carried out at Mobile Army Surgical Hospital facilities at battlefield locations across Korea. The young surgeons, mostly draftees and reservists, resisted rigid doctrine and orders to desist, and in the face of threatened punishment, were committed to do the right thing, and ultimately went on to change military medicine and vascular surgery. The "on-the-job" training in vascular surgery that was carried out in Korea by military surgeons who demonstrated substantially higher limb salvage rates energized the field from the battlefield laboratory. Many wounded soldiers had limbs saved by the new techniques in vascular repair pioneered by surgeons in the Korean War, and countless thousands who entered civilian hospitals for emergency vascular surgery in subsequent years also ultimately benefited from their work. Copyright © 2016 Elsevier Inc. All rights reserved.

The effect of platelet-rich fibrin matrix on rotator cuff tendon healing: a prospective, randomized clinical study.

PubMed

Rodeo, Scott A; Delos, Demetris; Williams, Riley J; Adler, Ronald S; Pearle, Andrew; Warren, Russell F

2012-06-01

There is a strong need for methods to improve the biological potential of rotator cuff tendon healing. Platelet-rich fibrin matrix (PRFM) allows delivery of autologous cytokines to healing tissue, and limited evidence suggests a positive effect of platelet-rich plasma on tendon biology. To evaluate the effect of platelet-rich fibrin matrix on rotator cuff tendon healing. Randomized controlled trial; Level of evidence, 2. Seventy-nine patients undergoing arthroscopic rotator cuff tendon repair were randomized intraoperatively to either receive PRFM at the tendon-bone interface (n = 40) or standard repair with no PRFM (n = 39). Standardized repair techniques were used for all patients. The postoperative rehabilitation protocol was the same in both groups. The primary outcome was tendon healing evaluated by ultrasound (intact vs defect at repair site) at 6 and 12 weeks. Power Doppler ultrasound was also used to evaluate vascularity in the peribursal, peritendinous, and musculotendinous and insertion site areas of the tendon and bone anchor site. Secondary outcomes included standardized shoulder outcome scales (American Shoulder and Elbow Surgeons [ASES] and L'Insalata) and strength measurements using a handheld dynamometer. Patients and the evaluator were blinded to treatment group. All patients were evaluated at minimum 1-year follow-up. A logistic regression model was used to predict outcome (healed vs defect) based on tear severity, repair type, treatment type (PRFM or control), and platelet count. Overall, there were no differences in tendon-to-bone healing between the PRFM and control groups. Complete tendon-to-bone healing (intact repair) was found in 24 of 36 (67%) in the PRFM group and 25 of 31 (81%) in the control group (P = .20). There were no significant differences in healing by ultrasound between 6 and 12 weeks. There were gradual increases in ASES and L'Insalata scores over time in both groups, but there were no differences in scores between the groups. We also found no difference in vascularity in the peribursal, peritendinous, and musculotendinous areas of the tendon between groups. There were no differences in strength between groups. Platelet count had no effect on healing. Logistic regression analysis demonstrated that PRFM was a significant predictor (P = .037) for a tendon defect at 12 weeks, with an odds ratio of 5.8. Platelet-rich fibrin matrix applied to the tendon-bone interface at the time of rotator cuff repair had no demonstrable effect on tendon healing, tendon vascularity, manual muscle strength, or clinical rating scales. In fact, the regression analysis suggests that PRFM may have a negative effect on healing. Further study is required to evaluate the role of PRFM in rotator cuff repair.

Regional Differences in Case Mix and Peri-operative Outcome After Elective Abdominal Aortic Aneurysm Repair in the Vascunet Database.

PubMed

Mani, K; Venermo, M; Beiles, B; Menyhei, G; Altreuther, M; Loftus, I; Björck, M

2015-06-01

National differences exist in the outcome of elective abdominal aortic aneurysm (AAA) repair. The role of case mix variation was assessed based on an international vascular registry collaboration. All elective AAA repairs with aneurysm size data in the Vascunet database in the period 2005-09 were included. AAA size and peri-operative outcome (crude and age adjusted mortality) were analysed overall and in risk cohorts, as well as per country. Glasgow Aneurysm Score (GAS) was calculated as risk score, and patients were stratified in three equal sized risk cohorts based on GAS. Predictors of peri-operative mortality were analysed with multiple regression. Missing data were handled with multiple imputation. Patients from Australia, Finland, Hungary, Norway, Sweden and the UK (n = 5,895) were analysed; mean age was 72.7 years and 54% had endovascular repair (EVAR). There were significant variations in GAS (lowest = Finland [75.7], highest = UK [79.4], p for comparison of all regions < .001), proportion of AAA < 5.5 cm (lowest = UK [6.4%], highest = Hungary [29.0%]; p < .001), proportion undergoing EVAR (lowest = Finland [10.1%], highest = Australia [58.9%]; p < .001), crude mortality (lowest = Norway [2.0%], highest = Finland [5.0%]; p = .006), and age adjusted mortality (lowest = Norway [2.5%], highest = Finland [6.0%]; p = .048). Both aneurysm size and peri-operative mortality were highest among patients with a GAS >82. Of those with a GAS >82, 8.4% of men and 20.8% of women had an AAA <5.5 cm. Important regional differences exist in case selection for elective AAA repair, including variations in AAA size and patient risk profile. These differences partly explain the variations in peri-operative mortality. Further audit is warranted to assess the underlying reasons for the regional variation in case-mix. Copyright © 2015 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.

Risk-adjusted predictive models of mortality after index arterial operations using a minimal data set.

PubMed

Prytherch, D R; Ridler, B M F; Ashley, S

2005-06-01

Reducing the data required for a national vascular database (NVD) without compromising the statistical basis of comparative audit is an important goal. This work attempted to model outcomes (mortality and morbidity) from a small and simple subset of the NVD data items, specifically urea, sodium, potassium, haemoglobin, white cell count, age and mode of admission. Logistic regression models of risk of adverse outcome were built from the 2001 submission to the NVD using all records that contained the complete data required by the models. These models were applied prospectively against the equivalent data from the 2002 submission to the NVD. As had previously been found using the P-POSSUM (Portsmouth POSSUM) approach, although elective abdominal aortic aneurysm (AAA) repair and infrainguinal bypass (IIB) operations could be described by the same model, separate models were required for carotid endarterectomy (CEA) and emergency AAA repair. For CEA there were insufficient adverse events recorded to allow prospective testing of the models. The overall mean predicted risk of death in 530 patients undergoing elective AAA repair or IIB operations was 5.6 per cent, predicting 30 deaths. There were 28 reported deaths (chi(2) = 2.75, 4 d.f., P = 0.600; no evidence of lack of fit). Similarly, accurate predictions were obtained across a range of predicted risks as well as for patients undergoing repair of ruptured AAA and for morbidity. A 'data economic' model for risk stratification of national data is feasible. The ability to use a minimal data set may facilitate the process of comparative audit within the NVD. Copyright (c) 2005 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

Experience with endovascular abdominal aortic aneurysm repair in nonagenarians.

PubMed

Baril, Donald T; Palchik, Eugene; Carroccio, Alfio; Olin, Jeffrey W; Ellozy, Sharif H; Jacobs, Tikva S; Ponzio, Marc M; Teodorescu, Victoria J; Marin, Michael L

2006-06-01

To report a single-institution experience with endovascular abdominal aortic aneurysm (AAA) repair (EVAR) in nonagenarians. A retrospective review was performed of all patients >90 years old undergoing EVAR over an 8-year period at a major academic medical center. The patient population was investigated for the presence of various comorbidities, initial aneurysm size, successful aneurysm exclusion, perioperative complications, disposition, endoleaks, secondary interventions, and overall survival. EVAR was performed in 18 male nonagenarians (mean age 92.4 years, range 90- 95). Mean aneurysm diameter was 7.3 cm (range 5.5-9.8). The cohort had an average of 3.2 comorbid conditions. Sixteen patients were treated electively, while 2 patients underwent emergent repair for contained rupture and bleeding aortoenteric fistula, respectively. Immediate technical success was 100%. Perioperative local/vascular complications occurred in 4 (22%) patients. Perioperative systemic complications occurred in 3 (17%) patients. There were 2 (11%) perioperative (<30 days) deaths. Three (17%) patients required secondary interventions. Mean survival in patients who expired during the follow-up period beyond the first 30 days was 34 months (range 8-78). Mean survival in 8 patients who are still alive is 17.4 months (range 9-39). Endovascular AAA repair in nonagenarians is associated with a high rate of technical success and relatively low morbidity rate. Survival times following successful hospital discharge are significant. Suitable patients over 90 years of age may benefit from an endovascular AAA repair.

Racial/Ethnic Disparities in Perioperative Outcomes of Major Procedures: Results From the National Surgical Quality Improvement Program.

PubMed

Ravi, Praful; Sood, Akshay; Schmid, Marianne; Abdollah, Firas; Sammon, Jesse D; Sun, Maxine; Klett, Dane E; Varda, Briony; Peabody, James O; Menon, Mani; Kibel, Adam S; Nguyen, Paul L; Trinh, Quoc-Dien

2015-12-01

To determine the association between race/ethnicity and perioperative outcomes in individuals undergoing major oncologic and nononcologic surgical procedures in the United States. Prior work has shown that there are significant racial/ethnic disparities in perioperative outcomes after several types of major cardiac, general, vascular, orthopedic, and cancer surgical procedures. However, recent evidence suggests attenuation of these racial/ethnic differences, particularly at academic institutions. We utilized the American College of Surgeons National Surgical Quality Improvement Program database to identify 142,344 patients undergoing one of the 16 major cancer and noncancer surgical procedures between 2005 and 2011. Eighty-five percent of the cohort was white, with black and Hispanic individuals comprising 8% and 4%, respectively. In multivariable analyses, black patients had greater odds of experiencing prolonged length of stay after 10 of the 16 procedures studied (all P < 0.05), though there was no disparity in odds of 30-day mortality after any surgery. Hispanics were more likely to experience prolonged length of stay after 5 surgical procedures (all P < 0.04), and were at greater odds of dying within 30 days after colectomy, heart valve repair/replacement, or abdominal aortic aneurysm repair (all P < 0.03). Fewer disparities were observed for Hispanics, than for black patients, and also for cancer, than for noncancer surgical procedures. Important racial/ethnic disparities in perioperative outcomes were observed among patients undergoing major cancer and noncancer surgical procedures at American College of Surgeons National Surgical Quality Improvement Program institutions. There were fewer disparities among individuals undergoing cancer surgery, though black patients, in particular, were more likely to experience prolonged length of stay.

Risk factors for cerebrospinal fluid leak in pediatric patients undergoing endoscopic endonasal skull base surgery.

PubMed

Stapleton, Amanda L; Tyler-Kabara, Elizabeth C; Gardner, Paul A; Snyderman, Carl H; Wang, Eric W

2017-02-01

To determine the risk factors associated with cerebrospinal fluid (CSF) leak following endoscopic endonasal surgery (EES) for pediatric skull base lesions. Retrospective chart review of pediatric patients (ages 1 month to 18 years) treated for skull base lesions with EES from 1999 to 2014. Five pathologies were reviewed: craniopharyngioma, clival chordoma, pituitary adenoma, pituitary carcinoma, and Rathke's cleft cyst. Fisher's exact tests were used to evaluate the different factors to determine which had a statistically higher risk of leading to a post-operative CSF leak. 55 pediatric patients were identified who underwent 70 EES's for tumor resection. Of the 70 surgeries, 47 surgeries had intraoperative CSF leaks that were repaired at the time of surgery. 11 of 47 (23%) surgeries had post-operative CSF leaks that required secondary operative repair. Clival chordomas had the highest CSF leak rate at 36%. There was no statistical difference in leak rate based on the type of reconstruction, although 28% of cases that used a vascularized flap had a post-operative leak, whereas only 9% of those cases not using a vascularized flap had a leak. Post-operative hydrocephalus and perioperative use of a lumbar drain were not significant risk factors. Pediatric patients with an intra-operative CSF leak during EES of the skull base have a high rate of post-operative CSF leaks. Clival chordomas appear to be a particularly high-risk group. The use of vascularized flaps and perioperative lumbar drains did not statistically decrease the rate of post-operative CSF leak. Copyright © 2017 Elsevier B.V. All rights reserved.

Early harvesting of the vascularized pedicled nasoseptal flap during endoscopic skull base surgery.

PubMed

Eloy, Jean Anderson; Patel, Amit A; Shukla, Pratik A; Choudhry, Osamah J; Liu, James K

2013-01-01

The vascularized pedicled nasoseptal flap (PNSF) represents a successful option for reconstruction of large skull base defects after expanded endoscopic endonasal approaches (EEA). This vascularized flap can be harvested early or late in the operation depending on the anticipation of high-flow CSF leaks. Each harvesting technique (early vs. late) is associated with different advantages and disadvantages. In this study, we evaluate our experience with early harvesting of the PNSF for repair of large skull base defects after EEA. A retrospective review was performed at a tertiary care medical center on patients who underwent early PNSF harvesting during reconstruction of intraoperative high-flow CSF leaks after EEA between December 2008 and March 2012. Demographic data, repair materials, surgical approach, and incidence of PNSF usage were collected. Eighty-seven patients meeting the inclusion criteria were identified. In 86 procedures (98.9%), the PNSF harvested at the beginning of the operation was used. In 1 case (1.1%), the PNSF was not used because a high-flow intraoperative CSF leak was not encountered. This patient had recurrence of intradural disease 8months later, and the previously elevated PNSF was subsequent used after tumor resection. Based on our data, a high-flow CSF leak and need for a PNSF can be accurately anticipated in patients undergoing EEA for skull base lesions. Because of the advantages of early harvesting of the PNSF and the high preoperative predictive value of CSF leak anticipations, this technique represents a feasible harvesting practice for EEA surgeries. Copyright © 2013 Elsevier Inc. All rights reserved.

Atherosclerosis as a disease of failed endogenous repair

PubMed Central

Zenovich, Andrey G.; Taylor, Doris A.

2009-01-01

As coronary artery disease (CAD) continues to be the primary cause of mortality, a more in-depth understanding of pathophysiology and novel treatments are being sought. The past two decades have established inflammation as a driving force behind CAD – from endothelial dysfunction to heart failure. Recent advances in stem/progenitor cell biology have led to initial applications of progenitor cells in CAD continuum and have revealed that atherosclerosis is, at least in part, a disease of failed endogenous vascular repair. Several key progenitor cell populations including endothelial progenitor cells (AC133+/CD34+ population), vascular progenitors (CD31+/CD45low population), KDR+ cells and other bone marrow subtypes are mobilized for vascular repair. However, age and risk factors negatively impact these cells even prior to clinical CAD. Sex-based differences in progenitor cell capacity for repair have emerged as a new research focus that may offer mechanistic insights into clinical CAD discrepancies between men and women. Quantifying injury and cell-based repair and better defining their interactions should enable us to halt or even prevent CAD by enhancing the repair side of the repair/injury equation. PMID:18508460

Outcomes after endovascular aneurysm repair conversion and primary aortic repair for urgent and emergency indications in the Society for Vascular Surgery Vascular Quality Initiative.

PubMed

Scali, Salvatore T; Runge, Sara J; Feezor, Robert J; Giles, Kristina A; Fatima, Javairiah; Berceli, Scott A; Huber, Thomas S; Beck, Adam W

2016-08-01

Open conversion after endovascular aortic aneurysm repair (EVAR-c) is performed nonelectively in up to 60% of cases. EVAR-c has been reported to have significantly greater risk of postoperative morbidity and mortality than primary aortic repair, but few data exist on outcomes for symptomatic or ruptured presentations. This study determined outcomes and identified predictors of postoperative major adverse cardiac events (MACEs) and mortality for patients undergoing nonelective EVAR-c compared with nonelective primary aortic repair (PAR) in the Vascular Quality Initiative (VQI). All VQI patients undergoing urgent/emergency EVAR-c or urgent/emergency PAR from 2002 to 2014 were reviewed. Urgent presentation was defined by repair ≤24 hours of a nonelective admission, and emergency operations had clinical or radiographic evidence, or both, of rupture. End points included in-hospital MACE (myocardial infarction, dysrhythmia, congestive heart failure) and 30-day mortality. Possible covariates identified on univariate analysis (P < .2) were entered into a multivariable model, and stepwise elimination identified the best subset of predictors. Generalized estimating equations logistic regression analysis was used to determine the relative effect of EVAR-c compared with PAR on outcomes. During the study interval, we identified 277 EVAR-c, and 118 (43%) underwent urgent/emergency repair. nonelective PAR was performed in 1388 of 6152 total (23%). EVAR-c patients were older (75 ± 9 vs 71 ± 10 years; P < .0001), more likely to be male (84% vs 74%; P = .02), and had a higher prevalence of hypertension (88% vs 79%; P = .02) and coronary artery disease (38% vs 27%; P = .01). No differences in MACE (EVAR-c, 31% [n = 34] vs PAR, 30% [n = 398]) or any major postoperative complication (EVAR-c, 57% [n = 63] vs PAR, 55% [n = 740]; P = .8) were found; however, 30-day mortality was significantly greater in EVAR-c (37% [n = 41]) than in (PAR, 24% [n = 291]; P = .003), with an odds ratio (OR) of 2.2 (95% confidence interval [CI], 1.04-4.77; P = .04) for EVAR-c. Predictors of any MACE included age (OR, × 1.03 for each additional year; 95% CI, 1.01-1.03; P = .0002), male gender (OR, 1.3; 95% CI, 1.03-1.67; P = .03), body mass index ≤20 kg/m 2 (OR, 1.8; 95% CI, 1.13-2.87; P = .01), chronic obstructive pulmonary disease (OR, 1.2; 95% CI, 0.86-1.80; P = .25), congestive heart failure (OR, 1.5; 95% CI, 0.98-2.34; P = .06), preoperative chronic β-blocker use (OR, 1.3; 95% CI, 0.97-1.63; P = .09), and emergency presentation (OR, 2.3; 95% CI, 1.8-3.01; area under the curve, 0.70; P < .0001). Significant predictors for 30-day mortality were age (OR × 1.07 for each additional year; 95% CI, 1.05-1.09; P < .0001), female gender (OR, 1.6; 95% CI, 1.01-2.46; P = .04), preoperative creatinine >1.8 mg/dL (OR, 1.6; 95% CI, 1.04-2.35; P = .03), an emergency presentation (OR, 4.8; 95% CI, 2.93-7.93; P < .0001), and renal/visceral ischemia (OR, × 1.1 for each unit increase log (time-minutes); 95% CI, 1.02-1.22; area under the curve, 0.84; P = .01). Nonelective EVAR-c patients are older and have higher prevalence of cardiovascular risk factors than PAR patients. Similar rates of postoperative complications occur; however, urgent/emergency EVAR-c has a significantly higher risk of 30-day mortality than nonelective PAR. Several variables are identified that predict outcomes after these repairs and may help risk stratify patients to further inform clinical decision making when patients present nonelectively with EVAR failure. Copyright © 2016 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.

A prokineticin-driven epigenetic switch regulates human epicardial cell stemness and fate.

PubMed

Qureshi, Rehana; Kindo, Michel; Boulberdaa, Mounia; von Hunolstein, Jean-Jacques; Steenman, Marja; Nebigil, Canan G

2018-06-06

Epicardial adipose tissues (EAT) and vascular tissues may both belong to the mesoepithelial lineage that develops from epicardium-derived progenitor cells (EPDCs) in developing and injured hearts. Very little is known of the molecular mechanisms of EPDC contribution in EAT development and neovascularization in adult heart, which the topic remains a subject of intense therapeutic interest and scientific debate. Here we studied the epigenetic control of stemness and anti-adipogenic and pro-vasculogenic fate of hEPDCs, through investigating an angiogenic hormone, prokineticin-2 (PK2) signaling via its receptor PKR1. We found that hEPDCs spontaneously undergoes epithelial-to-mesenchymal transformation (EMT), and are not predestined for the vascular lineages. However, PK2 via a histone demethylase KDM6A inhibits EMT, and induces asymmetric division, leading to self-renewal and formation of vascular and epithelial/endothelial precursors with angiogenic potential capable of differentiating into vascular smooth muscle and endothelial cells. PK2 upregulates and activates KDM6A to inhibit repressive histone H3K27me3 marks on promoters of vascular genes (Flk-1 and SM22α) involved in vascular lineage commitment and maturation. In PK2-mediated anti-adipogenic signaling, KDM6A stabilizes and increases cytoplasmic β-catenin levels to repress PPARγ expression and activity. Our findings offer additional molecular targets to manipulate hEPDCs-involved tissue repair/regeneration in cardiometabolic and ischemic heart diseases. This article is protected by copyright. All rights reserved. © 2018 AlphaMed Press.

Percutaneous repair or surgery for mitral regurgitation.

PubMed

Feldman, Ted; Foster, Elyse; Glower, Donald D; Glower, Donald G; Kar, Saibal; Rinaldi, Michael J; Fail, Peter S; Smalling, Richard W; Siegel, Robert; Rose, Geoffrey A; Engeron, Eric; Loghin, Catalin; Trento, Alfredo; Skipper, Eric R; Fudge, Tommy; Letsou, George V; Massaro, Joseph M; Mauri, Laura

2011-04-14

Mitral-valve repair can be accomplished with an investigational procedure that involves the percutaneous implantation of a clip that grasps and approximates the edges of the mitral leaflets at the origin of the regurgitant jet. We randomly assigned 279 patients with moderately severe or severe (grade 3+ or 4+) mitral regurgitation in a 2:1 ratio to undergo either percutaneous repair or conventional surgery for repair or replacement of the mitral valve. The primary composite end point for efficacy was freedom from death, from surgery for mitral-valve dysfunction, and from grade 3+ or 4+ mitral regurgitation at 12 months. The primary safety end point was a composite of major adverse events within 30 days. At 12 months, the rates of the primary end point for efficacy were 55% in the percutaneous-repair group and 73% in the surgery group (P=0.007). The respective rates of the components of the primary end point were as follows: death, 6% in each group; surgery for mitral-valve dysfunction, 20% versus 2%; and grade 3+ or 4+ mitral regurgitation, 21% versus 20%. Major adverse events occurred in 15% of patients in the percutaneous-repair group and 48% of patients in the surgery group at 30 days (P<0.001). At 12 months, both groups had improved left ventricular size, New York Heart Association functional class, and quality-of-life measures, as compared with baseline. Although percutaneous repair was less effective at reducing mitral regurgitation than conventional surgery, the procedure was associated with superior safety and similar improvements in clinical outcomes. (Funded by Abbott Vascular; EVEREST II ClinicalTrials.gov number, NCT00209274.).

Disparities in outcomes for Hispanic patients undergoing endovascular and open abdominal aortic aneurysm repair.

PubMed

Williams, Timothy K; Schneider, Eric B; Black, James H; Lum, Ying Wei; Freischlag, Julie A; Perler, Bruce A; Abularrage, Christopher J

2013-01-01

Previous studies have demonstrated racial and ethnic disparities associated with the outcomes of abdominal aortic aneurysm (AAA) repair, although little is known about the influence of race and ethnicity on the costs associated with these disparities. The current study was undertaken to examine the influence of race and ethnicity on the outcomes of endovascular (EVAR) and open repair (open AAA) of unruptured AAA and its effect on costs in contemporary practice. The Nationwide Inpatient Sample (2005 to 2008) was queried using ICD-9-CM codes for unruptured AAA (441.4). The primary outcomes were mortality and total hospital charges. Multivariate analyses were performed adjusting for age, gender, race, comorbidities (Charlson index), year, insurance type, and hospital characteristics. A total of 62,728 patients underwent EVAR and 24,253 patients underwent open AAA. White patients (72%) were more likely to undergo EVAR than Hispanic (69%) or black patients (69%; P = 0.02). On univariate analysis, in-hospital mortality after EVAR was increased in Hispanic patients compared with white patients (1% vs 2%; P = 0.02). There were no differences in mortality after EVAR between white and black patients, and there were no racial or ethnic differences in mortality after open AAA. Hispanic ethnicity remained an independent risk factor for increased mortality after AAA repair on multivariate analysis (RR 1.64; 95% CI [1.05 to 2.57]; P = 0.03). Hispanic ethnicity was associated with increased hospital charges compared with white ethnicity after both EVAR ($108,886 vs $77,748; P < 0.001) and open AAA ($134,356 vs $85,536; P < 0.001) and for black patients after open AAA ($101,168 vs $85,536; P = 0.04). Hispanic ethnicity is an independent risk factor for mortality after AAA repair independent of insurance type or hospital characteristics. There were dramatic disparities in hospital costs for Hispanic patients undergoing either EVAR or open AAA and for black patients after open AAA compared with white patients. This observation seems unrelated to length of stay, postoperative complications, and admission status. Further studies are needed to determine whether these disparities extend beyond the primary hospitalization. Copyright © 2013 Annals of Vascular Surgery Inc. Published by Elsevier Inc. All rights reserved.

Metrics of Cellular and Vascular Infiltration of Human Acellular Dermal Matrix in Ventral Hernia Repairs

PubMed Central

Campbell, Kristin Turza; Burns, Nadja K.; Ensor, Joe; Butler, Charles E.

2012-01-01

Background Human acellular dermal matrix (HADM) is used for ventral hernia repair, as it resists infection and remodels via surrounding tissue. However, the tissue source and impact of basement membrane (BM) on cell and vessel infiltration have not been determined. We hypothesized that musculofascia would be the primary tissue source of cells and vessels infiltrating into HADM and the BM would inhibit infiltration. Methods Fifty-six guinea pigs underwent inlay HADM ventral hernia repair with the BM oriented toward or away from the peritoneum. At postoperative weeks 1, 2, or 4, repair sites were completely excised. Histologic and immunohistochemical analyses were performed to quantify cell and vessel density within repair-site zones, including interface (lateral, beneath musculofascia) and center (beneath subcutaneous fat) zones. Cell and vessel quantities were compared as functions of zone, BM orientation, and time. Results Cellular and vascular infiltration increased over time universally. The interface demonstrated greater mean cell density than the center (weeks 1 and 2, p=0.01, p<0.0001). Cell density was greater with the BM oriented toward the peritoneum at week 4 (p=0.02). The interface zone had greater mean vessel density than the center zone at week 4 (p<0.0001). Orienting the BM toward the peritoneum increased vessel density at week 4 (p=0.0004). Conclusion Cellular and vascular infiltration into HADM for ventral hernia repairs was greater from musculofascia than subcutaneous and the BM inhibited cellular and vascular. HADM should be placed adjacent to the best vascularizing tissue to improve fibrovascular incorporation. PMID:22456361

Extended use of cardiopulmonary bypass in a multidisciplinary hospital

PubMed Central

Shahabuddin, Syed; Habib, Nabeel

2015-01-01

Objective To share our experience highlighting the additional use of cardiopulmonary bypass (CPB) in cases other than the conventional ischemic, congenital and valvular heart diseases. Methodology All patients undergoing non-traditional cardiac surgery utilizing the cardiopulmonary bypass during a period from 1999 to 2009 reviewed. Their preoperative presentation, operative strategy and immediate postoperative status were assessed. Results A total of six such cases were identified including three female and three male patients. Two patients presented with road traffic accident having aortic transection along with other injuries. They underwent repair utilizing partial cardiopulmonary bypass. One patient presented with large PDA aneurysm and symptoms related to its pressure effect on respiratory system. He underwent repair under hypothermic circulatory arrest. These three patients were done via left thoracotomy. Three patients underwent deep hypothermic circulatory arrest, one for removal of thrombus from right atrium after complicated liver abscess, one patient required vascular graft interposition in left internal carotid artery for aneurysm extending into cranium and the third one underwent resection of vascular tumor of posterior cranial fossa. One patient required exploration for bleeding. One patient died after prolonged hospitalization. Rest of the patient had unremarkable postoperative course and were discharged home. Conclusion Our short experience highlights the extended use of cardiopulmonary bypass in a multidisciplinary hospital, facilitating to perform complex, technically challenging non cardiac procedures which otherwise may not be possible. PMID:26309443

Mesenchymal-endothelial-transition contributes to cardiac neovascularization

PubMed Central

Ubil, Eric; Duan, Jinzhu; Pillai, Indulekha C.L.; Rosa-Garrido, Manuel; Wu, Yong; Bargiacchi, Francesca; Lu, Yan; Stanbouly, Seta; Huang, Jie; Rojas, Mauricio; Vondriska, Thomas M.; Stefani, Enrico; Deb, Arjun

2014-01-01

Endothelial cells contribute to a subset of cardiac fibroblasts by undergoing endothelial-to-mesenchymal-transition, but whether cardiac fibroblasts can adopt an endothelial cell fate and directly contribute to neovascularization after cardiac injury is not known. Here, using genetic fate map techniques, we demonstrate that cardiac fibroblasts rapidly adopt an endothelial cell like phenotype after acute ischemic cardiac injury. Fibroblast derived endothelial cells exhibit anatomical and functional characteristics of native endothelial cells. We show that the transcription factor p53 regulates such a switch in cardiac fibroblast fate. Loss of p53 in cardiac fibroblasts severely decreases the formation of fibroblast derived endothelial cells, reduces post infarct vascular density and worsens cardiac function. Conversely, stimulation of the p53 pathway in cardiac fibroblasts augments mesenchymal to endothelial transition, enhances vascularity and improves cardiac function. These observations demonstrate that mesenchymal-to-endothelial-transition contributes to neovascularization of the injured heart and represents a potential therapeutic target for enhancing cardiac repair. PMID:25317562

Stem cell derived endochondral cartilage stimulates bone healing by tissue transformation

PubMed Central

Bahney, Chelsea S; Hu, Diane P; Taylor, Aaron J; Ferro, Federico; Britz, Hayley M; Hallgrimsson, Benedikt; Johnstone, Brian; Miclau, Theodore; Marcucio, Ralph S

2016-01-01

Although bone has great capacity for repair, there are a number of clinical situations (fracture non-unions, spinal fusions, revision arthroplasty, segmental defects) in which auto- or allografts augment bone regeneration. Critical failures associated with current grafting treatments include osteonecrosis and limited integration between graft and host tissue. We speculated that the underlying problem with current bone grafting techniques is that they promote bone regeneration through direct osteogenesis. We hypothesized that using cartilage to promote endochondral bone regeneration would leverage normal developmental and repair sequences to produce a well-vascularized regenerate that integrates with the host tissue. In this study we use a translational murine model of a segmental tibia defect to test the clinical utility of bone regeneration from a cartilage graft. We further test the mechanism by which cartilage promotes bone regeneration using in vivo lineage tracing and in vitro culture experiments. Our data show that cartilage grafts support regeneration of a vascularized and integrated bone tissue in vivo, and subsequently propose a translational tissue engineering platform using chondrogenesis of MSCs. Interestingly, lineage tracing experiments show the regenerate was graft derived, suggesting transformation of the chondrocytes into bone. In vitro culture data shows that cartilage explants mineralize with the addition of BMP or by exposure to HUVEC conditioned medium, indicating that endothelial cells directly promote ossification. This study provides pre-clinical data for endochondral bone repair that has potential to significantly improve patient outcomes in a variety of musculoskeletal diseases and injuries. Further, in contrast to the dogmatic view that hypertrophic chondrocytes undergo apoptosis prior to bone formation, our data suggest cartilage can transform into bone by activating the pluripotent transcription factor Oct4A. Together these data represent a paradigm shift describing the mechanism of endochondral bone repair and open the door for novel regenerative strategies based on improved biology. PMID:24259230

Impact of surgeon and hospital experience on outcomes of abdominal aortic aneurysm repair in New York State.

PubMed

Meltzer, Andrew J; Connolly, Peter H; Schneider, Darren B; Sedrakyan, Art

2017-09-01

This study aimed to assess the impact of the surgeon's and hospital's experience on the outcomes of open surgical repair (OSR) and endovascular aneurysm repair (EVAR) of intact and ruptured abdominal aortic aneurysms (AAAs) in New York State. New York Statewide Planning and Research Cooperative System data were used to identify patients undergoing AAA repair from 2000 to 2011. Characteristics of the provider and hospital were determined by linkage to the New York Office of Professions and National Provider Identification databases. Distinct hierarchical logistic regression models for EVAR and OSR for intact and ruptured AAAs were created to adjust for the patient's comorbidities and to evaluate the impact of the surgeon's and hospital's experience on outcomes. The provider's years since medical school graduation as well as annual volume of the facility and provider are examined in tertiles. Adjusted odds ratios and 95% confidence intervals are presented. A total of 18,842 patients underwent AAA repair by a vascular surgeon. For intact AAAs (n = 17,118), 26.2% of patients underwent OSR and 73.8% underwent EVAR. For ruptured AAAs (n = 1724), 63.9% underwent OSR and 36.1% underwent EVAR. After intact AAA repair, OSR adjusted outcomes were significantly influenced by the surgeon's annual volume but not by the facility's volume or the surgeon's age. The lowest volume providers (1-4 OSRs) had higher in-hospital mortality rates than high-volume (>11 OSRs) surgeons (adjusted odds ratio, 1.87 [95% confidence interval, 1.1-3.17]). Low-volume providers also had higher odds of major complications (1.23 [1-1.51]). For patients with intact AAA undergoing EVAR, mortality was higher at low-volume facilities (2.6 [1.3-5.3] and 2.7 [1.5-4.8] for <33 EVARs and 34-81 EVARs, respectively). After OSR for ruptured AAA, treatment at a low-volume facility (<9 OSRs for ruptured AAA) was associated with greater mortality than at high-volume (>27 OSRs for ruptured AAA) centers (1.56 [1.02-2.39]), whereas low-volume physicians (<4 OSRs for ruptured AAA) had higher odds of major complications (1.58 [1.04-2.41]). In the case of EVAR for rupture, there were no characteristics of the hospital or surgeon significantly associated with poorer outcomes. For intact AAA, the surgeon's volume was an important factor for OSR outcomes, whereas low facility volume was associated with worse outcomes after EVAR. For ruptured AAA, low-volume surgeons and low-volume facilities had worse outcomes after OSR but not after EVAR. The interaction between the surgeon's volume and the hospital's volume is complex and varies on the basis of the acuity of presentation and treatment modality. Copyright © 2017 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.

Osteocalcin expression by circulating endothelial progenitor cells in patients with coronary atherosclerosis.

PubMed

Gössl, Mario; Mödder, Ulrike I; Atkinson, Elizabeth J; Lerman, Amir; Khosla, Sundeep

2008-10-14

This study was designed to test whether patients with coronary atherosclerosis have increases in circulating endothelial progenitor cells (EPCs) expressing an osteogenic phenotype. Increasing evidence indicates a link between bone and the vasculature, and bone marrow and circulating osteogenic cells have been identified by staining for the osteoblastic marker, osteocalcin (OCN). Endothelial progenitor cells contribute to vascular repair, but repair of vascular injury may result in calcification. Using cell surface markers (CD34, CD133, kinase insert domain receptor [KDR]) to identify EPCs, we examined whether patients with coronary atherosclerosis had increases in the percentage of EPCs expressing OCN. We studied 72 patients undergoing invasive coronary assessment: control patients (normal coronary arteries and no endothelial dysfunction, n = 21) versus 2 groups with coronary atherosclerosis-early coronary atherosclerosis (normal coronary arteries but with endothelial dysfunction, n = 22) and late coronary atherosclerosis (severe, multivessel coronary artery disease, n = 29). Peripheral blood mononuclear cells were analyzed using flow cytometry. Compared with control patients, patients with early or late coronary atherosclerosis had significant increases (approximately 2-fold) in the percentage of CD34+/KDR+ and CD34+/CD133+/KDR+ cells costaining for OCN. Even larger increases were noted in the early and late coronary atherosclerosis patients in the percentage of CD34+/CD133-/KDR+ cells costaining for OCN (5- and 2-fold, p < 0.001 and 0.05, respectively). A higher percentage of EPCs express OCN in patients with coronary atherosclerosis compared with subjects with normal endothelial function and no structural coronary artery disease. These findings have potential implications for the mechanisms of vascular calcification and for the development of novel markers for coronary atherosclerosis.

Endothelial microparticle-mediated transfer of MicroRNA-126 promotes vascular endothelial cell repair via SPRED1 and is abrogated in glucose-damaged endothelial microparticles.

PubMed

Jansen, Felix; Yang, Xiaoyan; Hoelscher, Marion; Cattelan, Arianna; Schmitz, Theresa; Proebsting, Sebastian; Wenzel, Daniela; Vosen, Sarah; Franklin, Bernardo S; Fleischmann, Bernd K; Nickenig, Georg; Werner, Nikos

2013-10-29

Repair of the endothelium after vascular injury is crucial for preserving endothelial integrity and preventing the development of vascular disease. The underlying mechanisms of endothelial cell repair are largely unknown. We sought to investigate whether endothelial microparticles (EMPs), released from apoptotic endothelial cells (ECs), influence EC repair. Systemic treatment of mice with EMPs after electric denudation of the endothelium accelerated reendothelialization in vivo. In vitro experiments revealed that EMP uptake in ECs promotes EC migration and proliferation, both critical steps in endothelial repair. To dissect the underlying mechanisms, Taqman microRNA array was performed, and microRNA (miR)-126 was identified as the predominantly expressed miR in EMPs. The following experiments demonstrated that miR-126 was transported into recipient human coronary artery endothelial cells by EMPs and functionally regulated the target protein sprouty-related, EVH1 domain-containing protein 1 (SPRED1). Knockdown of miR-126 in EMPs abrogated EMP-mediated effects on human coronary artery endothelial cell migration and proliferation in vitro and reendothelialization in vivo. Interestingly, after simulating diabetic conditions, EMPs derived from glucose-treated ECs contained significantly lower amounts of miR-126 and showed reduced endothelial repair capacity in vitro and in vivo. Finally, expression analysis of miR-126 in circulating microparticles from 176 patients with stable coronary artery disease with and without diabetes mellitus revealed a significantly reduced miR-126 expression in circulating microparticles from diabetic patients. Endothelial microparticles promote vascular endothelial repair by delivering functional miR-126 into recipient cells. In pathological hyperglycemic conditions, EMP-mediated miR-126-induced EC repair is altered.

Functional genomics indicate that schizophrenia may be an adult vascular-ischemic disorder

PubMed Central

Moises, H W; Wollschläger, D; Binder, H

2015-01-01

In search for the elusive schizophrenia pathway, candidate genes for the disorder from a discovery sample were localized within the energy-delivering and ischemia protection pathway. To test the adult vascular-ischemic (AVIH) and the competing neurodevelopmental hypothesis (NDH), functional genomic analyses of practically all available schizophrenia-associated genes from candidate gene, genome-wide association and postmortem expression studies were performed. Our results indicate a significant overrepresentation of genes involved in vascular function (P<0.001), vasoregulation (that is, perivascular (P<0.001) and shear stress (P<0.01), cerebral ischemia (P<0.001), neurodevelopment (P<0.001) and postischemic repair (P<0.001) among schizophrenia-associated genes from genetic association studies. These findings support both the NDH and the AVIH. The genes from postmortem studies showed an upregulation of vascular-ischemic genes (P=0.020) combined with downregulated synaptic (P=0.005) genes, and ND/repair (P=0.003) genes. Evidence for the AVIH and the NDH is critically discussed. We conclude that schizophrenia is probably a mild adult vascular-ischemic and postischemic repair disorder. Adult postischemic repair involves ND genes for adult neurogenesis, synaptic plasticity, glutamate and increased long-term potentiation of excitatory neurotransmission (i-LTP). Schizophrenia might be caused by the cerebral analog of microvascular angina. PMID:26261884

Functional genomics indicate that schizophrenia may be an adult vascular-ischemic disorder.

PubMed

Moises, H W; Wollschläger, D; Binder, H

2015-08-11

In search for the elusive schizophrenia pathway, candidate genes for the disorder from a discovery sample were localized within the energy-delivering and ischemia protection pathway. To test the adult vascular-ischemic (AVIH) and the competing neurodevelopmental hypothesis (NDH), functional genomic analyses of practically all available schizophrenia-associated genes from candidate gene, genome-wide association and postmortem expression studies were performed. Our results indicate a significant overrepresentation of genes involved in vascular function (P < 0.001), vasoregulation (that is, perivascular (P < 0.001) and shear stress (P < 0.01), cerebral ischemia (P < 0.001), neurodevelopment (P < 0.001) and postischemic repair (P < 0.001) among schizophrenia-associated genes from genetic association studies. These findings support both the NDH and the AVIH. The genes from postmortem studies showed an upregulation of vascular-ischemic genes (P = 0.020) combined with downregulated synaptic (P = 0.005) genes, and ND/repair (P = 0.003) genes. Evidence for the AVIH and the NDH is critically discussed. We conclude that schizophrenia is probably a mild adult vascular-ischemic and postischemic repair disorder. Adult postischemic repair involves ND genes for adult neurogenesis, synaptic plasticity, glutamate and increased long-term potentiation of excitatory neurotransmission (i-LTP). Schizophrenia might be caused by the cerebral analog of microvascular angina.

Metrics of cellular and vascular infiltration of human acellular dermal matrix in ventral hernia repairs.

PubMed

Campbell, Kristin Turza; Burns, Nadja K; Ensor, Joe; Butler, Charles E

2012-04-01

Human acellular dermal matrix is used for ventral hernia repair, as it resists infection and remodels by means of surrounding tissue. However, the tissue source and impact of basement membrane on cell and vessel infiltration have not been determined. The authors hypothesized that musculofascia would be the primary tissue source of cells and vessels infiltrating into human acellular dermal matrix and that the basement membrane would inhibit infiltration. Fifty-six guinea pigs underwent inlay human acellular dermal matrix ventral hernia repair with the basement membrane oriented toward or away from the peritoneum. At postoperative weeks 1, 2, or 4, repair sites were completely excised. Histologic and immunohistochemical analyses were performed to quantify cell and vessel density within repair-site zones, including interface (lateral, beneath musculofascia) and center (beneath subcutaneous fat) zones. Cell and vessel quantities were compared as functions of zone, basement membrane orientation, and time. Cellular and vascular infiltration increased over time universally. The interface demonstrated greater mean cell density than the center (weeks 1 and 2, p = 0.01 and p < 0.0001, respectively). Cell density was greater with the basement membrane oriented toward the peritoneum at week 4 (p = 0.02). The interface zone had greater mean vessel density than the center zone at week 4 (p < 0.0001). Orienting the basement membrane toward the peritoneum increased vessel density at week 4 (p = 0.0004). Cellular and vascular infiltration into human acellular dermal matrix for ventral hernia repairs was greater from musculofascia than from subcutaneous fat, and the basement membrane inhibited cellular and vascular infiltration. Human acellular dermal matrix should be placed adjacent to the best vascularizing tissue to improve fibrovascular incorporation.

External validation of Vascular Study Group of New England risk predictive model of mortality after elective abdominal aorta aneurysm repair in the Vascular Quality Initiative and comparison against established models.

PubMed

Eslami, Mohammad H; Rybin, Denis V; Doros, Gheorghe; Siracuse, Jeffrey J; Farber, Alik

2018-01-01

The purpose of this study is to externally validate a recently reported Vascular Study Group of New England (VSGNE) risk predictive model of postoperative mortality after elective abdominal aortic aneurysm (AAA) repair and to compare its predictive ability across different patients' risk categories and against the established risk predictive models using the Vascular Quality Initiative (VQI) AAA sample. The VQI AAA database (2010-2015) was queried for patients who underwent elective AAA repair. The VSGNE cases were excluded from the VQI sample. The external validation of a recently published VSGNE AAA risk predictive model, which includes only preoperative variables (age, gender, history of coronary artery disease, chronic obstructive pulmonary disease, cerebrovascular disease, creatinine levels, and aneurysm size) and planned type of repair, was performed using the VQI elective AAA repair sample. The predictive value of the model was assessed via the C-statistic. Hosmer-Lemeshow method was used to assess calibration and goodness of fit. This model was then compared with the Medicare, Vascular Governance Northwest model, and Glasgow Aneurysm Score for predicting mortality in VQI sample. The Vuong test was performed to compare the model fit between the models. Model discrimination was assessed in different risk group VQI quintiles. Data from 4431 cases from the VSGNE sample with the overall mortality rate of 1.4% was used to develop the model. The internally validated VSGNE model showed a very high discriminating ability in predicting mortality (C = 0.822) and good model fit (Hosmer-Lemeshow P = .309) among the VSGNE elective AAA repair sample. External validation on 16,989 VQI cases with an overall 0.9% mortality rate showed very robust predictive ability of mortality (C = 0.802). Vuong tests yielded a significant fit difference favoring the VSGNE over then Medicare model (C = 0.780), Vascular Governance Northwest (0.774), and Glasgow Aneurysm Score (0.639). Across the 5 risk quintiles, the VSGNE model predicted observed mortality significantly with great accuracy. This simple VSGNE AAA risk predictive model showed very high discriminative ability in predicting mortality after elective AAA repair among a large external independent sample of AAA cases performed by a diverse array of physicians nationwide. The risk score based on this simple VSGNE model can reliably stratify patients according to their risk of mortality after elective AAA repair better than other established models. Copyright © 2017 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.

Proangiogenic hematopoietic cells of monocytic origin: roles in vascular regeneration and pathogenic processes of systemic sclerosis.

PubMed

Yamaguchi, Yukie; Kuwana, Masataka

2013-02-01

New blood vessel formation is critical, not only for organ development and tissue regeneration, but also for various pathologic processes, such as tumor development and vasculopathy. The maintenance of the postnatal vascular system requires constant remodeling, which occurs through angiogenesis, vasculogenesis, and arteriogenesis. Vasculogenesis is mediated by the de novo differentiation of mature endothelial cells from endothelial progenitor cells (EPCs). Early studies provided evidence that bone marrow-derived CD14⁺ monocytes can serve as a subset of EPCs because of their expression of endothelial markers and ability to promote neovascularization in vitro and in vivo. However, the current consensus is that monocytic cells do not give rise to endothelial cells in vivo, but function as support cells, by promoting vascular formation and repair through their immediate recruitment to the site of vascular injury, secretion of proangiogenic factors, and differentiation into mural cells. These monocytes that function in a supporting role in vascular repair are now termed monocytic pro-angiogenic hematopoietic cells (PHCs). Systemic sclerosis (SSc) is a multisystem connective tissue disease characterized by excessive fibrosis and microvasculopathy, along with poor vascular formation and repair. We recently showed that in patients with SSc, circulating monocytic PHCs increase dramatically and have enhanced angiogenic potency. These effects may be induced in response to defective vascular repair machinery. Since CD14⁺ monocytes can also differentiate into fibroblast-like cells that produce extracellular matrix proteins, here we propose a new hypothesis that aberrant monocytic PHCs, once mobilized into circulation, may also contribute to the fibrotic process of SSc.

Increased vascularization during early healing after biologic augmentation in repair of chronic rotator cuff tears using autologous leukocyte- and platelet-rich fibrin (L-PRF): a prospective randomized controlled pilot trial.

PubMed

Zumstein, Matthias A; Rumian, Adam; Lesbats, Virginie; Schaer, Michael; Boileau, Pascal

2014-01-01

We hypothesized that arthroscopic rotator cuff repairs using leukocyte- and platelet-rich fibrin (L-PRF) in a standardized, modified protocol is technically feasible and results in a higher vascularization response and watertight healing rate during early healing. Twenty patients with chronic rotator cuff tears were randomly assigned to 2 treatment groups. In the test group (N = 10), L-PRF was added in between the tendon and the bone during arthroscopic rotator cuff repair. The second group served as control (N = 10). They received the same arthroscopic treatment without the use of L-PRF. We used a double-row tension band technique. Clinical examinations including subjective shoulder value, visual analog scale, Constant, and Simple Shoulder Test scores and measurement of the vascularization with power Doppler ultrasonography were made at 6 and 12 weeks. There have been no postoperative complications. At 6 and 12 weeks, there was no significant difference in the clinical scores between the test and the control groups. The mean vascularization index of the surgical tendon-to-bone insertions was always significantly higher in the L-PRF group than in the contralateral healthy shoulders at 6 and 12 weeks (P = .0001). Whereas the L-PRF group showed a higher vascularization compared with the control group at 6 weeks (P = .001), there was no difference after 12 weeks of follow-up (P = .889). Watertight healing was obtained in 89% of the repaired cuffs. Arthroscopic rotator cuff repair with the application of L-PRF is technically feasible and yields higher early vascularization. Increased vascularization may potentially predispose to an increased and earlier cellular response and an increased healing rate. Copyright © 2014 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Mosby, Inc. All rights reserved.

Abdominal Aortic Aneurysms in “High-Risk” Surgical Patients

PubMed Central

Jordan, William D.; Alcocer, Francisco; Wirthlin, Douglas J.; Westfall, Andrew O.; Whitley, David

2003-01-01

Objective To evaluate the early results of endovascular grafting for high-risk surgical candidates in the treatment of abdominal aortic aneurysms (AAA). Summary Background Data Since the approval of endoluminal grafts for treatment of AAA, endovascular repair of AAA (EVAR) has expanded to include patients originally considered too ill for open AAA repair. However, some concern has been expressed regarding technical failure and the durability of endovascular grafts. Methods The University of Alabama at Birmingham (UAB) Computerized Vascular Registry identified all patients who underwent abdominal aneurysm repair between January 1, 2000, and June 12, 2002. Patients were stratified by type of repair (open AAA vs. EVAR) and were classified as low risk or high risk. Patients with at least one of the following classifications were classified as high risk: age more than 80 years, chronic renal failure (creatinine > 2.0), compromised cardiac function (diminished ventricular function or severe coronary artery disease), poor pulmonary function, reoperative aortic procedure, a “hostile” abdomen, or an emergency operation. Death, systemic complications, and length of stay were tabulated for each group. Results During this 28-month period, 404 patients underwent AAA repair at UAB. Eighteen patients (4.5%) died within 30 days of their repair or during the same hospitalization. Two hundred seventeen patients (53%) were classified as high risk. Two hundred fifty-nine patients (64%) underwent EVAR repair, and 130 (50%) of these were considered high-risk patients (including four emergency procedures). One hundred forty-five patients (36%) underwent open AAA repair, including 15 emergency operations. All deaths occurred in the high-risk group: 12 (8.3%) died after open AAA repair and 6 (2.3%) died after EVAR repair. Postoperative length of stay was shorter for EVAR repair compared to open AAA. Conclusions High-risk and low-risk patients can undergo EVAR repair with a lower rate of short-term systemic complications and a shorter length of stay compared to open AAA. Despite concern regarding the durability of EVAR, high-risk patients should be evaluated for EVAR repair before committing to open AAA repair. PMID:12724628

ETS transcription factor ETV2/ER71/Etsrp in hematopoietic and vascular development, injury, and regeneration.

PubMed

Zhao, Haiyong; Xu, Canxin; Lee, Tae-Jin; Liu, Fang; Choi, Kyunghee

2017-04-01

The major goal in regenerative medicine is to repair and restore injured, diseased or aged tissue function, thereby promoting general health. As such, the field of regenerative medicine has great translational potential in undertaking many of the health concerns and needs that we currently face. In particular, hematopoietic and vascular systems supply oxygen and nutrients and thus play critical roles in tissue development and tissue regeneration. Additionally, tissue vasculature serves as a tissue stem cell niche and thus contributes to tissue homeostasis. Notably, hematopoietic and vascular systems are sensitive to injury and subject to regeneration. As such, successful hematopoietic and vascular regeneration is prerequisite for efficient tissue repair and organismal survival and health. Recent studies have established that the interplay among the ETS transcription factor ETV2, vascular endothelial growth factor, and its receptor VEGFR2/FLK1 is essential for hematopoietic and vascular development. Emerging studies also support the role of these three factors and possible interplay in hematopoietic and vascular regeneration. Comprehensive understanding of the molecular mechanisms involved in the regulation and function of these three factors may lead to more effective approaches in promoting tissue repair and regeneration. Developmental Dynamics 246:318-327, 2017. © 2016 Wiley Periodicals, Inc. © 2016 Wiley Periodicals, Inc.

Open and endovascular aneurysm repair in the Society for Vascular Surgery Vascular Quality Initiative.

PubMed

Spangler, Emily L; Beck, Adam W

2017-12-01

The Society for Vascular Surgery Vascular Quality Initiative is a patient safety organization and a collection of procedure-based registries that can be utilized for quality improvement initiatives and clinical outcomes research. The Vascular Quality Initiative consists of voluntary participation by centers to collect data prospectively on all consecutive cases within specific registries which physicians and centers elect to participate. The data capture extends from preoperative demographics and risk factors (including indications for operation), through the perioperative period, to outcomes data at up to 1-year of follow-up. Additionally, longer-term follow-up can be achieved by matching with Medicare claims data, providing long-term longitudinal follow-up for a majority of patients within the Vascular Quality Initiative registries. We present the unique characteristics of the Vascular Quality Initiative registries and highlight important insights gained specific to open and endovascular abdominal aortic aneurysm repair. Copyright © 2017 Elsevier Inc. All rights reserved.

Clopidogrel is not associated with major bleeding complications during peripheral arterial surgery.

PubMed

Stone, David H; Goodney, Philip P; Schanzer, Andres; Nolan, Brian W; Adams, Julie E; Powell, Richard J; Walsh, Daniel B; Cronenwett, Jack L

2011-09-01

Persistent variation in practice surrounds preoperative clopidogrel management at the time of vascular surgery. While some surgeons preferentially discontinue clopidogrel citing a perceived risk of perioperative bleeding, others will proceed with surgery in patients taking clopidogrel for an appropriate indication. The purpose of this study was to determine whether preoperative clopidogrel use was associated with significant bleeding complications during peripheral arterial surgery. We reviewed a prospective regional vascular surgery registry recorded by 66 surgeons from 15 centers in New England from 2003 to 2009. Preoperative clopidogrel use within 48 hours of surgery was analyzed among patients undergoing carotid endarterectomy (CEA), lower extremity bypass (LEB), endovascular abdominal aortic aneurysm repair (EVAR), and open abdominal aortic aneurysm repair (oAAA). Ruptured AAAs were excluded. Endpoints included postoperative bleeding requiring reoperation, as well as the incidence and volume of blood transfusion. Statistical analysis was performed using analysis of variance, Fisher exact, χ(2), and Wilcoxon rank-sum tests. Over the study interval, a total of 10,406 patients underwent surgery, including 5264 CEA, 2883 LEB, 1125 EVAR, and 1134 oAAA repair. Antiplatelet use among all patients varied, with 19% (n = 2010) taking no antiplatelet agents, 69% (n = 7132) taking aspirin (ASA) alone, 2.2% (n = 229) taking clopidogrel alone, and 9.7% (n = 1017) taking both ASA and clopidogrel. Clopidogrel alone or as dual antiplatelet therapy was most frequently used prior to CEA and least frequently prior to oAAA group (CEA 16.1%, LEB 9.0%, EVAR 6.5%, oAAA 5%). Reoperation for bleeding was not significantly different among patients based on antiplatelet regimen (none 1.5%, ASA 1.3%, clopidogrel 0.9%, ASA/clopidogrel 1.5%, P = .74). When analyzed by operation type, no difference in reoperation for bleeding was seen across antiplatelet regimens. There was also no difference in the incidence of transfusion among antiplatelet treatment groups (none 18%, ASA 17%, clopidogrel 0%, ASA/clopidogrel 24%, P = .1) and none when analyzed by individual operation type. Among patients who did require transfusion, there was no significant difference in the mean number of units of packed red blood cells required (none 0.7 units, ASA 0.5 units, clopidogrel 0 units, ASA/clopidogrel 0.6 units, P = .1) or when stratified by operation type. Patients undergoing peripheral arterial surgery in whom clopidogrel was continued either alone or as part of dual antiplatelet therapy did not have significant bleeding complications compared with patients taking no antiplatelet therapy or ASA alone at the time of surgery. These data suggest that clopidogrel can safely be continued preoperatively in patients with appropriate indications for its use, such as symptomatic carotid disease or recent drug-eluting coronary stents. Copyright © 2011 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.

Economic evaluation of open vs endovascular repair of blunt traumatic thoracic aortic injuries.

PubMed

Tong, Michael Zhen-Yu; Koka, Pavan; Forbes, Thomas L

2010-07-01

During the last decade, endovascular repair (EV) has replaced open surgical repair (OSR) as the preferred method of treatment of blunt traumatic thoracic aortic injuries (BTAIs) at many trauma centers. This has resulted in reductions in mortality, length of stay, and major complications, including paraplegia, with the added expense of the initial endograft, subsequent surveillance, and reinterventions. The purpose of this study was to conduct an economic evaluation comparing these two methods of repair. We performed an economic comparison of EV and OSR for the treatment of BTAI using a decision tree analysis with transition points derived from our institution's experience and through a review of the literature. Over a 15-year period (1991-2006), 28 patients with BTAI were treated at our center (15 EV, 13 OSR). Costs were obtained from our hospital's case costing center, the Ontario Case Costing Initiative, Ontario's Drug Benefit Formulary, and Ontario's Schedule of Benefits for physician costs. Our center's results were then combined with those from the literature to arrive at an economic model. These combined results revealed that EV, when compared to OSR, resulted in decreased early mortality (7.2% vs 22.5%), decreased composite outcome of mortality and paraplegia (7.7% vs 27.6%) and decreased composite outcome of mortality and major complication (42.5% vs 69.8%). Patients undergoing EV also had shorter intensive care unit stays (12.2 vs 15.3 days), total hospital length of stays (22.5 vs 28.6 days), and ventilator days (8.0 vs 9.2 days). Additionally, patients undergoing EV had decreased total 1-year costs compared with OSR ($70,442 vs $72,833). EV repair of BTAIs offers a survival advantage as well as a reduction in major morbidity, including paraplegia, compared with OSR, and results in a reduction in costs at 1 year. As a result, from the cost-effectiveness point of view, EV is the DOMINANT therapy over OSR for these injuries. Copyright (c) 2010 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.

Emergency repair of upper extremity large soft tissue and vascular injuries with flow-through anterolateral thigh free flaps.

PubMed

Zhan, Yi; Fu, Guo; Zhou, Xiang; He, Bo; Yan, Li-Wei; Zhu, Qing-Tang; Gu, Li-Qiang; Liu, Xiao-Lin; Qi, Jian

2017-12-01

Complex extremity trauma commonly involves both soft tissue and vascular injuries. Traditional two-stage surgical repair may delay rehabilitation and functional recovery, as well as increase the risk of infections. We report a single-stage reconstructive surgical method that repairs soft tissue defects and vascular injuries with flow-through free flaps to improve functional outcomes. Between March 2010 and December 2016 in our hospital, 5 patients with severe upper extremity trauma received single-stage reconstructive surgery, in which a flow-through anterolateral thigh free flap was applied to repair soft tissue defects and vascular injuries simultaneously. Cases of injured artery were reconstructed with the distal trunk of the descending branch of the lateral circumflex femoral artery. A segment of adjacent vein was used if there was a second artery injury. Patients were followed to evaluate their functional recoveries, and received computed tomography angiography examinations to assess peripheral circulation. Two patients had post-operative thumb necrosis; one required amputation, and the other was healed after debridement and abdominal pedicle flap repair. The other 3 patients had no major complications (infection, necrosis) to the recipient or donor sites after surgery. All the patients had achieved satisfactory functional recovery by the end of the follow-up period. Computed tomography angiography showed adequate circulation in the peripheral vessels. The success of these cases shows that one-step reconstructive surgery with flow-through anterolateral thigh free flaps can be a safe and effective treatment option for patients with complex upper extremity trauma with soft tissue defects and vascular injuries. Copyright © 2017. Published by Elsevier Ltd.

Principles for Management of Intraoperative Acute Type A Aortic Dissection.

PubMed

Gukop, Philemon; Chandrasekaran, Vankatachalam

2015-12-01

Intraoperative Type A aortic dissection is a rare pathology with incidence of 0.06-0.32%. It is associated with a high mortality between 30-50%. Some associated risk factors, including hypertension, enlarged aorta, peripheral vascular disease, advanced age, atheroma, and high arterial pressure on cardiopulmonary bypass, have been identified. Modification of these risk factors could reduce the incidence of this event. Prompt diagnosis and management, with the aid of intraoperative trans-esophageal echocardiography and/or epi-aortic ultrasound has been shown to reduce the mortality to 17%. We illustrate the principles of management of this pathology with the case of a 62-year-old female who developed acute Type A aortic dissection while undergoing minimally invasive mitral valve repair.

Endovascular repair of an iliac artery aneurysm in a patient with Ehlers-Danlos syndrome type IV.

PubMed

Tonnessen, Britt H; Sternbergh, W Charles; Mannava, Krishna; Money, Samuel R

2007-01-01

Ehlers-Danlos type IV (EDS-IV) is an inherited condition most notable for its associated vascular complications. Patients are prone to aneurysm formation, arterial dissection, and spontaneous vessel rupture. Intervention for the vascular pathology of EDS-IV carries high morbidity and mortality. We describe a case of a 57-year-old man with EDS-IV and an expanding iliac aneurysm who underwent successful endovascular repair with a stent-graft. Endovascular aneurysm repair is feasible and should be considered for patients with EDS-IV.

Successful Occlusion of a Ruptured Aortic Aneurysm Using the Amplatzer Vascular Plug: A Technical Note

DOE Office of Scientific and Technical Information (OSTI.GOV)

Zander, Tobias, E-mail: tobiaszander@gmx.de; Baldi, Sebastian; Rabellino, Martin

2011-02-15

Ruptured abdominal aortic aneurysm is related with a 100% mortality rate if left untreated. Even with surgical intervention or endovascular repair, mortality is still extremely high. However, there are conditions in which neither open surgical aneurysm repair nor endovascular aneurysm repair can be considered a viable therapeutic option because of comorbidities or anatomic reasons. We report a case of successful endovascular treatment in a patient with ruptured abdominal aortic aneurysm by occluding the abdominal aneurysm using the Amplatzer Vascular Plug (AVP II).

Instructive role of the vascular niche in promoting tumour growth and tissue repair by angiocrine factors

PubMed Central

Butler, Jason M.; Kobayashi, Hideki; Rafii, Shahin

2010-01-01

The precise mechanisms whereby anti-angiogenesis therapy blocks tumour growth or causes vascular toxicity are unknown. We propose that endothelial cells establish a vascular niche that promotes tumour growth and tissue repair not only by delivering nutrients and O2 but also through an ‘angiocrine’ mechanism by producing stem and progenitor cell-active trophogens. Identification of endothelial-derived instructive angiocrine factors will allow direct tumour targeting, while diminishing the unwanted side effects associated with the use of anti-angiogenic agents. PMID:20094048

Instructive role of the vascular niche in promoting tumour growth and tissue repair by angiocrine factors.

PubMed

Butler, Jason M; Kobayashi, Hideki; Rafii, Shahin

2010-02-01

The precise mechanisms whereby anti-angiogenesis therapy blocks tumour growth or causes vascular toxicity are unknown. We propose that endothelial cells establish a vascular niche that promotes tumour growth and tissue repair not only by delivering nutrients and O2 but also through an 'angiocrine' mechanism by producing stem and progenitor cell-active trophogens. Identification of endothelial-derived instructive angiocrine factors will allow direct tumour targeting, while diminishing the unwanted side effects associated with the use of anti-angiogenic agents.

Methods for Studying the Role of RAAS in the Modulation of Vascular Repair-Relevant Functions of Stem/Progenitor Cells.

PubMed

Jarajapu, Yagna P R

2017-01-01

In recent years, previously unknown functions have been conferred to the RAAS and have been explored in mechanistic studies and disease models. Implication of bone marrow stem/progenitor cells in the cardiovascular protective or detrimental effects of RAAS is a prominent advancement because of the translational significance. Selected members of RAAS are now known to modulate migration, proliferation, and mobilization of bone marrow cells in response to ischemic insult, which are sensitive indicators of vascular repair-relevant functions. In this Chapter, protocols for most frequently used, in vitro, ex vivo, and in vivo assays to explore the potential of RAAS members to stimulate vascular repair-relevant functions of bone marrow stem/progenitor cells of human and murine origin.

Adipose tissue-derived stem cells enhance bioprosthetic mesh repair of ventral hernias.

PubMed

Altman, Andrew M; Abdul Khalek, Feras J; Alt, Eckhard U; Butler, Charles E

2010-09-01

Bioprosthetic mesh used for ventral hernia repair becomes incorporated into the musculofascial edge by cellular infiltration and vascularization. Adipose tissue-derived stem cells promote tissue repair and vascularization and may increase the rate or degree of tissue incorporation. The authors hypothesized that introducing these cells into bioprosthetic mesh would result in adipose tissue-derived stem cell engraftment and proliferation and enhance incorporation of the bioprosthetic mesh. Adipose tissue-derived stem cells were isolated from the subcutaneous adipose tissue of syngeneic Brown Norway rats, expanded in vitro, and labeled with green fluorescent protein. Thirty-six additional rats underwent inlay ventral hernia repair with porcine acellular dermal matrix. Two 12-rat groups had the cells (1.0 x 10(6)) injected directly into the musculofascial/porcine acellular dermal matrix interface after repair or received porcine acellular dermal matrix on which the cells had been preseeded; the 12-rat control group received no stem cells. At 2 weeks, adipose tissue-derived stem cells in both stem cell groups engrafted, survived, migrated, and proliferated. Mean cellular infiltration into porcine acellular dermal matrix at the musculofascial/graft interface was significantly greater in the preseeded and injected stem cell groups than in the control group. Mean vascular infiltration of the porcine acellular dermal matrix was significantly greater in both stem cell groups than in the control group. Preseeded and injected adipose tissue-derived stem cells engraft, migrate, proliferate, and enhance the vascularity of porcine acellular dermal matrix grafts at the musculofascial/graft interface. These cells can thus enhance incorporation of porcine acellular dermal matrix into the abdominal wall after repair of ventral hernias.

No increased risk of carcinogenesis with mesh-based hernia repairs.

PubMed

Chughtai, Bilal; Sedrakyan, Art; Thomas, Dominique; Mao, Jialin; Eilber, Karyn S; Clemens, J Quentin; Anger, Jennifer T

2017-12-06

The use of synthetic mesh has been placed under considerable scrutiny. We sought to evaluate whether there is a link between placement of synthetic polypropylene mesh for hernia repair and a subsequent cancer diagnosis. Adult men undergoing mesh-based hernia repair from January 2008-December 2009 in New York State were identified and followed through December 2014. Control cohorts of men undergoing cholecystectomy and total knee replacement were control cohorts. 1894 patients undergoing hernia repair, 912 patients in the cholecystectomy control cohort, and 1099 in the TKA control cohort with a cancer diagnosis. In the matched analyses of mesh-based hernia repair and cholecystectomy patients 6.5% vs. 7.1% developed cancer. In the matched analysis of hernia patients and TKA patients, 9.3% vs. 9.1% developed cancer. No association between mesh-based hernia surgery and increased risk of cancer was found. Mesh-based hernia repair was not associated with an increased risk of subsequent development of cancer in men. Copyright © 2017 Elsevier Inc. All rights reserved.

Vascular and micro-environmental influences on MSC-coral hydroxyapatite construct-based bone tissue engineering.

PubMed

Cai, Lei; Wang, Qian; Gu, Congmin; Wu, Jingguo; Wang, Jian; Kang, Ning; Hu, Jiewei; Xie, Fang; Yan, Li; Liu, Xia; Cao, Yilin; Xiao, Ran

2011-11-01

Bone tissue engineering (BTE) has been demonstrated an effective approach to generate bone tissue and repair bone defect in ectopic and orthotopic sites. The strategy of using a prevascularized tissue-engineered bone grafts (TEBG) fabricated ectopically to repair bone defects, which is called live bone graft surgery, has not been reported. And the quantitative advantages of vascularization and osteogenic environment in promoting engineered bone formation have not been defined yet. In the current study we generated a tissue engineered bone flap with a vascular pedicle of saphenous arteriovenous in which an organized vascular network was observed after 4 weeks implantation, and followed by a successful repaire of fibular defect in beagle dogs. Besides, after a 9 months long term observation of engineered bone formation in ectopic and orthotopic sites, four CHA (coral hydroxyapatite) scaffold groups were evaluated by CT (computed tomography) analysis. By the comparison of bone formation and scaffold degradation between different groups, the influences of vascularization and micro-environment on tissue engineered bone were quantitatively analyzed. The results showed that in the first 3 months vascularization improved engineered bone formation by 2 times of non-vascular group and bone defect micro-environment improved it by 3 times of ectopic group, and the CHA-scaffold degradation was accelerated as well. Copyright © 2011 Elsevier Ltd. All rights reserved.

Vitamins E and C - effects on matrix components in the vascular system

USDA-ARS?s Scientific Manuscript database

The connective tissue in the vascular system, consisting mainly of vascular smooth muscle cells (VSMC) and the interstitial extracellular matrix (ECM), plays important roles in the maintenance of an intact vascular wall as well as in the repair of atherosclerotic lesions during disease development. ...

Open repair of chronic distal aortic dissection in the endovascular era: Implications for disease management.

PubMed

Pujara, Akshat C; Roselli, Eric E; Hernandez, Adrian V; Vargas Abello, Lina M; Burke, Jacob M; Svensson, Lars G; Greenberg, Roy K

2012-10-01

Controversy surrounds the treatment of chronic aortic dissection. Open surgical and endovascular experiences include mixed populations treated with evolving strategies and limited follow-up. We establish a standard against which endovascular repair can be compared by assessing outcomes after open repair of chronic distal aortic dissections anatomically suitable to stent-grafting. From 2000 to 2008, 169 patients underwent open repair of the descending thoracic artery only (n = 88) or thoracoabdominal (n = 81) chronic aortic dissection (elective in 98, urgent/emergency in 71). Chart review and 3-dimensional assessment of computed tomography were performed. Poor outcome included all-cause mortality or vascular reintervention. Thirty-day mortality was 8% (n = 14). Serious complications included neurologic (n = 12 [spinal cord n = 4, 2.4%]), respiratory (n = 32), and renal failure (n = 1 descending thoracic artery only vs 17 thoracoabdominal, P < .001). Chronic obstructive pulmonary disease predicted early mortality (hazard ratio 8.0, P = .005). Survival at 1, 2, and 5 years was 76%, 69%, and 55%, respectively; 23 patients (14%) required reintervention. Event-free survival at 5 years was 51% and 47% after descending thoracic artery only or thoracoabdominal repair, respectively. Greater maximum aortic diameter (hazard ratio 1.9, P = .03) and greater diameter at the diaphragm (hazard ratio 3.7, P = .01) or renal segment (hazard ratio 4.3, P = .03) predicted poor outcome. Early outcomes are good and late outcomes are less than desirable after open repair of chronic distal aortic dissection, regardless of the extent of repair. High-risk and late-stage patients with larger and more extensive aneurysmal degeneration warrant further investigation, including the use of newer, less-invasive techniques. Select patients at risk for aneurysmal degeneration should undergo a more aggressive initial approach with aortic dissection repair. Copyright © 2012 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.

Comparison of open and endovascular repair of inflammatory aortic aneurysms.

PubMed

Stone, William M; Fankhauser, Grant T; Bower, Thomas C; Oderich, Gustavo S; Oldenburg, W Andrew; Kalra, Manju; Naidu, Sailendra; Money, Samuel R

2012-10-01

Inflammatory abdominal aortic aneurysms (IAAAs) have been traditionally managed with open repair. Endovascular aneurysm repair (EVAR) was approved September of 1999. Some authors have suggested that EVAR is not an acceptable option for management of an IAAA. However, several recent reports have suggested EVAR is a reasonable management option in these patients. The purpose of our study was to review our experience with the contemporary management of IAAA involving both open and endovascular approaches. A retrospective review of all patients undergoing repair of IAAAs from 1999 to 2011 was conducted at three geographically separate institutions. Basic demographics, diagnostic workup, treatment, and outcomes were reviewed. Between 1999 and 2011, 69 patients underwent surgical repair of IAAAs, 59 by open repair and 10 by EVAR. Eighty-three percent of patients were men with a mean age of 67. Aneurysm size was similar in both groups (6.3 cm open repair vs 5.9 cm EVAR). Follow-up for the open group was a mean of 42.6 months and 33.6 months for the EVAR group. Periaortic fibrosis decreased from a mean of 5.4 mm to 2.7 mm after EVAR. Hydronephrosis was present preoperatively in one patient and did not change after EVAR. Aneurysm size decreased in seven patients (70%) who underwent EVAR. Two patients had no change with one lost to follow-up. Mean aneurysm size decrease after EVAR was 1.12 cm (17.8%). There were no aneurysm-related deaths or major morbidities in the EVAR group. Twenty-two patients (37%) in the open surgical group suffered major complications, including myocardial infarction, renal failure, lower extremity amputation, sepsis, and prolonged ventilation. Endovascular repair for IAAA results in successful management with improvement of periaortic inflammation. EVAR should be considered as first-line therapy in which anatomic parameters are favorable. Copyright © 2012 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.

Mechanical cause for acute left lung atelectasis after neonatal aortic arch repair with arterial switch operation: Conservative management.

PubMed

Maddali, Madan Mohan; Kandachar, Pranav Subbaraya; Al-Hanshi, Said; Al Ghafri, Mohammed; Valliattu, John

2017-01-01

Respiratory complications due to mechanical obstruction of the airways can occur following pediatric cardiac surgery. Clinically significant intrathoracic vascular compression of the airway can occur when extensive dissection and mobilization of arch and neck vessels is involved as in repair of interrupted aortic arch. This case report describes a neonate who underwent interrupted aortic arch repair along with an arterial switch operation and developed a left lung collapse immediately after tracheal extubation. Fiber-optic bronchoscopy revealed vascular compression as the real culprit. The child was successfully managed conservatively.

Vascular Surgery in World War II: The Shift to Repairing Arteries.

PubMed

Barr, Justin; Cherry, Kenneth J; Rich, Norman M

2016-03-01

Vascular surgery in World War II has long been defined by DeBakey and Simeone's classic 1946 article describing arterial repair as exceedingly rare. They argued ligation was and should be the standard surgical response to arterial trauma in war. We returned to and analyzed the original records of World War II military medical units housed in the National Archives and other repositories in addition to consulting published accounts to determine the American practice of vascular surgery in World War II. This research demonstrates a clear shift from ligation to arterial repair occurring among American military surgeons in the last 6 months of the war in the European Theater of Operations. These conclusions not only highlight the role of war as a catalyst for surgical change but also point to the dangers of inaccurate history in stymieing such advances.

Platelets secrete stromal cell–derived factor 1α and recruit bone marrow–derived progenitor cells to arterial thrombi in vivo

PubMed Central

Massberg, Steffen; Konrad, Ildiko; Schürzinger, Katrin; Lorenz, Michael; Schneider, Simon; Zohlnhoefer, Dietlind; Hoppe, Katharina; Schiemann, Matthias; Kennerknecht, Elisabeth; Sauer, Susanne; Schulz, Christian; Kerstan, Sandra; Rudelius, Martina; Seidl, Stefan; Sorge, Falko; Langer, Harald; Peluso, Mario; Goyal, Pankaj; Vestweber, Dietmar; Emambokus, Nikla R.; Busch, Dirk H.; Frampton, Jon; Gawaz, Meinrad

2006-01-01

The accumulation of smooth muscle and endothelial cells is essential for remodeling and repair of injured blood vessel walls. Bone marrow–derived progenitor cells have been implicated in vascular repair and remodeling; however, the mechanisms underlying their recruitment to the site of injury remain elusive. Here, using real-time in vivo fluorescence microscopy, we show that platelets provide the critical signal that recruits CD34+ bone marrow cells and c-Kit+ Sca-1+ Lin− bone marrow–derived progenitor cells to sites of vascular injury. Correspondingly, specific inhibition of platelet adhesion virtually abrogated the accumulation of both CD34+ and c-Kit+ Sca-1+ Lin− bone marrow–derived progenitor cells at sites of endothelial disruption. Binding of bone marrow cells to platelets involves both P-selectin and GPIIb integrin on platelets. Unexpectedly, we found that activated platelets secrete the chemokine SDF-1α, thereby supporting further primary adhesion and migration of progenitor cells. These findings establish the platelet as a major player in the initiation of vascular remodeling, a process of fundamental importance for vascular repair and pathological remodeling after vascular injury. PMID:16618794

Platelets secrete stromal cell-derived factor 1alpha and recruit bone marrow-derived progenitor cells to arterial thrombi in vivo.

PubMed

Massberg, Steffen; Konrad, Ildiko; Schürzinger, Katrin; Lorenz, Michael; Schneider, Simon; Zohlnhoefer, Dietlind; Hoppe, Katharina; Schiemann, Matthias; Kennerknecht, Elisabeth; Sauer, Susanne; Schulz, Christian; Kerstan, Sandra; Rudelius, Martina; Seidl, Stefan; Sorge, Falko; Langer, Harald; Peluso, Mario; Goyal, Pankaj; Vestweber, Dietmar; Emambokus, Nikla R; Busch, Dirk H; Frampton, Jon; Gawaz, Meinrad

2006-05-15

The accumulation of smooth muscle and endothelial cells is essential for remodeling and repair of injured blood vessel walls. Bone marrow-derived progenitor cells have been implicated in vascular repair and remodeling; however, the mechanisms underlying their recruitment to the site of injury remain elusive. Here, using real-time in vivo fluorescence microscopy, we show that platelets provide the critical signal that recruits CD34+ bone marrow cells and c-Kit+ Sca-1+ Lin- bone marrow-derived progenitor cells to sites of vascular injury. Correspondingly, specific inhibition of platelet adhesion virtually abrogated the accumulation of both CD34+ and c-Kit+ Sca-1+ Lin- bone marrow-derived progenitor cells at sites of endothelial disruption. Binding of bone marrow cells to platelets involves both P-selectin and GPIIb integrin on platelets. Unexpectedly, we found that activated platelets secrete the chemokine SDF-1alpha, thereby supporting further primary adhesion and migration of progenitor cells. These findings establish the platelet as a major player in the initiation of vascular remodeling, a process of fundamental importance for vascular repair and pathological remodeling after vascular injury.

Massive Blood Transfusion in Patients with Ruptured Abdominal Aortic Aneurysm.

PubMed

Montan, C; Hammar, U; Wikman, A; Berlin, E; Malmstedt, J; Holst, J; Wahlgren, C M

2016-11-01

The aim was to study blood transfusions and blood product ratios in massively transfused patients treated for ruptured abdominal aortic aneurysms (rAAAs). This was a registry based cohort study of rAAA patients repaired at three major vascular centres between 2008 and 2013. Data were collected from the Swedish Vascular Registry, hospitals medical records, and local transfusion registries. The transfusion data were analysed for the first 24 h of treatment. Massive transfusion (MT) was defined as 4 or more units of red blood cell (RBC) transfused within 1 h, or 10 or more RBC units within 24 h. Logistic regression was used to calculate the odds ratio of 30 day mortality associated with the ratios of blood products and timing of first units of platelets (PLTs) and fresh frozen plasma (FFP) transfused. Three hundred sixty nine rAAA patients were included: 80% men; 173 endovascular aneurysm repairs (EVARs) and 196 open repairs (ORs) with median RBC transfusion 8 units (Q1-Q3, 4-14) and 14 units (Q1-Q3, 8-28), respectively. A total of 261 (71%) patients required MT. EVAR patients with MT (n = 96) required less transfusion than OR patients (n = 165): median RBC 10 units (Q1-Q3, 6-16.5) vs. 15 units (Q1-Q3, 9-26) (p = .002), FFP 6 units (Q1-Q3, 2-14.5) vs. 13 units (Q1-Q3, 7-24) (p < .001), and PLT 0 units (Q1-Q3, 0-2) vs. 2 units (Q1-Q3, 0-4) (p = .01). Median blood product ratios in MT patients were FFP/RBC (EVAR group 0.59 [0.33-0.86], OR group 0.84 [0.67-1.2]; p < .001], and PLT/RBC (EVAR 0 [0-0.17], OR 0.12 (0-0.18); p < .001]. In patients repaired by OR a FFP/RBC ratio close to 1 was associated with reduced 30 day mortality (p = .003). The median PLT/RBC ratio was higher during the later part of the study period (p < .001, median test), whereas there was no significant difference in median FFP/RBC ratio (p = .101, median test). The majority of rAAA patients undergoing EVAR required MT. EVAR patients treated with MT had lower FFP/RBC and PLT/RBC ratios than OR patients with MT. The mortality risk was lower with FFP/RBC ratio close to 1:1 in open repaired patients requiring MT. The 24 h PLT/RBC ratio increased over the study period. Copyright © 2016 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.

Textbook Outcome: A Composite Measure for Quality of Elective Aneurysm Surgery.

PubMed

Karthaus, Eleonora G; Lijftogt, Niki; Busweiler, Linde A D; Elsman, Bernard H P; Wouters, Michel W J M; Vahl, Anco C; Hamming, Jaap F

2017-11-01

To investigate a new composite quality measurement, which comprises a desirable outcome for elective aneurysm surgery, called "Textbook Outcome" (TO). Single-quality indicators in vascular surgery are often not distinctive and insufficiently reflect the quality of care. All patients undergoing elective abdominal aortic aneurysm repair, registered in the Dutch Surgical Aneurysm Audit between 2014 and 2015 were included. TO was defined as the percentage of patients who had abdominal aortic aneurysm-repair without intraoperative complications, postoperative surgical complications, reinterventions, prolonged hospital stay [endovascular aneurysm repair (EVAR) ≤4 d, open surgical repair (OSR) ≤10 d], readmissions, and postoperative mortality (≤30 d after surgery/at discharge). Case-mix adjusted TO rates were used to compare hospitals and to compare individual hospital results for different procedures. Five thousand one hundred seventy patients were included, of whom 4039 were treated with EVAR and 1131 with OSR. TO was achieved in 71% of EVAR and 53% of OSR. Important obstacles for achieving TO were a prolonged hospital stay, postoperative complications, and readmissions. Adjusted TO rates varied from 38% to 89% (EVAR) and from 0% to 97% (OSR) between individual hospitals. Hospitals with a high TO for OSR also had a high TO for EVAR; however, a high TO for EVAR did not implicate a high TO for OSR. TO generates additional information to evaluate the overall quality of the care of elective aneurysm surgery, which subsequently can be used by hospitals to improve the quality of their care.

National Trends of Thoracic Endovascular Aortic Repair (TEVAR) Versus Open Repair in Blunt Thoracic Aortic Injury.

PubMed

Grigorian, Areg; Spencer, Dean; Donayre, Carlos; Nahmias, Jeffry; Schubl, Sebastian; Gabriel, Viktor; Barrios, Cristobal

2018-06-07

Blunt thoracic aortic injury (BTAI) occurs in <1% of all trauma admissions. Considering the advent of multiple thoracic endovascular aortic repair (TEVAR) devices over the past decade, improved outcomes of TEVAR supported in the literature, rapid diagnosis and improved preoperative planning of BTAI using computed tomography imaging, we hypothesized that the national incidence of TEVAR in BTAI has increased while open repair has decreased. In addition, we hypothesized that the mortality risk in BTAI patients undergoing TEVAR would be lower than open repair. This was a retrospective analysis of the National Trauma Data Bank from 2007-2015. The primary end-points of interest included the incidence of TEVAR and open repair, as well as mortality in BTAI patients undergoing intervention. Covariates were included in a multivariable analysis to determine risk for mortality in BTAI patients undergoing open repair versus TEVAR. We identified 3,628 BTAI patients undergoing intervention. Of these, 3,226 underwent TEVAR (87.9%) and 445 (12.1%) underwent open repair. Compared to open repair, TEVAR had a shorter mean length of stay (19.8 vs. 21.3 days, p<0.05) and lower rates of acute kidney injury (5.6% vs. 9.0%, p<0.05) and mortality (8.8% vs. 12.8%, p<0.05). Open repair had greater risk for mortality compared to TEVAR (OR=1.63, CI=1.19-2.23, p<0.05). The rate of open repair decreased from 7.4% in 2007 to 1.9% in 2015, while TEVAR increased from 12.1% to 25.7% during the same time-period. We confirmed previous findings that endovascular repair is associated with decreased mortality, length of stay and major complications including acute kidney injury. Future investigations should focus on identifying the ideal patient candidate for TEVAR and elucidate precise indications for TEVAR in BTAI. Copyright © 2018. Published by Elsevier Inc.

Penetrating duodenal trauma: A 19-year experience.

PubMed

Schroeppel, Thomas J; Saleem, Kashif; Sharpe, John P; Magnotti, Louis J; Weinberg, Jordan A; Fischer, Peter E; Croce, Martin A; Fabian, Timothy C

2016-03-01

Multiple techniques are used for repair in duodenal injury ranging from simple suture repair for low-grade injuries to pancreaticoduodenectomy for complicated high-grade injuries. Drains, both intraluminal and extraluminal, are placed variably depending on associated injuries and confidence with the repair. It is our contention that a simplified approach to repair will limit complications and mortality. The major complication of duodenal leak (DL) was the outcome used to assess methods of repair in this study. After early deaths from associated vascular injuries were excluded, patients with a penetrating duodenal injury admitted during a 19-year period ending in 2014 constituted the study population. A total of 125 patients with penetrating duodenal injuries were included. Overall, the leak rate was 8% with two duodenal-related mortalities. No differences were seen in patients who had a DL as compared with no leak with respect to demographics, injury severity, or admission variables. Patients with DL were more likely to have a major vascular injury (60% vs. 23%, p = 0.02) and a combined pancreatic injury (70% vs. 31%, p = 0.03). No differences were identified by repair technique, location, or grade of injury. DLs were more likely to have an extraluminal drain (90% vs. 45%, p = 0.008). Primary suture repair should be the initial approach considered for most injuries. Major vascular injuries and concomintant pancreatic injuries were associated with most leaks; therefore, adjuncts to repair including intraluminal drainage and pyloric exclusion should be considered on the initial operation. Extraluminal drains should be avoided unless required for associated injuries. Therapeutic/care management study, level IV.

Octogenarians Undergoing Open Repair Have Higher Mortality Compared with Fenestrated Endovascular Repair of Intact Abdominal Aortic Aneurysms Involving the Visceral Vessels.

PubMed

Locham, Satinderjit; Faateh, Muhammad; Dakour-Aridi, Hanaa; Nejim, Besma; Malas, Mahmoud

2018-04-18

Prior studies have shown that octogenarians have a higher risk of mortality than nonoctogenarians undergoing open aneurysm repair (OAR) and endovascular aneurysm repair (EVAR) for abdominal aortic aneurysm (AAA). Fenestrated endovascular aneurysm repair (F-EVAR) was approved by the Food and Drug Administration (FDA) in 2012 and has been used as a less invasive approach to treat patients with suboptimal neck anatomy with favorable outcomes compared with traditional OAR. The aim of the study is to compare 30-day outcomes of F-EVAR versus OAR in octogenarians undergoing repair of AAA involving the visceral vessels in the United States. All patients with postoperative diagnosis of nonruptured AAA repair were identified in the National Surgical Quality Improvement Program database (2006-2015). Univariate and multivariate analyses were implemented to examine 30-day morbidity and mortality adjusting for patient demographics and comorbidities. A total of 548 octogenarians underwent repair of nonruptured AAA involving the visceral vessels, of which 242 (44%) were F-EVARs, and 306 (56%) were OARs. Octogenarians undergoing F-EVAR were on average 1-year older (median age [interquartile range]: 83 [82, 86] versus 82 [81, 85], P = 0.004) and more likely to be male (82% vs. 64%, P < 0.001) compared with OAR. Prevalence of diabetes (13% vs. 6%, P = 0.005) and progressive renal failure (57% vs. 47%, P = 0.03) was also higher in patients undergoing F-EVAR compared with OAR. Thirty-day postoperative mortality was higher after OAR (8.5% vs. 4.1%, P = 0.04). Secondary outcomes including cardiopulmonary (27.1% vs. 5.8%, P < 0.001) and renal injury (10.8% vs. 2.1%, P < 0.001) were also significantly higher in OAR compared with F-EVAR. After adjusting for patients' demographics and comorbidities, OAR had almost 4-fold increased risk of 30-day postoperative mortality compared with F-EVAR (odds ratio [95% confidence interval]: 3.90 [1.48-10.31], P = 0.006). In this large national cohort of octogenarians undergoing repair for complex AAA's, we showed that F-EVAR is associated with significantly lower postoperative morbidity and mortality than open repair. One of the main limitations of the study is the lack of anatomical data. However, despite that, our findings support the shifting paradigm toward minimally invasive approach in this frail population for treatment of complex AAA's. Further studies are needed to evaluate the long-term benefit of any repair in octogenarians. Copyright © 2018 Elsevier Inc. All rights reserved.

Management of traumatic popliteal vascular injuries in a level I trauma center: A 6-year experience.

PubMed

Sciarretta, Jason D; Macedo, Francisco Igor B; Otero, Christian A; Figueroa, Jose N; Pizano, Louis R; Namias, Nicholas

2015-06-01

Popliteal vascular trauma remains a challenging entity, and carries the greatest risk of limb loss among the lower extremity vascular injuries. Operative management of traumatic popliteal vascular injuries continues to evolve. We aim at describing our experience with such complex injuries, with associated patterns of injury, diagnostic and therapeutic challenges, and outcomes. From January 2006 to September 2011, 191 adult trauma patients presented to an urban level I trauma center in Miami, Florida with traumatic lower extremity vascular injuries. Variables collected included age, gender, mechanism of injury, and clinical status at presentation. Surgical data included vessel injury, technical aspects of repair, associated complications and outcomes. Forty-seven (24.6%) patients were diagnosed with traumatic popliteal vascular injuries. Mean age was 38.1 ± 16.1 years, and the majority of patients were males (43 patients, 91.4%). There were 21 (44.7%) penetrating injuries, and 26 (55.3%) blunt injuries. Vascular repair with saphenous venous interposition graft and PTFE (polytetrafluoroethylene) grafting were performed in 36 (70.7%) and 2 (3.9%) patients, respectively. Blunt popliteal injuries were significantly more associated with major tissue loss, and length of hospital and intensive care unit (ICU) stays. The risk for amputation is increased with longer ICU stays and the use of PTFE grafting for vascular repair. The overall mortality rate in this series was 8.5%. Blunt popliteal vascular injuries are associated with increased morbidity compared to penetrating trauma. Early restoration of blood perfusion, frequent use of interposition grafts with autogenous saphenous vein, and liberal use of fasciotomies play important role to achieve acceptable outcomes. Copyright © 2015 IJS Publishing Group Limited. Published by Elsevier Ltd. All rights reserved.

The Impact of Physician Specialization on Clinical and Hospital Outcomes in Patients Undergoing EVAR and TEVAR.

PubMed

Dua, Anahita; Andre, Jason; Nolte, Nicholas; Pan, James; Hood, Douglas; Hodgson, Kim J; Desai, Sapan S

2016-08-01

Endovascular aneurysm repair (EVAR) and Thoracic endovascular aortic repair (TEVAR) are commonly performed by interventional radiologists, cardiologists, general surgeons, cardiothoracic surgeons, and vascular surgeons, with each specialty having differences in residency structure, operative experience, and subspecialty training. The aim of this study is to evaluate the impact of surgeon specialty on outcomes following EVAR and TEVAR. Patients who underwent EVAR and TEVAR were identified from the 2007 to 2009 Nationwide Inpatient Sample (NIS). Physician identifiers in the NIS were used to determine surgical specialty and operative experience. Multivariate analysis adjusted for mortality risk was used to compare differences in demographics, complications, outcomes, and hospital covariates. A total of 5147 EVARs were identified within the NIS, of which 88.3% were completed by vascular surgeons. There were no significant differences in demographics between the specialties. Cardiothoracic surgeons were more likely to have a postoperative stroke (3.1% vs. 0.2%, odds ratio [OR] 14.6, 95% confidence interval [CI] 1.8-117.8, P < 0.05) and cardiac complications (9.4% vs. 2.0%, OR 5.0, 95% CI 1.5-16.6, P < 0.01) compared with other specialties. Costs were lowest for vascular surgeons ($32,094), and highest for cardiothoracic surgeons ($41,663, P < 0.05). Only vascular surgeons completed more than 10 EVARs per year. A total of 2531 TEVAR cases were completed during the study period, of which 73.8% were completed by vascular surgeons, 15.8% by cardiothoracic surgeons, 8.0% by interventional radiologists, and the remainder by interventional cardiologists and general surgeons. Interventional radiologists had significantly more elective cases (77.8%, P < 0.001) than cardiothoracic surgeons (47.2%) or vascular surgeons (53.8%), but had a significantly higher rate of stroke (7.6% vs. 1.1%, P < 0.001) and cardiac events (7.2% vs. 3.6%, P < 0.001). Length of stay (LOS, 10.7 days) and median costs ($52,156) were similar across specialties. Vascular surgeons have a low stroke rate (1.1%, P < 0.05 vs. interventional radiologists) and lower rate of cardiac events (3.6% vs. 6.1%, P < 0.01) despite caring for patients with higher diagnosis-related group mortality scores (3.6 vs. 3.4, P < 0.05). Vascular surgeons appear to have a comparative advantage over other specialties for EVAR because not only are their complication and mortality rates comparable but overall LOS and hospital charges are lower. Furthermore, primarily only vascular surgeons are performing the high volume of annual EVARs necessary to ensure optimal patient outcomes. For TEVAR, vascular surgeons have the lowest overall morbidity compared with the other specialties, and lower mortality compared with cardiothoracic surgeons. These findings may impact patient referral patterns and hospital privileges for providers. Copyright © 2016 Elsevier Inc. All rights reserved.

Colonic Ischemia After Standard Endovascular Abdominal Aortic Aneurysm Repair, A Rare But Dangerous Complication.

PubMed

Berchiolli, R; Adami, D; Marconi, M; Mari, M; Puta, B; Ferrari, M

2018-05-21

Colonic Ischemia (CI) after abdominal aortic aneurysm (AAA) repair, although rare, is associated with severe prognosis. Endovascular Aneurysm Repair (EVAR) is becoming the standard of practice in most vascular centers, and it also may reduce CI incidence in comparison to conventional open repair. Copyright © 2018 Elsevier Inc. All rights reserved.

Management of penetrating carotid arterial injury.

PubMed Central

Liekweg, W G; Greenfield, L J

1978-01-01

A review of the experience with penetrating wounds to the carotid artery was undertaken in an effort to establish concise clinical criteria for surgical management. These results were compared with similar cases from the literature reported since 1963. In these 233 cases, the presence or absence of preoperative neurological deficits was correlated with vascular repair or ligation of the carotid artery. The presence of coma preoperatively was the single most influential factor in determining operative management and prognosis. Patients without a neurological defect should have restoration of vascular continuity (0% mortality, 0.6% morbidity), which produces significantly better results than carotid ligation (p less than 0.002). Patients with all grades of neurological deficit, short of coma, should also have primary vascular repair. Morbidity and mortality rates are significantly less than those following ligation (15 vs. 50%, p less than 0.05). In comatose patients, neither repair nor ligation appear to influence the poor prognosis. At the present time, ligation of the carotid artery is only indicated in the comatose patient who has no evidence of prograde flow or if repair is technically impossible. PMID:718284

Carbon nanotubes as VEGF carriers to improve the early vascularization of porcine small intestinal submucosa in abdominal wall defect repair

PubMed Central

Liu, Zhengni; Feng, Xueyi; Wang, Huichun; Ma, Jun; Liu, Wei; Cui, Daxiang; Gu, Yan; Tang, Rui

2014-01-01

Insufficient early vascularization in biological meshes, resulting in limited host tissue incorporation, is thought to be the primary cause for the failure of abdominal wall defect repair after implantation. The sustained release of exogenous angiogenic factors from a biocompatible nanomaterial might be a way to overcome this limitation. In the study reported here, multiwalled carbon nanotubes (MWNT) were functionalized by plasma polymerization to deliver vascular endothelial growth factor165 (VEGF165). The novel VEGF165-controlled released system was incorporated into porcine small intestinal submucosa (PSIS) to construct a composite scaffold. Scaffolds incorporating varying amounts of VEGF165-loaded functionalized MWNT were characterized in vitro. At 5 weight percent MWNT, the scaffolds exhibited optimal properties and were implanted in rats to repair abdominal wall defects. PSIS scaffolds incorporating VEGF165-loaded MWNT (VEGF–MWNT–PSIS) contributed to early vascularization from 2–12 weeks postimplantation and obtained more effective collagen deposition and exhibited improved tensile strength at 24 weeks postimplantation compared to PSIS or PSIS scaffolds, incorporating MWNT without VEGF165 loading (MWNT–PSIS). PMID:24648727

Platelet chemokines in vascular disease

PubMed Central

Gleissner, Christian A.; von Hundelshausen, Philipp; Ley, Klaus

2009-01-01

Platelets are a rich source of different chemokines and express chemokine receptors. CXCL4 is highly abundant in platelets and involved in promoting monocyte arrest from rolling and monocyte differentiation to macrophages. CXCL4 can also associate with CCL5 and amplify its effect on monocytes. The megakaryocyte CXCL7 gene product is proteolytically cleaved into the strong neutrophil chemoattractant, NAP-2, which has also been implicated in repair cell homing to vascular lesions. Platelet adhesion can induce release of CCL2 and CXCL8 from endothelial cells. Conversely, the chemokines CCL17, CCL22 and CXCL12 made by other cells amplify platelet activation. Platelet chemokines enhance recruitment of various hematopoietic cells to the vascular wall, fostering processes such as neointima formation, atherosclerosis, and thrombosis but also vessel repair and regeneration after vascular injury. PMID:18723831

Hematopoietic stem cell capture and directional differentiation into vascular endothelial cells for metal stent-coated chitosan/hyaluronic acid loading CD133 antibody.

PubMed

Zhang, Shixuan; Zhang, Fan; Feng, Bo; Fan, Qingyu; Yang, Feng; Shang, Debin; Sui, Jinghan; Zhao, Hong

2015-03-01

A series of metal stents coated with chitosan/hyaluronic acid (CS/HA) loading antibodies by electrostatic self-assembled method were prepared, and the types of cells captured by antibodies and their differentiation in vascular endothelial cells (ECs) evaluated by molecular biology and scanning electron microscope. The results showed that CD133 stent can selectively capture hematopoietic stem cells (HSC),which directionally differentiate into vascular ECs in peripheral blood by (CS/HA) induction, and simultaneously inhibit migration and proliferation of immune cells and vascular smooth muscle cells (MCs). CD34 stent can capture HSC, hematopoietic progenitor cells that differentiate into vascular ECs and immune cells, promoting smooth MCs growth, leading to thrombosis, inflammation, and rejection. CD133 stent can be implanted into miniature pig heart coronary and can repair vascular damage by capturing own HSC, thus contributing to the rapid natural vascular repair, avoiding inflammation and rejection, thrombosis and restenosis. These studies demonstrated that CD133 stent of HSC capture will be an ideal coated metal stent providing a new therapeutic approach for cardiovascular and cerebrovascular disease.

Blood Flow Modulation of Vascular Dynamics

PubMed Central

Lee, Juhyun; Sevag Packard, René R.; Hsiai, Tzung K.

2015-01-01

Purpose of review Blood flow is intimately linked with cardiovascular development, repair, and dysfunction. The current review will build on the fluid mechanical principle underlying hemodynamic shear forces, mechanotransduction, and metabolic effects. Recent findings Pulsatile flow produces both time- (∂τ /∂t)and spatial-varying shear stress (∂τ /∂x) to modulate vascular oxidative stress and inflammatory response with pathophysiological significance to atherosclerosis. The characteristics of hemodynamic shear forces; namely, steady laminar (∂τ /∂t= 0), pulsatile (PSS: unidirectional forward flow), and oscillatory shear stress (OSS: bidirectional with a near net 0 forward flow) modulate mechano-signal transduction to influence metabolic effects on vascular endothelial function. Atheroprotective PSS promotes anti-oxidant, anti-inflammatory, and anti-thrombotic responses, whereas atherogenic OSS induces NADPH oxidase–JNK signaling to increase mitochondrial superoxide production, protein degradation of manganese superoxide dismutase (MnSOD), and post-translational protein modifications of LDL particles in the disturbed flow-exposed regions of vasculature. In the era of tissue regeneration, shear stress has been implicated in re-activation of developmental genes; namely, Wnt and Notch signaling, for vascular development and repair. Summary Blood flow imparts a dynamic continuum from vascular development to repair. Augmentation of PSS confers atheroprotection and re-activation of developmental signaling pathways for regeneration. PMID:26218416

Endovascular aortic repair: first twenty years.

PubMed

Koncar, Igor; Tolić, Momcilo; Ilić, Nikola; Cvetković, Slobodan; Dragas, Marko; Cinara, Ilijas; Kostić, Dusan; Davidović, Lazar

2012-01-01

Endovascular aortic/aneurysm repair (EVAR) was introduced into clinical practice at the beginning of the nineties. Its fast development had a great influence on clinicians, vascular surgeons and interventional radiologists, educational curriculums, patients, industry and medical insurance. The aim of this paper is to present the contribution of clinicians and industry to the development and advancement of endovascular aortic repair over the last 20 years. This review article presents the development of EVAR by focusing on the contribution of physicians, surgeons and interventional radiologists in the creation of the new field of vascular surgery termed hybrid vascular surgery, and also the contribution of technological advancement by a significant help of industrial representatives--engineers and their counselors. This article also analyzes studies conducted in order to compare the successfulness of EVAR with up-to-now applied open surgical repair of aortic aneurysms, and some treatment techniques of other aortic diseases. During the first two decades of its development the EVAR method was rapidly progressing and was adopted concurrently with the expansion of technology. Owing to large randomized studies, early and long-term results indicate specific complications of this method, thus influencing further technological improvement and defining risk patients groups in whom the use of the technique should be avoided. Good results are insured only in centers, specialized in vascular surgery, which have on their disposal adequate conditions for solving all complications associated with this method.

Endovascular repair of multiple infrageniculate aneurysms in a patient with vascular type Ehlers-Danlos syndrome.

PubMed

Domenick, Natalie; Cho, Jae S; Abu Hamad, Ghassan; Makaroun, Michel S; Chaer, Rabih A

2011-09-01

Patients with vascular type Ehler-Danlos syndrome can develop aneurysms in unusual locations. We describe the case of a 33-year-old woman with vascular type Ehlers-Danlos syndrome who developed metachronous tibial artery aneurysms that were sequentially treated with endovascular means. Copyright © 2011 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.

The use of a whole animal biophotonic model as a screen for the angiogenic potential of estrogenic compounds

USDA-ARS?s Scientific Manuscript database

Vascular endothelial growth factor (VEGF) is essential for normal vascular growth and development during wound repair. VEGF is estrogen responsive and capable of regulating its own receptor, vascular endothelial growth factor receptor-2 (VEGFR-2). Several agricultural pesticides (e.g., methoxychlor)...

Results of complex aortic stent grafting of abdominal aortic aneurysms stratified according to the proximal landing zone using the Society for Vascular Surgery classification.

PubMed

Patel, Sanjay D; Constantinou, Jason; Simring, Dominic; Ramirez, Manfred; Agu, Obiekezie; Hamilton, Hamish; Ivancev, Krassi

2015-08-01

Advances in endovascular technology have led to the successful treatment of complex abdominal aortic aneurysms. However, there is currently no consensus on what constitutes a juxtarenal, pararenal, or suprarenal aneurysm. There is emerging evidence that the extent of the aneurysm repair is associated with outcome. We compare the outcomes of 150 consecutive patients treated with a fenestrated or branched stent graft and present the data stratified according to the Society for Vascular Surgery classification based on proximal anatomic landing zones. A prospectively collected database of consecutive patients undergoing fenestrated or branched stent graft insertion in a tertiary center between 2008 and 2013 was retrospectively analyzed. Aneurysms were subdivided into zones according to where the area of proximal seal could be achieved in relation to the visceral arteries. Zone 8 covers the renal arteries, zone 7 covers the superior mesenteric artery, and zone 6 covers the celiac axis. Patient demographics, operative variables, mortality, and major morbidity were analyzed by univariate and multivariate analysis to assess for differences between zones. During the study period, 150 patients were treated. There were 49 in zone 8, 76 in zone 7, and 25 in zone 6. Prior aortic surgery had been performed in 19 patients, which included 11 patients with previous endovascular aneurysm repairs. There was significantly increased blood loss (P < .001), operative time (P < .0001), total hospital stay (P = .018), and intensive care unit stay (P < .0001) as the zones ascended the aorta. There were 14 inpatient deaths recorded across all zones with a 30-day mortality rate of 8%. Logistic regression analysis for 30 day mortality showed a significant increase as the zones ascended (P = .007). Kaplan-Meier analysis showed that 5-year survival significantly deteriorated as the zones ascended (P = .039), with no significant difference in the freedom from reintervention curves between zones (P = .37). We have shown that the extent of the aneurysm repair as determined by the proximal sealing zone is associated with outcome. Mortality, operative duration, blood loss, and hospital stay all significantly increased as the zones ascended. These data also validate the use of the proposed new classification based on aortic anatomy. Copyright © 2015 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.

High-intensity Interval training enhances mobilization/functionality of endothelial progenitor cells and depressed shedding of vascular endothelial cells undergoing hypoxia.

PubMed

Tsai, Hsing-Hua; Lin, Chin-Pu; Lin, Yi-Hui; Hsu, Chih-Chin; Wang, Jong-Shyan

2016-12-01

Exercise training improves endothelium-dependent vasodilation, whereas hypoxic stress causes vascular endothelial dysfunction. Monocyte-derived endothelial progenitor cells (Mon-EPCs) contribute to vascular repair process by differentiating into endothelial cells. This study investigates how high-intensity interval (HIT) and moderate-intensity continuous (MCT) exercise training affect circulating Mon-EPC levels and EPC functionality under hypoxic condition. Sixty healthy sedentary males were randomized to engage in either HIT (3-min intervals at 40 and 80 % VO 2max for five repetitions, n = 20) or MCT (sustained 60 % VO 2max , n = 20) for 30 min/day, 5 days/week for 6 weeks, or to a control group (CTL) that did not received exercise intervention (n = 20). Mon-EPC characteristics and EPC functionality under hypoxic exercise (HE, 100 W under 12 % O 2 ) were determined before and after HIT, MCT, and CTL. The results demonstrated that after the intervention, the HIT group exhibited larger improvements in VO 2peak , estimated peak cardiac output (Q C ), and estimated peak perfusions of frontal cerebral lobe (Q FC ) and vastus lateralis (Q VL ) than the MCT group. Furthermore, HIT (a) increased circulating CD14 ++ /CD16 - /CD34 + /KDR + (Mon-1 EPC) and CD14 ++ /CD16 + /CD34 + /KDR + (Mon-2 EPC) cell counts, (b) promoted the migration and tube formation of EPCs, (c) diminished the shedding of endothelial (CD34 - /KDR + /phosphatidylserine + ) cells, and (d) elevated plasma nitrite plus nitrate, stromal cell-derived factor-1, matrix metalloproteinase-9, and vascular endothelial growth factor-A concentrations at rest or following HE, compared to those of MCT. In addition, Mon-1 and -2 EPC counts were directly related to VO 2peak and estimated peak Q C , Q FC , and Q VL . HIT is superior to MCT for improving hemodynamic adaptation and Mon-EPC production. Moreover, HIT effectively enhances EPC functionality and suppresses endothelial injury undergoing hypoxia.

Outcomes in adult pectus excavatum patients undergoing Nuss repair

PubMed Central

Ewais, MennatAllah M; Chaparala, Shivani; Uhl, Rebecca

2018-01-01

Pectus excavatum (PEx) is one of the most common congenital chest wall deformities. Depending on the severity, presentation of PEx may range from minor cosmetic issues to disabling cardiopulmonary symptoms. The effect of PEx on adult patients has not been extensively studied. Symptoms may not occur until the patient ages, and they may worsen over the years. More recent publications have implied that PEx may have significant cardiopulmonary implications and repair is of medical benefit. Adults presenting for PEx repair can undergo a successful repair with a minimally invasive “Nuss” approach. Resolution of symptoms, improved quality of life, and satisfying results are reported. PMID:29430201

Cardiovascular Bio-Engineering: Current State of the Art.

PubMed

Simon-Yarza, Teresa; Bataille, Isabelle; Letourneur, Didier

2017-04-01

Despite the introduction of new drugs and innovative devices contributing in the last years to improve patients' quality of life, morbidity and mortality from cardiovascular diseases remain high. There is an urgent need for addressing the underlying problem of the loss of cardiac or vascular tissues and therefore developing new therapies. Autologous vascular transplants are often limited by poor quality of donor sites and heart organ transplantation by donor shortage. Vascular and cardiac tissue engineering, whose aim is to repair or replace cardiovascular tissues by the use of cells, engineering and materials, as well as biochemical and physicochemical factors, appears in this scenario as a promising tool to repair the damaged hearts and vessels. We will present a general overview on the fundamentals in the area of cardiac and vascular tissue engineering as well as on the latest progresses and challenges.

Outcomes and Resource Utilization of Endoscopic Mass-Closure Technique for Laryngeal Clefts.

PubMed

Balakrishnan, Karthik; Cheng, Esther; de Alarcon, Alessandro; Sidell, Douglas R; Hart, Catherine K; Rutter, Michael J

2015-07-01

To compare resource utilization and clinical outcomes between endoscopic mass-closure and open techniques for laryngeal cleft repair. Case series with chart review. Tertiary academic children's hospital. Pediatric patients undergoing repair for Benjamin-Inglis type 1-3 laryngeal clefts over a 15-year period. All 20 patients undergoing endoscopic repair were included. Eight control patients undergoing open repair were selected using matching by age and cleft type. Demographic, clinical, and resource utilization data were collected. Twenty-eight patients were included (20 endoscopic, 8 open). Mean age, rates of tracheostomy and vocal fold immobility, and distribution of cleft types were not different between the 2 groups (all P > .2). Mean operative time (P = .004) and duration of hospital stay (P < .001) were significantly shorter in the endoscopic group. All repairs were intact in both groups at final postoperative endoscopy. Rates of persistent laryngeal penetration or aspiration on swallow study were not different between groups (P = 1.000), although results were available for only 11 patients. Endoscopic laryngeal cleft repair using a mass-closure technique provides a durable result while requiring significantly shorter operative times and hospital stays than open repair and avoiding the potential morbidity of laryngofissure. However, open repair may allow the simultaneous performance of other airway reconstructive procedures and may be a useful salvage technique when endoscopic repair fails. Postoperative swallowing results require further study. © American Academy of Otolaryngology—Head and Neck Surgery Foundation 2015.

Nuclear ARP2/3 drives DNA break clustering for homology-directed repair.

PubMed

Schrank, Benjamin R; Aparicio, Tomas; Li, Yinyin; Chang, Wakam; Chait, Brian T; Gundersen, Gregg G; Gottesman, Max E; Gautier, Jean

2018-06-20

DNA double-strand breaks repaired by non-homologous end joining display limited DNA end-processing and chromosomal mobility. By contrast, double-strand breaks undergoing homology-directed repair exhibit extensive processing and enhanced motion. The molecular basis of this movement is unknown. Here, using Xenopus laevis cell-free extracts and mammalian cells, we establish that nuclear actin, WASP, and the actin-nucleating ARP2/3 complex are recruited to damaged chromatin undergoing homology-directed repair. We demonstrate that nuclear actin polymerization is required for the migration of a subset of double-strand breaks into discrete sub-nuclear clusters. Actin-driven movements specifically affect double-strand breaks repaired by homology-directed repair in G2 cell cycle phase; inhibition of actin nucleation impairs DNA end-processing and homology-directed repair. By contrast, ARP2/3 is not enriched at double-strand breaks repaired by non-homologous end joining and does not regulate non-homologous end joining. Our findings establish that nuclear actin-based mobility shapes chromatin organization by generating repair domains that are essential for homology-directed repair in eukaryotic cells.

Modified Graded Repair of Cerebrospinal Fluid Leaks in Endoscopic Endonasal Transsphenoidal Surgery

PubMed Central

Park, Jae-Hyun; Choi, Jai Ho; Kim, Young-Il; Kim, Sung Won

2015-01-01

Objective Complete sellar floor reconstruction is critical to avoid postoperative cerebrospinal fluid (CSF) leakage during transsphenoidal surgery. Recently, the pedicled nasoseptal flap has undergone many modifications and eventually proved to be valuable and efficient. However, using these nasoseptal flaps in all patients who undergo transsphenoidal surgery, including those who had none or only minor CSF leakage, appears to be overly invasive and time-consuming. Methods Patients undergoing endoscopic endonasal transsphenoidal tumor surgery within a 5 year-period were reviewed. Since 2009, we classified the intraoperative CSF leakage into grades from 0 to 3. Sellar floor reconstruction was tailored to each leak grade. We did not use any tissue grafts such as abdominal fat and did not include any procedures of CSF diversions such as lumbar drainage. Results Among 200 cases in 188 patients (147 pituitary adenoma and 41 other pathologies), intraoperative CSF leakage was observed in 27.4% of 197 cases : 14.7% Grade 1, 4.6% Grade 2a, 3.0% Grade 2b, and 5.1% Grade 3. Postoperative CSF leakage was observed in none of the cases. Septal bone buttress was used for Grade 1 to 3 leakages instead of any other foreign materials. Pedicled nasoseptal flap was used for Grades 2b and 3 leakages. Unused septal bones and nasoseptal flaps were repositioned. Conclusion Modified classification of intraoperative CSF leaks and tailored repair technique in a multilayered fashion using an en-bloc harvested septal bone and vascularized nasoseptal flaps is an effective and reliable method for the prevention of postoperative CSF leaks. PMID:26279811

Converging roads: evidence for an adult hemangioblast.

PubMed

Bailey, Alexis S; Fleming, William H

2003-11-01

Classical studies of the developing embryo first suggested the existence of the hemangioblast, a precursor cell with the potential to differentiate into both blood and blood vessels. Several lines of investigation demonstrated that many of the genes activated during early hematopoietic development are also expressed in the vascular endothelium. Gene-targeting studies using embryonic stem cells have identified Flk-1, SCL, and Runx-1 as important regulatory molecules that specify both hematopoietic and vascular outcomes. Although it was anticipated that the hemangioblast would be present only during the earliest stages of vascular development in the yolk sac, accumulating evidence now indicates that hematopoietic cells with hemangioblast activity persist into adulthood. In the adult, bone marrow-derived, circulating endothelial progenitors contribute to postnatal neovascularization and enhance vascular repair following ischemic injury. Highly purified populations of hematopoietic stem cells from humans and mice can differentiate into both blood cells and vascular tissue at the single cell level. These recent findings suggest that bone marrow-derived hematopoietic stem cells or their progeny may contribute to the maintenance and repair of both the hematopoietic and the vascular systems during adult life.

Management of major vascular injury during pedicle screw instrumentation of thoracolumbar spine.

PubMed

Mirza, Aleem K; Alvi, Mohammed Ali; Naylor, Ryan M; Kerezoudis, Panagiotis; Krauss, William E; Clarke, Michelle J; Shepherd, Daniel L; Nassr, Ahmad; DeMartino, Randall R; Bydon, Mohamad

2017-12-01

Vascular injury is a rare complication of spinal instrumentation. Presentation can vary from immediate hemorrhage to pseudoaneurysm formation. In the literature, surgical approach to repair has varied based on anatomy, acuity of diagnosis, infection, and available technology. In this manuscript, we aim to describe our institutional experience with vascular injuries in thoraco-lumbar spine surgery. We report our institutional experience of three cases of vascular injury secondary to pedicle screw misplacement and their management, as well as a review of the literature. The first case had a history of previous instrumentation and presented with back pain and fever. The patient was taken for instrumentation exploration via a posterior approach. Aortic violation was discovered at T6 intraoperatively during instrumentation removal and the patient underwent emergent endovascular repair. The second case presented with chronic back pain after multiple prior posterior fusions and CT angiogram showing screw perforation on the aorta at T10. The patient underwent elective endovascular repair with synchronous removal of the instrumentation. The third case presented with radicular leg pain 6 months after L4-S1 posterior lumbar interbody fusion, with CT scan demonstrating the left S1 screw abutting the L5 nerve root and common iliac vein. The patient underwent elective instrumentation revision with intraoperative venography. Major vascular injury is a known complication of spinal surgery, especially if it involves instrumentation with pedicle screws. Treatment approach has evolved with the advancement of endovascular technology; however, open surgery remains an option when anatomy or infection is prohibitive. In the elective setting, preoperative planning with attention to surgical approach, positioning, and contingencies, should occur in a multidisciplinary fashion. Repair with an aortic stent-graft cuff may minimize unnecessary coverage of the descending thoracic aorta and intercostal arteries. Copyright © 2017 Elsevier B.V. All rights reserved.

The Promise of Cell Based Therapies for Diabetic Complications: challenges and solutions

PubMed Central

Jarajapu, Yagna P.R.; Grant, Maria B.

2013-01-01

The discovery of endothelial progenitor cells (EPCs) in human peripheral blood advanced the field of cell-based therapeutics for many pathological conditions. Despite the lack of agreement about the existence and characteristics of EPCs, autologous EPC populations represent a novel treatment option for complications requiring therapeutic revascularization and vascular repair. Patients with diabetic complications represent a population of patients that may benefit from cellular therapy yet their broadly dysfunctional cells may limit the feasibility of this approach. Diabetic EPCs have decreased migratory prowess and reduced proliferative capacity and an altered cytokine/ growth factor secretory profile that can accelerates deleterious repair mechanisms rather than support proper vascular repair. Furthermore, the diabetic environment poses additional challenges for the autologous transplantation of cells. The present review is focused on correcting diabetic EPC dysfunction and the challenges involved in the application of cell-based therapies for treatment of diabetic vascular complications. In addition, ex vivo and in vivo functional manipulation(s) of EPCs to overcome these hurdles are discussed. PMID:20299675

The skeletal vascular system - Breathing life into bone tissue.

PubMed

Stegen, Steve; Carmeliet, Geert

2017-08-26

During bone development, homeostasis and repair, a dense vascular system provides oxygen and nutrients to highly anabolic skeletal cells. Characteristic for the vascular system in bone is the serial organization of two capillary systems, each typified by specific morphological and physiological features. Especially the arterial capillaries mediate the growth of the bone vascular system, serve as a niche for skeletal and hematopoietic progenitors and couple angiogenesis to osteogenesis. Endothelial cells and osteoprogenitor cells interact not only physically, but also communicate to each other by secretion of growth factors. A vital angiogenic growth factor is vascular endothelial growth factor and its expression in skeletal cells is controlled by osteogenic transcription factors and hypoxia signaling, whereas the secretion of angiocrine factors by endothelial cells is regulated by Notch signaling, blood flow and possibly hypoxia. Bone loss and impaired fracture repair are often associated with reduced and disorganized blood vessel network and therapeutic targeting of the angiogenic response may contribute to enhanced bone regeneration. Copyright © 2017 Elsevier Inc. All rights reserved.

Cardiovascular autonomic dysfunction and carotid stiffness in adults with repaired tetralogy of Fallot.

PubMed

Novaković, Marko; Prokšelj, Katja; Starc, Vito; Jug, Borut

2017-06-01

Adults after surgical repair of tetralogy of Fallot (ToF) may have impaired vascular and cardiac autonomic function. Thus, we wanted to assess interrelations between heart rate variability (HRV) and heart rate recovery (HRR), as parameters of cardiac autonomic function, and arterial stiffness, as a parameter of vascular function, in adults with repaired ToF as compared to healthy controls. In a case-control study of adults with repaired ToF and healthy age-matched controls we measured: 5-min HRV variability (with time and frequency domain data collected), carotid artery stiffness (through pulse-wave analysis using echo-tracking ultrasound) and post-exercise HRR (cycle ergometer exercise testing). Twenty-five patients with repaired ToF (mean age 38 ± 10 years) and 10 healthy controls (mean age 39 ± 8 years) were included. Selected HRR and HRV (time-domain) parameters, but not arterial stiffness were significantly reduced in adults after ToF repair. Moreover, a strong association between late/slow HRR (after 2, 3 and 4 min) and carotid artery stiffness was detected in ToF patients (r = -0.404, p = 0.045; r = -0.545, p = 0.005 and r = -0.545, p = 0.005, respectively), with statistical significance retained even after adjusting for age, gender, resting heart rate and β-blockers use (r = -0.393, p = 0.024 for HRR after 3 min). Autonomic cardiac function is impaired in patients with repaired ToF, and independently associated with vascular function in adults after ToF repair, but not in age-matched healthy controls. These results might help in introducing new predictors of cardiovascular morbidity in a growing population of adults after surgical repair of ToF.

Age-related macular degeneration: beyond anti-angiogenesis.

PubMed

Kent, David L

2014-01-06

Recently, anti-vascular endothelial growth factor therapies for neovascular age-related macular degeneration have been developed. These agents, originally developed for their anti-angiogenic mechanism of action, probably also work through an anti-permeability effect in preventing or reducing the amount of leakage from submacular neovascular tissue. Other treatment modalities include laser photocoagulation, photodynamic therapy with verteporfin, and submacular surgery. In reality, these latter treatments can be similarly categorized as anti-angiogenic because their sole aim is destroying or removing choroidal neovascularization (CNV). At the cellular level, CNV resembles stereotypical tissue repair that consists of several matricellular components in addition to neovascularization. In the retina, the clinical term CNV is a misnomer since the term may more appropriately be referred to as aberrant submacular repair. Furthermore, CNV raises a therapeutic conundrum: To complete or correct any reparative process in the body, angiogenesis becomes an essential component. Anti-angiogenic therapy, in all its guises, arrests repair and causes the hypoxic environment to persist, thus fueling pro-angiogenesis and further development of CNV as a component of aberrant repair. However, we realize that anti-vascular endothelial growth factor therapy preserves vision in patients with age-related macular degeneration, albeit temporarily and therefore, repeated treatment is needed. More importantly, however, anti-angiogenic therapy demonstrates that we can at the very least tolerate neovascular tissue beneath the macula and preserve vision in contrast to our historical approach of total vascular destruction. In this clinical scenario, it may be possible to look beyond anti-angiogenesis if our goal is facilitating submacular repair without destroying the neurosensory retina. Thus, in this situation of neovascular tolerance, it may be timely to consider treatments that facilitate vascular maturation, rather than its arrest or destruction. This would neutralize hypoxia, thus removing the stimulus that drives neovascularization and in turn the need for repeated lifelong intravitreal therapy. A pro-angiogenic approach would eliminate neovascular leakage and ultimately complete repair and preserve the neurosensory retina.

Mortality outcomes of ruptured abdominal aortic aneurysms and rural presentation.

PubMed

Munday, Emily; Walker, Stuart

2016-10-01

Centralisation of vascular surgery services has coincided with a move towards endovascular repair of ruptured abdominal aortic aneurysms with the goal to improve patient outcomes. The aim of this study was to assess the effect of rural presentation and transfer times on survival from ruptured abdominal aortic aneurysm. A retrospective review. All patients presenting with ruptured abdominal aortic aneurysm to public hospitals in Tasmania between July 2006 and April 2013. Demographic data, Glasgow aneurysm score, Hardman index, transfer times, operative technique and 30-day mortality were collected from medical records. Over the study period 127 patients presented to public hospitals in Tasmania with ruptured abdominal aortic aneurysm. A total of 27 presented to north west hospitals where no vascular surgery service is provided (NWRH), 23 to a northern hospital where an intermittent vascular surgery service is provided (LGH) and 77 to the state tertiary vascular surgery service (RHH). Of these, 4 (14.8%) died at NWRH, 6 (26.1%) died at LGH and 43 (55.8%) died at RHH without operation. Of the 35 patients transferred from NWRH and LGH to RHH, 5 died without operation. Median time from presentation to theatre at RHH if transferred from NWRH was 6.25 hours, from the LGH 4.75 hours, compared to 2.75 hours when presenting directly to RHH. Open repair was performed in 41 patients and endovascular repair in 23 patients. Overall 30-day mortality in those treated at RHH was 26.6% (39.0% for open repair, 4.3% for endovascular repair). Mortality for intended operative patients initially presenting to non-RHH hospitals was 33.3% vs. 32.3% for those initially presenting to RHH. p Value 0.93. There was no clinical or statistical disadvantage to rural presentation and transfer for patients presenting with ruptured abdominal aortic aneurysm in Tasmania. Endovascular repair has a role despite long transfer times. © The Author(s) 2015.

Primary nerve grafting: A study of revascularization.

PubMed

Chalfoun, Charbel; Scholz, Thomas; Cole, Matthew D; Steward, Earl; Vanderkam, Victoria; Evans, Gregory R D

2003-01-01

It was the purpose of this study to evaluate the revascularization of primary nerve repair and grafts using orthogonal polarization spectral (OPS) (Cytometrix, Inc.) imaging, a novel method for real-time evaluation of microcirculatory blood flow. Twenty male Sprague Dawley rats (250 g) were anesthetized with vaporized halothane and surgically prepared for common peroneal nerve resection. Group I animals (n = 10) underwent primary neurorraphy following transection, utilizing a microsurgical technique with 10-0 nylon suture. Group II (n = 10) animals had a 7-mm segment of nerve excised, reversed, and subsequently replaced as a nerve graft under similar techniques. All animals were evaluated using the OPS imaging system on three portions (proximal, transection site/graft, and distal) of the nerve following repair or grafting. Reevaluation of 5 animals randomly selected from each group using the OPS imaging system was again performed on days 14 and 28 following microsurgical repair/grafting. Values were determined by percent change in vascularity of the common peroneal nerve at 0 hr following surgery. Real-time evaluation of blood flow was utilized as an additional objective criterion. Percent vascularity in group I and II animals increased from baseline in all segments at day 14. By day 28, vascularity in nerves of group I rats decreased in all segments to values below baseline, with the exception of the transection site, which remained at a higher value than obtained directly after surgical repair. In group II animals, vascularity remained above baseline in all segments except the distal segment, which returned to vascularity levels similar to those at 0 hr. Further, occlusion of the vessels demonstrated in the graft and distal segments following initial transection appeared to be corrected. This study suggests that revascularization may occur via bidirectional inosculation with favored proximal vascular growth advancement. The use of real-time imaging offers a unique evaluation of tissues through emerging technologies. Copyright 2003 Wiley-Liss, Inc.

Hematopoietic Stem Cell Capture and Directional Differentiation into Vascular Endothelial Cells for Metal Stent-Coated Chitosan/Hyaluronic Acid Loading CD133 Antibody

PubMed Central

Zhang, Fan; Feng, Bo; Fan, Qingyu; Yang, Feng; Shang, Debin; Sui, Jinghan; Zhao, Hong

2015-01-01

A series of metal stents coated with chitosan/hyaluronic acid (CS/HA) loading antibodies by electrostatic self-assembled method were prepared, and the types of cells captured by antibodies and their differentiation in vascular endothelial cells (ECs) evaluated by molecular biology and scanning electron microscope. The results showed that CD133 stent can selectively capture hematopoietic stem cells (HSC),which directionally differentiate into vascular ECs in peripheral blood by (CS/HA) induction, and simultaneously inhibit migration and proliferation of immune cells and vascular smooth muscle cells (MCs). CD34 stent can capture HSC, hematopoietic progenitor cells that differentiate into vascular ECs and immune cells, promoting smooth MCs growth, leading to thrombosis, inflammation, and rejection. CD133 stent can be implanted into miniature pig heart coronary and can repair vascular damage by capturing own HSC, thus contributing to the rapid natural vascular repair, avoiding inflammation and rejection, thrombosis and restenosis. These studies demonstrated that CD133 stent of HSC capture will be an ideal coated metal stent providing a new therapeutic approach for cardiovascular and cerebrovascular disease. PMID:25404533

Cardiovascular causes of airway compression.

PubMed

Kussman, Barry D; Geva, Tal; McGowan, Francis X

2004-01-01

Compression of the paediatric airway is a relatively common and often unrecognized complication of congenital cardiac and aortic arch anomalies. Airway obstruction may be the result of an anomalous relationship between the tracheobronchial tree and vascular structures (producing a vascular ring) or the result of extrinsic compression caused by dilated pulmonary arteries, left atrial enlargement, massive cardiomegaly, or intraluminal bronchial obstruction. A high index of suspicion of mechanical airway compression should be maintained in infants and children with recurrent respiratory difficulties, stridor, wheezing, dysphagia, or apnoea unexplained by other causes. Prompt diagnosis is required to avoid death and minimize airway damage. In addition to plain chest radiography and echocardiography, diagnostic investigations may consist of barium oesophagography, magnetic resonance imaging (MRI), computed tomography, cardiac catheterization and bronchoscopy. The most important recent advance is MRI, which can produce high quality three-dimensional reconstruction of all anatomic elements allowing for precise anatomic delineation and improved surgical planning. Anaesthetic technique will depend on the type of vascular ring and the presence of any congenital heart disease or intrinsic lesions of the tracheobronchial tree. Vascular rings may be repaired through a conventional posterolateral thoracotomy, or utilizing video-assisted thoracoscopic surgery (VATS) or robotic endoscopic surgery. Persistent airway obstruction following surgical repair may be due to residual compression, secondary airway wall instability (malacia), or intrinsic lesions of the airway. Simultaneous repair of cardiac defects and vascular tracheobronchial compression carries a higher risk of morbidity and mortality.

Comparison of Three Contemporary Risk Scores for Mortality Following Elective Abdominal Aortic Aneurysm Repair

PubMed Central

Grant, S.W.; Hickey, G.L.; Carlson, E.D.; McCollum, C.N.

2014-01-01

Objective/background A number of contemporary risk prediction models for mortality following elective abdominal aortic aneurysm (AAA) repair have been developed. Before a model is used either in clinical practice or to risk-adjust surgical outcome data it is important that its performance is assessed in external validation studies. Methods The British Aneurysm Repair (BAR) score, Medicare, and Vascular Governance North West (VGNW) models were validated using an independent prospectively collected sample of multicentre clinical audit data. Consecutive, data on 1,124 patients undergoing elective AAA repair at 17 hospitals in the north-west of England and Wales between April 2011 and March 2013 were analysed. The outcome measure was in-hospital mortality. Model calibration (observed to expected ratio with chi-square test, calibration plots, calibration intercept and slope) and discrimination (area under receiver operating characteristic curve [AUC]) were assessed in the overall cohort and procedural subgroups. Results The mean age of the population was 74.4 years (SD 7.7); 193 (17.2%) patients were women and the majority of patients (759, 67.5%) underwent endovascular aneurysm repair. All three models demonstrated good calibration in the overall cohort and procedural subgroups. Overall discrimination was excellent for the BAR score (AUC 0.83, 95% confidence interval [CI] 0.76–0.89), and acceptable for the Medicare and VGNW models, with AUCs of 0.78 (95% CI 0.70–0.86) and 0.75 (95% CI 0.65–0.84) respectively. Only the BAR score demonstrated good discrimination in procedural subgroups. Conclusion All three models demonstrated good calibration and discrimination for the prediction of in-hospital mortality following elective AAA repair and are potentially useful. The BAR score has a number of advantages, which include being developed on the most contemporaneous data, excellent overall discrimination, and good performance in procedural subgroups. Regular model validations and recalibration will be essential. PMID:24837173

Endovascular repair of abdominal aortic aneurysms: vascular anatomy, device selection, procedure, and procedure-specific complications.

PubMed

Bryce, Yolanda; Rogoff, Philip; Romanelli, Donald; Reichle, Ralph

2015-01-01

Abdominal aortic aneurysm (AAA) is abnormal dilatation of the aorta, carrying a substantial risk of rupture and thereby marked risk of death. Open repair of AAA involves lengthy surgery time, anesthesia, and substantial recovery time. Endovascular aneurysm repair (EVAR) provides a safer option for patients with advanced age and pulmonary, cardiac, and renal dysfunction. Successful endovascular repair of AAA depends on correct selection of patients (on the basis of their vascular anatomy), choice of the correct endoprosthesis, and familiarity with the technique and procedure-specific complications. The type of aneurysm is defined by its location with respect to the renal arteries, whether it is a true or false aneurysm, and whether the common iliac arteries are involved. Vascular anatomy can be divided more technically into aortic neck, aortic aneurysm, pelvic perfusion, and iliac morphology, with grades of difficulty with respect to EVAR, aortic neck morphology being the most common factor to affect EVAR appropriateness. When choosing among the devices available on the market, one must consider the patient's vascular anatomy and choose between devices that provide suprarenal fixation versus those that provide infrarenal fixation. A successful technique can be divided into preprocedural imaging, ancillary procedures before AAA stent-graft placement, the procedure itself, postprocedural medical therapy, and postprocedural imaging surveillance. Imaging surveillance is important in assessing complications such as limb thrombosis, endoleaks, graft migration, enlargement of the aneurysm sac, and rupture. Last, one must consider the issue of radiation safety with regard to EVAR. (©)RSNA, 2015.

Preliminary study of the effects of smectite granules (WoundStat) on vascular repair and wound healing in a swine survival model.

PubMed

Gerlach, Travis; Grayson, J Kevin; Pichakron, Kullada O; Sena, Matthew J; DeMartini, Steven D; Clark, Beth Z; Estep, J Scot; Zierold, Dustin

2010-11-01

WoundStat (WS) (TraumaCure, Bethesda, MD) is a topical hemostatic agent that effectively stops severe hemorrhage in animal models. To the best of our knowledge, no survival study has been conducted to ensure long-term product safety. We evaluated vascular patency and tissue responses to WS in a swine femoral artery injury model with survival up to 5 weeks. Anesthetized swine received a standardized femoral artery injury with free hemorrhage for 45 seconds followed by WS application. One hour after application, the WS was removed, the wound copiously irrigated, and the artery repaired using a vein patch. Six groups of three animals received WS and were killed either immediately after surgery or at weekly intervals up to 5 weeks. Three control animals were treated with gauze packing and direct pressure followed by identical vascular repair and survival for 1 week. At the time of killing, angiograms were performed, and tissue was collected for histopathology. Hemostasis was complete in all WS animals. All animals survived the procedure, and there were no clinically evident postoperative complications. Vascular repairs were angiographically patent in 15 of 18 animals (83%) receiving WS. Histopathologic examination of WS animals revealed severe diffuse fibrogranulomatous inflammation, early endothelial degeneration with subsequent intimal hyperplasia, moderate myocyte necrosis, and fibrogranulomatous nerve entrapment with axonal degeneration. Although an effective hemostatic agent, WS use was associated with a substantial local inflammatory response and neurovascular changes up to 5 weeks postinjury.

Sex differences in mortality after abdominal aortic aneurysm repair in the UK

PubMed Central

Saratzis, A.; Sweeting, M. J.; Michaels, J.; Powell, J. T.; Thompson, S. G.; Bown, M. J.

2017-01-01

Background The UK abdominal aortic aneurysm (AAA) screening programmes currently invite only men for screening because the benefit in women is uncertain. Perioperative risk is critical in determining the effectiveness of screening, and contemporary estimates of these risks in women are lacking. The aim of this study was to compare mortality following AAA repair between women and men in the UK. Methods Anonymized data from the UK National Vascular Registry (NVR) for patients undergoing AAA repair (January 2010 to December 2014) were analysed. Co‐variables were extracted for analysis by sex. The primary outcome measure was in‐hospital mortality. Secondary outcome measures included mortality by 5‐year age groups and duration of hospital stay. Logistic regression was performed to adjust for age, calendar time, AAA diameter and smoking status. NVR‐based outcomes were checked against Hospital Episode Statistics (HES) data. Results A total of 23 245 patients were included (13·0 per cent women). Proportionally, more women than men underwent open repair. For elective open AAA repair, the in‐hospital mortality rate was 6·9 per cent in women and 4·0 per cent in men (odds ratio (OR) 1·48, 95 per cent c.i. 1·08 to 2·02; P = 0·014), whereas for elective endovascular AAA repair it was 1·8 per cent in women and 0·7 per cent in men (OR 2·86, 1·72 to 4·74; P < 0·001); the results in HES were similar. For ruptured AAA, there was no sex difference in mortality within the NVR; however, in HES, for ruptured open AAA repair, the in‐hospital mortality rate was higher in women (33·6 versus 27·1 per cent; OR 1·36, 1·16 to 1·59; P < 0·001). Conclusion Women have a higher in‐hospital mortality rate than men after elective AAA repair even after adjustment. This higher mortality may have an impact on the benefit offered by any screening programme offered to women. PMID:28745403

46 CFR Sec. 17 - Performance of work resulting from damage sustained while undergoing repairs.

Code of Federal Regulations, 2011 CFR

2011-10-01

... SHIPPING AUTHORITY MASTER LUMP SUM REPAIR CONTRACT-NSA-LUMPSUMREP Sec. 17 Performance of work resulting... performance of repairs under the NSA Master Contract, negotiations for accomplishment of work necessary to...

46 CFR Sec. 17 - Performance of work resulting from damage sustained while undergoing repairs.

Code of Federal Regulations, 2010 CFR

2010-10-01

... SHIPPING AUTHORITY MASTER LUMP SUM REPAIR CONTRACT-NSA-LUMPSUMREP Sec. 17 Performance of work resulting... performance of repairs under the NSA Master Contract, negotiations for accomplishment of work necessary to...

46 CFR Sec. 17 - Performance of work resulting from damage sustained while undergoing repairs.

Code of Federal Regulations, 2013 CFR

2013-10-01

... SHIPPING AUTHORITY MASTER LUMP SUM REPAIR CONTRACT-NSA-LUMPSUMREP Sec. 17 Performance of work resulting... performance of repairs under the NSA Master Contract, negotiations for accomplishment of work necessary to...

46 CFR Sec. 17 - Performance of work resulting from damage sustained while undergoing repairs.

Code of Federal Regulations, 2012 CFR

2012-10-01

... SHIPPING AUTHORITY MASTER LUMP SUM REPAIR CONTRACT-NSA-LUMPSUMREP Sec. 17 Performance of work resulting... performance of repairs under the NSA Master Contract, negotiations for accomplishment of work necessary to...

46 CFR Sec. 17 - Performance of work resulting from damage sustained while undergoing repairs.

Code of Federal Regulations, 2014 CFR

2014-10-01

... SHIPPING AUTHORITY MASTER LUMP SUM REPAIR CONTRACT-NSA-LUMPSUMREP Sec. 17 Performance of work resulting... performance of repairs under the NSA Master Contract, negotiations for accomplishment of work necessary to...

Subtraction micro-computed tomography of angiogenesis and osteogenesis during bone repair using synchrotron radiation with a novel contrast agent.

PubMed

Matsumoto, Takeshi; Goto, Daichi; Sato, Syota

2013-09-01

Quantitative three-dimensional (3D) imaging of angiogenesis during bone repair remains an experimental challenge. We developed a novel contrast agent containing 0.07- to 0.1-μm particles of zirconium dioxide (ZrCA) and established subtraction μCT using synchrotron radiation (sSRCT) for quantitative imaging of angiogenesis and bone repair. This method was applied to a rat model of tibial bone repair 3 days (DAY3; n = 2), 5 days (DAY5; n = 8), or 10 days (DAY10; n = 8) after drill-hole injury. Using the same drill-hole defect model, its potential use was illustrated by comparison of bone repair between hindlimbs subjected to mechanical unloading (n = 6) and normal weight bearing (n = 6) for 10 days. Following vascular casting with ZrCA, the defect site was scanned with 17.9- and 18.1-keV X-rays. In the latter, image contrast between ZrCA-filled vasculature and bone was enhanced owing to the sharp absorption jump of zirconium dioxide at 18.0 keV (k-edge). The two scan data sets were reconstructed with 2.74-μm voxel resolution, registered by mutual information, and digitally subtracted to extract the contrast-enhanced vascular image. K2HPO4 phantom solutions were scanned at 17.9 keV for quantitative evaluation of bone mineral. Angiogenesis had already started, but new bone formation was not found on DAY3. New bone emerged near the defect boundary on DAY5 and took the form of trabecular-like structure invaded by microvessels on DAY10. Vascular and bone volume fractions, blood vessel and bone thicknesses, and mineralization were higher on DAY10 than on DAY5. All these parameters were found to be decreased after 10 days of hindlimb unloading, indicating the possible involvement of angiogenesis in bone repair impairment caused by reduced mechanical stimuli. In conclusion, the combined technique of sSRCT and ZrCA vascular casting is suitable for quantitative 3D imaging of angiogenesis and its surrounding bone regeneration. This method will be useful for better understanding the linkage between angiogenesis and bone repair.

Initial experience with the Cardiva Boomerang vascular closure device in diagnostic catheterization.

PubMed

Doyle, Brendan J; Godfrey, Michael J; Lennon, Ryan J; Ryan, James L; Bresnahan, John F; Rihal, Charanjit S; Ting, Henry H

2007-02-01

The authors studied the safety and efficacy of the Cardiva Boomerang vascular closure device in patients undergoing diagnostic cardiac catheterization. Conventional vascular closure devices (sutures, collagen plugs, or metal clips) have been associated with catastrophic complications including arterial occlusion and foreign body infections; furthermore, they cannot be utilized in patients with peripheral vascular disease or vascular access site in a vessel other than the common femoral artery. The Cardiva Boomerang device facilitates vascular hemostasis without leaving any foreign body behind at the access site, can be used in peripheral vascular disease, and can be used in vessels other than the common femoral artery A total of 96 patients undergoing transfemoral diagnostic cardiac catheterization were included in this study, including 25 (26%) patients with contraindications to conventional closure devices. Femoral angiography was performed prior to deployment of the Cardiva Boomerang closure device. Patients were ambulated at 1 hr after hemostasis was achieved. The device was successfully deployed and hemostasis achieved with the device alone in 95 (99%) patients. The device failed to deploy in 1 (1%) patient and required conversion to standard manual compression. Minor complications were observed in 5 (5%) patients. No patients experienced major complications including femoral hematoma > 4 cm, red blood cell transfusion, retroperitoneal bleed, arteriovenous fistula, pseudoaneurysm, infection, arterial occlusion, or vascular surgery. The Cardiva Boomerang device is safe and effective in patients undergoing diagnostic cardiac catheterization using the transfemoral approach, facilitating early ambulation with low rates of vascular complications. (c) 2006 Wiley-Liss, Inc.

Roles of Nicotinamide Adenine Dinucleotide Phosphate (NADPH) Oxidase in Angiogenesis: Isoform-Specific Effects

PubMed Central

Wang, Haibo; Hartnett, M. Elizabeth

2017-01-01

Angiogenesis is the formation of new blood vessels from preexisting ones and is implicated in physiologic vascular development, pathologic blood vessel growth, and vascular restoration. This is in contrast to vasculogenesis, which is de novo growth of vessels from vascular precursors, or from vascular repair that occurs when circulating endothelial progenitor cells home into an area and develop into blood vessels. The objective of this review is to discuss the isoform-specific role of nicotinamide adenine dinucleotide phosphate (NADPH) oxidase (NOX) in physiologic and pathologic angiogenesis and vascular repair, but will not specifically address vasculogenesis. As the major source of reactive oxygen species (ROS) in vascular endothelial cells (ECs), NOX has gained increasing attention in angiogenesis. Activation of NOX leads to events necessary for physiologic and pathologic angiogenesis, including EC migration, proliferation and tube formation. However, activation of different NOX isoforms has different effects in angiogenesis. Activation of NOX2 promotes pathologic angiogenesis and vascular inflammation, but may be beneficial in revascularization in the hindlimb ischemic model. In contrast, activation of NOX4 appears to promote physiologic angiogenesis mainly by protecting the vasculature during ischemia, hypoxia and inflammation and by restoring vascularization, except in models of oxygen-induced retinopathy and diabetes where NOX4 activation leads to pathologic angiogenesis. PMID:28587189

Collagen Augmentation Improves the Quality of Cartilage Repair After Microfracture in Patients Undergoing High Tibial Osteotomy: A Randomized Controlled Trial.

PubMed

Kim, Man Soo; Koh, In Jun; Choi, Young Jun; Pak, Kyu Hyung; In, Yong

2017-07-01

The quality of cartilage repair after marrow stimulation is unpredictable. To overcome the shortcomings of the microfracture technique, various augmentation techniques have been developed. However, their efficacies remain unclear. The quality of cartilage repair and clinical outcomes would be superior in patients undergoing high tibial osteotomy (HTO) with microfracture and collagen augmentation compared to those undergoing HTO with microfracture alone without collagen augmentation for the treatment of medial compartment osteoarthritis (OA) of the knee. Randomized controlled trial; Level of evidence, 2. Twenty-eight patients undergoing HTO were randomized into 2 groups: microfracture alone (group 1, n = 14) or microfracture with collagen augmentation (group 2, n = 14). At 1 year postoperatively, second-look arthroscopic surgery and biopsy of repaired cartilage were performed at the time of HTO plate removal. Biopsy specimens were graded using the International Cartilage Repair Society Visual Assessment Scale II (ICRS II). In addition, imaging outcomes in terms of the magnetic resonance observation of cartilage repair tissue (MOCART) score were assessed based on magnetic resonance imaging (MRI). Finally, clinical outcomes in terms of the visual analog scale (VAS) for pain score, Knee Injury and Osteoarthritis Outcome Score (KOOS), International Knee Documentation Committee (IKDC) score, and Tegner activity scale score were evaluated. The mean ICRS II score in group 2 was significantly higher than that in group 1 (1053.2 vs 885.4, respectively; P = .002). Group 2 showed greater improvement in tissue morphology, cell morphology, surface architecture, middle/deep zone assessment, and overall assessment compared with group 1 ( P < .050 for all comparisons). Imaging outcomes based on the MOCART score were superior in group 2 compared to those in group 1 on MRI at 1 year postoperatively (64.6 vs 45.4, respectively; P = .001). The degree of defect repair was better in group 2 than in group 1 ( P = .040). Clinical outcomes in terms of the VAS for pain score, KOOS, IKDC score, and Tegner activity scale score were improved in both groups without between-group differences ( P > .100 for all comparisons). The quality of cartilage repair after microfracture with collagen augmentation was superior to that after microfracture alone in patients undergoing HTO. Clinical results after 1 year did not reflect this difference in tissue repair. Therefore, a longer follow-up of the cohort is needed to answer this question.

Minimal cosmetic revision required after minimally invasive pectus repair.

PubMed

Murphy, Brittany L; Naik, Nimesh D; Roskos, Penny L; Glasgow, Amy E; Moir, Christopher R; Habermann, Elizabeth B; Klinkner, Denise B

2018-05-09

Despite surgical correction procedures for pectus deformities, remaining cosmetic asymmetry may have significant psychological effects. We sought to evaluate factors associated with plastic surgery (PS) consultation and procedures for these deformities at an academic institution. We reviewed patients aged 0-21 diagnosed with a pectus excavatum or carinatum deformity at our institution between January 2001 and October 2016. Pectus diagnoses were identified by ICD-9/ICD-10 codes and surgical repair by CPT codes; patients receiving PS consultation were identified by clinical note service codes. Student's t tests, Fisher's exact tests, and Chi-squared tests were utilized. 2158 patients were diagnosed with a pectus deformity; 442 (20.4%) underwent surgical correction. 19/442 (4.3%) sought PS consultation, either for pectus excavatum [14/19 (73.7%)], carinatum [4/19 (21.0%)], and both [1/19 (5.3%)], (p = 0.02). Patients seeking PS consultation were more likely to be female (p < 0.01), have scoliosis (p = 0.02), or undergo an open repair (p < 0.01). The need for PS consultation did not correlate with Haller index, p = 0.78. PS consultation associated with pectus deformity repair was rare, occurring in < 5% of patients undergoing repair. Patients who consulted PS more commonly included females, patients with scoliosis, and those undergoing open repair. These patients would likely benefit most from multidisciplinary pre-operative discussions regarding repair of the global deformity.

Perioperative outcomes and complications of open vs laparoscopic extraperitoneal inguinal hernia repair in a mature surgical practice.

PubMed

Winslow, E R; Quasebarth, M; Brunt, L M

2004-02-01

Although the laparoscopic totally extraperitoneal (TEP) approach to hernia repair has been associated with less pain and a faster postoperative recovery than traditional open repair, many practicing surgeons have been reluctant to adopt this technique because of the lengthy operative times and the learning curve for this procedure. Data from all patients undergoing TEP repair since 1997 and open mesh repair (OPEN) since 1999 were collected prospectively. Selection of surgical approach was based on local hernia factors, anesthetic risk, previous abdominal surgery, and patient preference. Statistical analyses were performed using unpaired t-tests and chi-squared tests. Data are mean +/- SD. TEP repairs were performed in 147 patients and open repairs in 198 patients. Patients in the OPEN group were significantly older (59 +/- 19 years OPEN vs 51 +/- 13 years TEP) and had a higher ASA (1.9 +/- 0.7 OPEN vs 1.5 +/- 0.6 TEP; p < 0.01). TEP repairs were more likely to be carried out for bilateral (33% TEP, 5% OPEN) or recurrent hernias (31% TEP, 11% OPEN) than were open repairs ( p < 0.01). Concurrent procedures accompanied 31% of TEP and 12% of OPEN repairs ( p < 0.01). Operative times (min) were significantly shorter in the TEP group for both unilateral (63 +/- 22 TEP, 70 +/- 20 OPEN; p = 0.02) and bilateral (78 +/- 27 TEP, 102 +/- 27 OPEN; p = 0.01) repairs. Mean operative times decreased over time in the TEP group for both unilateral and bilateral repairs ( p < 0.01). Patients undergoing TEP were more likely ( p < 0.01) to develop urinary retention (7.9% TEP, 1.1% OPEN), but were less likely ( p < 0.01) to have skin numbness (2.8% TEP, 35.8% OPEN) or prolonged groin discomfort (1.4% TEP, 5.3% OPEN). Despite a higher proportion of patients undergoing bilateral repairs, recurrent hernia repair, and concurrent procedures, operative times are shorter for laparoscopic TEP repair than for open mesh repair. TEP repairs can be performed efficiently and without major complications, even when the learning curve is included.

Multifactorial risk index for prediction of intraoperative blood transfusion in endovascular aneurysm repair.

PubMed

Mahmood, Eitezaz; Matyal, Robina; Mueller, Ariel; Mahmood, Feroze; Tung, Avery; Montealegre-Gallegos, Mario; Schermerhorn, Marc; Shahul, Sajid

2018-03-01

In some institutions, the current blood ordering practice does not discriminate minimally invasive endovascular aneurysm repair (EVAR) from open procedures, with consequent increasing costs and likelihood of blood product wastage for EVARs. This limitation in practice can possibly be addressed with the development of a reliable prediction model for transfusion risk in EVAR patients. We used the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database to create a model for prediction of intraoperative blood transfusion occurrence in patients undergoing EVAR. Afterward, we tested our predictive model on the Vascular Study Group of New England (VSGNE) database. We used the ACS NSQIP database for patients who underwent EVAR from 2011 to 2013 (N = 4709) as our derivation set for identifying a risk index for predicting intraoperative blood transfusion. We then developed a clinical risk score and validated this model using patients who underwent EVAR from 2003 to 2014 in the VSGNE database (N = 4478). The transfusion rates were 8.4% and 6.1% for the ACS NSQIP (derivation set) and VSGNE (validation) databases, respectively. Hemoglobin concentration, American Society of Anesthesiologists class, age, and aneurysm diameter predicted blood transfusion in the derivation set. When it was applied on the validation set, our risk index demonstrated good discrimination in both the derivation and validation set (C statistic = 0.73 and 0.70, respectively) and calibration using the Hosmer-Lemeshow test (P = .27 and 0.31) for both data sets. We developed and validated a risk index for predicting the likelihood of intraoperative blood transfusion in EVAR patients. Implementation of this index may facilitate the blood management strategies specific for EVAR. Copyright © 2017 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.

Transplantation of an LGR6+ Epithelial Stem Cell-Enriched Scaffold for Repair of Full-Thickness Soft-Tissue Defects: The In Vitro Development of Polarized Hair-Bearing Skin.

PubMed

Lough, Denver M; Wetter, Nathan; Madsen, Christopher; Reichensperger, Joel; Cosenza, Nicole; Cox, Lisa; Harrison, Carrie; Neumeister, Michael W

2016-02-01

Recent literature has shown that full-thickness wounds, devoid of the stem cell niche, can subsequently be reconstructed with functional skin elements following migration of the LGR6 epithelial stem cell into the wound bed. In this study, the authors use a variety of LGR6 epithelial stem cell-seeded scaffolds to determine therapeutic utility and regenerative potential in the immediate reconstruction of full-thickness wounds. Isolated LGR6 epithelial stem cells were seeded onto a spectrum of acellular matrices and monitored in both in vitro and in vivo settings to determine their relative capacity to regenerate tissues and heal wounds. Wound beds containing LGR6 stem cell-seeded scaffolds showed significantly augmented rates of healing, epithelialization, and hair growth compared with controls. Gene and proteomic expression studies indicate that LGR6 stem cell-seeded constructs up-regulate WNT, epidermal growth factor, and angiogenesis pathways. Finally, the addition of stromal vascular fraction to LGR6 stem cell-seeded constructs induces polarized tissue formation, nascent hair growth, and angiogenesis within wounds. LGR6 stem cells are able to undergo proliferation, differentiation, and migration following seeding onto a variety of collagen-based scaffolding. In addition, deployment of these constructs induces epithelialization, hair growth, and angiogenesis within wound beds. The addition of stromal vascular fraction to LGR6 stem cell-containing scaffolds initiated an early form of tissue polarization, providing for the first time a clinically applicable stem cell-based construct that is capable of the repair of full-thickness wounds and hair regeneration. Therapeutic, V.

Defective bone repair in mast cell-deficient Cpa3Cre/+ mice.

PubMed

Ramirez-GarciaLuna, Jose Luis; Chan, Daniel; Samberg, Robert; Abou-Rjeili, Mira; Wong, Timothy H; Li, Ailian; Feyerabend, Thorsten B; Rodewald, Hans-Reimer; Henderson, Janet E; Martineau, Paul A

2017-01-01

In the adult skeleton, cells of the immune system interact with those of the skeleton during all phases of bone repair to influence the outcome. Mast cells are immune cells best known for their pathologic role in allergy, and may be involved in chronic inflammatory and fibrotic disorders. Potential roles for mast cells in tissue homeostasis, vascularization and repair remain enigmatic. Previous studies in combined mast cell- and Kit-deficient KitW-sh/W-sh mice (KitW-sh) implicated mast cells in bone repair but KitW-sh mice suffer from additional Kit-dependent hematopoietic and non- hematopoietic deficiencies that could have confounded the outcome. The goal of the current study was to compare bone repair in normal wild type (WT) and Cpa3Cre/+ mice, which lack mast cells in the absence of any other hematopoietic or non- hematopoietic deficiencies. Repair of a femoral window defect was characterized using micro CT imaging and histological analyses from the early inflammatory phase, through soft and hard callus formation, and finally the remodeling phase. The data indicate 1) mast cells appear in healing bone of WT mice but not Cpa3Cre/+ mice, beginning 14 days after surgery; 2) re-vascularization of repair tissue and deposition of mineralized bone was delayed and dis-organised in Cpa3Cre/+ mice compared with WT mice; 3) the defects in Cpa3Cre/+ mice were associated with little change in anabolic activity and biphasic alterations in osteoclast and macrophage activity. The outcome at 56 days postoperative was complete bridging of the defect in most WT mice and fibrous mal-union in most Cpa3Cre/+ mice. The results indicate that mast cells promote bone healing, possibly by recruiting vascular endothelial cells during the inflammatory phase and coordinating anabolic and catabolic activity during tissue remodeling. Taken together the data indicate that mast cells have a positive impact on bone repair.

Defective bone repair in mast cell-deficient Cpa3Cre/+ mice

PubMed Central

Chan, Daniel; Samberg, Robert; Abou-Rjeili, Mira; Wong, Timothy H.; Li, Ailian; Feyerabend, Thorsten B.; Rodewald, Hans-Reimer; Henderson, Janet E.; Martineau, Paul A.

2017-01-01

In the adult skeleton, cells of the immune system interact with those of the skeleton during all phases of bone repair to influence the outcome. Mast cells are immune cells best known for their pathologic role in allergy, and may be involved in chronic inflammatory and fibrotic disorders. Potential roles for mast cells in tissue homeostasis, vascularization and repair remain enigmatic. Previous studies in combined mast cell- and Kit-deficient KitW-sh/W-sh mice (KitW-sh) implicated mast cells in bone repair but KitW-sh mice suffer from additional Kit-dependent hematopoietic and non- hematopoietic deficiencies that could have confounded the outcome. The goal of the current study was to compare bone repair in normal wild type (WT) and Cpa3Cre/+ mice, which lack mast cells in the absence of any other hematopoietic or non- hematopoietic deficiencies. Repair of a femoral window defect was characterized using micro CT imaging and histological analyses from the early inflammatory phase, through soft and hard callus formation, and finally the remodeling phase. The data indicate 1) mast cells appear in healing bone of WT mice but not Cpa3Cre/+ mice, beginning 14 days after surgery; 2) re-vascularization of repair tissue and deposition of mineralized bone was delayed and dis-organised in Cpa3Cre/+ mice compared with WT mice; 3) the defects in Cpa3Cre/+ mice were associated with little change in anabolic activity and biphasic alterations in osteoclast and macrophage activity. The outcome at 56 days postoperative was complete bridging of the defect in most WT mice and fibrous mal-union in most Cpa3Cre/+ mice. The results indicate that mast cells promote bone healing, possibly by recruiting vascular endothelial cells during the inflammatory phase and coordinating anabolic and catabolic activity during tissue remodeling. Taken together the data indicate that mast cells have a positive impact on bone repair. PMID:28350850

The dynamics of gas bubbles in conduits of vascular plants and implications for embolism repair.

PubMed

Konrad, W; Roth-Nebelsick, A

2003-09-07

Pressure-induced tensions in the xylem, the water conducting tissue of vascular plants, can lead to embolism in the water-conducting cells. The details and mechanisms of embolism repair in vascular plants are still not well understood. In particular, experimental results which indicate that embolism repair may occur during xylem tension cause great problems with respect to current paradigms of plant water transport. The present paper deals with a theoretical analysis of interfacial effects at the pits (pores in the conduit walls), because it was suggested that gas-water interfaces at the pit pores may be involved in the repair process by hydraulically isolating the embolized conduit. The temporal behaviour of bubbles at the pit pores was especially studied since the question of whether these pit bubbles are able to persist is of crucial importance for the suggested mechanism to work. The results indicate that (1) the physical preconditions which are necessary for the suggested mechanism appear to be satisfied, (2) pit bubbles can achieve temporal stability and therefore persist and (3) dissolving of bubbles in the conduit lumen may lead to the final breakdown of the hydraulic isolation. The whole process is, however, complex and strongly dependent on the detailed anatomy of the pit and the contact angle.

Quality of vascular surgery Web sites on the Internet.

PubMed

Grewal, Perbinder; Williams, Bryn; Alagaratnam, Swethan; Neffendorf, James; Soobrah, Ritish

2012-11-01

This study evaluated the readability, accessibility, usability, and reliability of vascular surgery information on the Internet in the English language. The Google, Yahoo, and MSN/Bing search engines were searched for "carotid endarterectomy," "EVAR or endovascular aneurysm repair," and "varicose veins or varicose veins surgery." The first 50 Web sites from each search engine for each topic were analyzed. The Flesch Reading Ease Score and Gunning Fog Index were calculated to assess readability. The LIDA tool (Minervation Ltd, Oxford, UK) was used to assess accessibility, usability, and reliability. The Web sites were difficult to read and comprehend. The mean Flesch Reading Ease scores were 53.53 for carotid endarterectomy, 50.53 for endovascular aneurysm repair, and 58.59 for varicose veins. The mean Gunning Fog Index scores were 12.3 for carotid endarterectomy, 12.12 for endovascular aneurysm repair, and 10.69 for varicose veins. The LIDA values for accessibility were good, but the results for usability and reliability were poor. Internet information on vascular surgical conditions and procedures is poorly written and unreliable. We suggest that health professionals should recommend Web sites that are easy to read and contain high-quality surgical information. Medical information on the Internet must be readable, accessible, usable, and reliable. Copyright © 2012 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.

Src inhibitor reduces permeability without disturbing vascularization and prevents bone destruction in steroid-associated osteonecrotic lesions in rabbits.

PubMed

He, Yi-Xin; Liu, Jin; Guo, Baosheng; Wang, Yi-Xiang; Pan, Xiaohua; Li, Defang; Tang, Tao; Chen, Yang; Peng, Songlin; Bian, Zhaoxiang; Liang, Zicai; Zhang, Bao-Ting; Lu, Aiping; Zhang, Ge

2015-03-09

To examine the therapeutic effect of Src inhibitor on the VEGF mediating vascular hyperpermeability and bone destruction within steroid-associated osteonecrotic lesions in rabbits. Rabbits with high risk for progress to destructive repair in steroid-associated osteonecrosis were selected according to our published protocol. The selected rabbits were systemically administrated with either Anti-VEGF antibody (Anti-VEGF Group) or Src inhibitor (Src-Inhibition Group) or VEGF (VEGF-Supplement Group) or a combination of VEGF and Src inhibitor (Supplement &Inhibition Group) or control vehicle (Control Group) for 4 weeks. At 0, 2 and 4 weeks after administration, in vivo dynamic MRI, micro-CT based-angiography, histomorphometry and immunoblotting were employed to evaluate the vascular and skeletal events in different groups. The incidence of the destructive repair in the Anti-VEGF Group, Src-Inhibition Group and Supplement &Inhibition Group was all significantly lower than that in the Control Group. The angiogenesis was promoted in VEGF-Supplement Group, Src-Inhibition Group and Supplement &Inhibition Group, while the hyperpermeability was inhibited in Anti-VEGF Group, Src-Inhibition Group and Supplement &Inhibition Group. The trabecular structure was improved in Src-Inhibition Group and Supplement &Inhibition Group. Src inhibitor could reduce permeability without disturbing vascularization and prevent destructive repair in steroid-associated osteonecrosis.

Comparative analysis of the outcomes of elective abdominal aortic aneurysm repair in England and Sweden

PubMed Central

Karthikesalingam, A.; Holt, P. J.; Vidal‐Diez, A.; Thompson, M. M.; Wanhainen, A.; Bjorck, M.; Mani, K.

2018-01-01

Background There is substantial international variation in mortality after abdominal aortic aneurysm (AAA) repair; many non‐operative factors influence risk‐adjusted outcomes. This study compared 90‐day and 5‐year mortality for patients undergoing elective AAA repair in England and Sweden. Methods Patients were identified from English Hospital Episode Statistics and the Swedish Vascular Registry between 2003 and 2012. Ninety‐day mortality and 5‐year survival were compared after adjustment for age and sex. Separate within‐country analyses were performed to examine the impact of co‐morbidity, hospital teaching status and hospital annual caseload. Results The study included 36 249 patients who had AAA treatment in England, with a median age of 74 (i.q.r. 69–79) years, of whom 87·2 per cent were men. There were 7806 patients treated for AAA in Sweden, with a median of age 73 (68–78) years, of whom 82·9 per cent were men. Ninety‐day mortality rates were poorer in England than in Sweden (5·0 versus 3·9 per cent respectively; P < 0·001), but were not significantly different after 2007. Five‐year survival was poorer in England (70·5 versus 72·8 per cent; P < 0·001). Use of EVAR was initially lower in England, but surpassed that in Sweden after 2010. In both countries, poor outcome was associated with increased age. In England, institutions with higher operative annual volume had lower mortality rates. Conclusion Mortality for elective AAA repair was initially poorer in England than Sweden, but improved over time alongside greater uptake of EVAR, and now there is no difference. Centres performing a greater proportion of EVAR procedures achieved better results in England. PMID:29468657

Blocking VEGF with sFlt1 improves the chondrogenic potential of mouse skeletal muscle-derived stem cells

PubMed Central

Kubo, Seiji; Cooper, Gregory M.; Matsumoto, Tomoyuki; Phillippi, Julie A.; Corsi, Karin A.; Usas, Arvydas; Li, Guangheng; Fu, Freddie H.; Huard, Johnny

2010-01-01

Objective To investigate the effect of VEGF stimulation and the effect of blocking VEGF with its antagonist, sFlt1, on chondrogenesis using skeletal muscle-derived stem cells (MDSCs). Methods The direct effect of VEGF on the in vitro chondrogenic ability of mouse MDSCs was tested using a pellet culture system followed by quantitative real time PCR and histological analyses. Next, the effect of VEGF on chondrogenesis within the synovial joint was tested using genetically engineered MDSCs implanted into the rat osteochondral defect. In this model, MDSCs, transduced with a retroviral vector to express BMP4, were co-implanted with MDSCs transduced to express either VEGF or sFlt1 (a VEGF antagonist) to provide a gain- and loss-of VEGF function experimental design. Histological scoring was used to compare cartilage formation among the treatment groups. Results Hyaline-like cartilage matrix production was observed in both VEGF-treated and VEGF-blocked (sFlt1-treated) pellet cultures, but real-time PCR revealed that sFlt1 treatment improved the expression of chondrogenic genes in MDSCs that were stimulated to undergo chondrogenic differentiation with BMP4 and TGF-β3. In vivo testing of articular cartilage repair showed that VEGF-transduced MDSCs caused an arthritic change in the knee joint, and sFlt1 improved the MDSC-mediated repair of articular cartilage, compared to BMP4 alone. Conclusion sFlt1 gene therapy improved BMP4- and TGF-β3-induced chondrogenic gene expression of MDSCs in vitro, and improved the persistence of repaired articular cartilage by preventing vascularization and bone invasion into the repaired articular cartilage. PMID:19116905

Assessment of failure to rescue after abdominal aortic aneurysm repair using the National Surgical Quality Improvement Program procedure-targeted data set.

PubMed

Dakour-Aridi, Hanaa; Paracha, Nawar Z; Locham, Satinderjit; Nejim, Besma; Malas, Mahmoud B

2018-05-18

Open aortic repair (OAR) is associated with higher risk of mortality compared with endovascular aneurysm repair (EVAR). The aim of this study was to compare failure to rescue (FTR) after major predischarge complications in patients undergoing OAR and EVAR. Patients who underwent OAR or EVAR in the American College of Surgeons National Surgical Quality Improvement Program between 2011 and 2015 were selected. Patients with ruptured aneurysm and those with type IV thoracoabdominal aneurysms were excluded. The primary outcome was FTR, defined as 30-day mortality in patients who developed at least one complication during their hospital stay. Univariable and multivariable statistics were used. A total of 9097 patients underwent abdominal aortic aneurysm repair. Of those, 3291 (36.2%) had at least one major predischarge complication, 82.5% after OAR (95% confidence interval [CI], 80.9%-84.1%) vs 21.3% after EVAR (95% CI, 20.4%-22.3%; P < .001). Increased FTR was seen after aneurysm rupture, cardiac arrest, septic shock, and acute kidney injury. On multivariable analysis, FTR was not significantly different between OAR and EVAR (adjusted odds ratio, 0.87; 95% CI, 0.61-1.24; P = .44). Propensity score matching and coarsened exact matching showed similar results. Although EVAR has fewer complications and lower in-hospital mortality than OAR, FTR after major predischarge complications does not depend on the type of surgical approach. When an in-hospital major complication occurs after EVAR, surgeons should be alert that FTR risk resulting in mortality is similar to that of OAR. Therefore, there is no safety net with EVAR. Copyright © 2018 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.

Implantation of healthy matrix-embedded endothelial cells rescues dysfunctional endothelium and ischemic tissue in liver engraftment

PubMed Central

Melgar-Lesmes, Pedro; Balcells, Mercedes; Edelman, Elazer R.

2017-01-01

Objective Liver transplantation is limited by ischemic injury which promotes endothelial cell and hepatocyte dysfunction and eventually organ failure. We sought to understand how endothelial state determines liver recover after hepatectomy and engraftment. Design Matrix-embedded endothelial cells (MEECs) with retained healthy phenotype or control acellular matrices were implanted in direct contact with the remaining median lobe of donor mice undergoing partial hepatectomy (70%), or in the interface between the remaining median lobe and an autograft or isograft from the left lobe in hepatectomized recipient mice. Hepatic vascular architecture, DNA fragmentation and apoptosis in the median lobe and grafts, serum markers of liver damage and phenotype of macrophage and lymphocyte subsets in the liver after engraftment were analyzed 7 days post-op. Results Healthy MEECs create a functional vascular splice in donor and recipient liver after 70% hepatectomy in mouse protecting these livers from ischemic injury, hepatic congestion and inflammation. Macrophages recruited adjacent to the vascular nodes into the implants switched to an anti-inflammatory and regenerative profile M2. MEECs improved liver function and the rate of liver regeneration and prevented apoptosis in donor liver lobes, autologous grafts, and allogeneic engraftment. Conclusions Implants with healthy endothelial cells rescue liver donor and recipient endothelium and parenchyma from ischemic injury after major hepatectomy and engraftment. This study highlights endothelial-hepatocyte crosstalk in hepatic repair and provides a promising new approach to improve regenerative medicine outcomes and liver transplantation. PMID:26851165

Absence of CD9 reduces endometrial VEGF secretion and impairs uterine repair after parturition.

PubMed

Kawano, Natsuko; Miyado, Kenji; Yoshii, Noriko; Kanai, Seiya; Saito, Hidekazu; Miyado, Mami; Inagaki, Noboru; Odawara, Yasushi; Hamatani, Toshio; Umezawa, Akihiro

2014-04-16

In mammals, uterine epithelium is remodeled cyclically throughout adult life for pregnancy. Despite the expression of CD9 in the uterine epithelium, its role in maternal reproduction is unclear. Here, we addressed this issue by examining uterine secretions collected from patients undergoing fertility treatment and fertilization-competent Cd9(-/-) mice expressing CD9-GFP in their eggs (Cd9(-/-)TG). CD9 in uterine secretions was observed as extracellular matrix-like feature, and its amount of the secretions associated with repeated pregnancy failures. We also found that the litter size of Cd9(-/-)TG female mice was significantly reduced after their first birth. Severely delayed re-epithelialization of the endometrium was then occurred. Concomitantly, vascular endothelial growth factor (VEGF) was remarkably reduced in the uterine secretions of Cd9(-/-)TG female mice. These results provide the first evidence that CD9-mediated VEGF secretion plays a role in re-epithelialization of the uterus.

Non-Elective Paraesophageal Hernia Repair Portends Worse Outcomes in Comparable Patients: a Propensity-Adjusted Analysis.

PubMed

Tam, Vernissia; Luketich, James D; Winger, Daniel G; Sarkaria, Inderpal S; Levy, Ryan M; Christie, Neil A; Awais, Omar; Shende, Manisha R; Nason, Katie S

2017-01-01

Patients undergoing non-elective paraesophageal hernia repair (PEHR) have worse perioperative outcomes. Because they are usually older and sicker, however, these patients may be more prone to adverse events, independent of surgical urgency. Our study aimed to determine whether non-elective PEHR is associated with differential postoperative outcome compared to elective repair, using propensity-score weighting. We abstracted data for patients undergoing PEHR (n = 924; non-elective n = 171 (19 %); 1997-2010). Using boosted regression, we generated a propensity-weighted dataset. Odds of 30-day/in-hospital mortality and major complications after non-elective surgery were determined. Patients undergoing non-elective repair were significantly older, had more adverse prognostic factors, and significantly more major complications (38 versus 18 %; p < 0.001) and death (8 versus 1 %; p < 0.001). After propensity weighting, median absolute percentage bias across 28 propensity-score variables improved from 19 % (significant imbalance) to 5.6 % (well-balanced). After adjusting propensity-weighted data for age and comorbidity score, odds of major complications were still nearly two times greater (OR 1.67, CI 1.07-2.61) and mortality nearly three times greater (OR 2.74, CI 0.93-8.1) than for elective repair. Even after balancing significant differences in baseline characteristics, non-elective PEHR was associated with worse outcomes than elective repair. Symptomatic patients should be referred for elective repair by experienced surgeons.

Endothelial progenitor cells (EPCs) in ageing and age-related diseases: How currently available treatment modalities affect EPC biology, atherosclerosis, and cardiovascular outcomes.

PubMed

Altabas, Velimir; Altabas, Karmela; Kirigin, Lora

2016-10-01

Endothelial progenitor cells (EPCs) are mononuclear cells that circulate in the blood and are derived from different tissues, expressing cell surface markers that are similar to mature endothelial cells. The discovery of EPCs has lead to new insights in vascular repair and atherosclerosis and also a new theory for ageing. EPCs from the bone marrow and some other organs aid in vascular repair by migrating to distant vessels where they differentiate into mature endothelial cells and replace old and injured endothelial cells. The ability of EPCs to repair vascular damage depends on their number and functionality. Currently marketed drugs used in a variety of diseases can modulate these characteristics. In this review, the effect of currently available treatment options for cardiovascular and metabolic disorders on EPC biology will be discussed. The various EPC-based therapies that will be discussed include lipid-lowering agents, antihypertensive agents, antidiabetic drugs, phosphodiesteraze inhibitors, hormones, as well as EPC capturing stents. Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.

Human versus non-cross-linked porcine acellular dermal matrix used for ventral hernia repair: comparison of in vivo fibrovascular remodeling and mechanical repair strength.

PubMed

Campbell, Kristin Turza; Burns, Nadja K; Rios, Carmen N; Mathur, Anshu B; Butler, Charles E

2011-06-01

Human acellular dermal matrix (HADM) and non-cross-linked porcine acellular dermal matrix (ncl-PADM) are clinically useful for complex ventral hernia repair. Direct comparisons between the two in vivo are lacking, however. This study compared clinically relevant early outcomes with these bioprosthetic materials when used for ventral hernia repair. Seventy-two guinea pigs underwent inlay repair of surgically created hernias with HADM (n = 37) or ncl-PADM (n = 35). Repair sites were harvested at 1, 2, or 4 weeks postoperatively. Adhesions were graded and quantified. Mechanical testing and histologic and immunohistologic (factor VIII) analyses of cellular and vascular infiltration were performed. No infections or recurrent hernias occurred. No difference was observed in mean adhesion surface area or tenacity between groups. Mean cellular infiltration (p < 0.002, weeks 1 and 4; p < 0.006, week 2) and vascular infiltration (p < 0.0003, week 1; p < 0.0001, weeks 2 and 4) were greater in HADM. Ultimate tensile strength at the implant-musculofascia interface increased over time with both materials, but no difference was observed at 4 weeks. The mean ultimate tensile strength of explanted ncl-PADM itself was consistently greater than that of HADM. The elastic modulus (stiffness) did not differ between groups at the interface but was greater in explanted ncl-PADM (p < 0.0001, weeks 1 and 2; p < 0.02, week 4). Both HADM and ncl-PADM become infiltrated with host cells and blood vessels within 4 weeks and have similar musculofascia-bioprosthetic interface strength. However, HADM has greater cellular and vascular infiltration. Longer-term studies will help determine whether later differences in material strength, stiffness, and remodeling affect hernia and/or bulge incidence.

Surgical RF ablation of atrial fibrillation in patients undergoing mitral valve repair for Barlow disease.

PubMed

Rostagno, Carlo; Droandi, G; Gelsomino, S; Carone, E; Gensini, G F; Stefàno, P L

2013-01-01

At present, limited experience exists on the treatment of atrial fibrillation (AF) in patients undergoing mitral valve repair (MVR) for Barlow disease. The aim of this investigation was to prospectively evaluate the radiofrequency ablation of AF in patients undergoing MVR for severe regurgitation due to Barlow disease. From January 1, 2007 to December 31, 2010, out of 85 consecutive patients with Barlow disease, 27 with AF underwent RF ablation associated with MVR. They were examined every 4 months in the first year after surgery and thereafter twice yearly. At follow-up, AF was observed in 4/25 (16.0%). NYHA (New York Heart Association) functional class improved significantly, with no patients in class III or IV (before surgery, 81.5% had been). Otherwise, among 58 patients in sinus rhythm, 6 (11%) developed AF during follow-up. No clinical or echocardiographic predictive factor was found in this subgroup. Results from our investigation suggest that radiofrequency ablation of AF in patients with Barlow disease undergoing MVR for severe regurgitation is effective and should be considered in every patient with Barlow disease and AF undergoing valve surgical repair. Copyright © 2013 S. Karger AG, Basel.

Lower extremity weakness is associated with elevated blood and cerebrospinal fluid glucose levels following multibranched endovascular aortic aneurysm repair.

PubMed

Hiramoto, Jade S; Fernandez, Charlene; Gasper, Warren; Vartanian, Shant; Reilly, Linda; Chuter, Timothy

2017-02-01

Hyperglycemia is associated with worsened clinical outcomes after central nervous system injury. The purpose of this study was to examine the association between lower extremity weakness (LEW) and the glucose levels of blood and cerebrospinal fluid (CSF) in patients undergoing multibranched endovascular aneurysm repair (MBEVAR) of thoracoabdominal and pararenal aortic aneurysms. Blood and CSF samples were collected preoperatively, immediately after aneurysm repair, and on postoperative day 1 in 21 patients undergoing MBEVAR. Data on demographics, operative repair, complications, and outcomes were collected prospectively. There were 21 patients who underwent successful MBEVAR. Two patients had pre-existing paraplegia from prior open aortic surgery and were excluded from the current analysis. The mean age was 73 ± 8 years, and 15 of 19 (79%) were men. In the postoperative period, 7 of 19 (37%) patients developed LEW. This was temporary in 5 of 19 (26%) patients and permanent in 2 of 19 (11%) patients. The LEW group was older than the non-LEW group (77 ± 6 vs 70 ± 9 years, respectively; P = .10), had a lower preoperative glomerular filtration rate (58.6 ± 18.5 vs 71.4 ± 23.5 mL/min per 1.73 m 2 ; P = .24), and was more likely to be taking a statin (100% vs 67%, respectively; P = .13), but these did not reach statistical significance. There was no significant difference in the prevalence of diabetes mellitus, hypertension, coronary artery disease, lung disease, or peripheral artery disease between the LEW and non-LEW groups. There was also no difference in operative time, blood loss, contrast material volume, or fluoroscopy times between the two groups. Preoperative blood and CSF glucose levels were similar in those with and without LEW. During the postoperative period, glucose values in the blood and CSF were significantly higher in those patients who developed LEW compared with those who did not develop LEW. In all patients with LEW, the elevation in the blood or CSF glucose level preceded the development of LEW. In a multivariable logistic regression model, CSF glucose concentration on postoperative day 1 was significantly and independently associated with the development of LEW (odds ratio, 2.30 [1.03-5.14] per 10 mg/dL increase in CSF glucose; P = .04). Elevated blood glucose and CSF glucose levels are associated with postoperative LEW in patients undergoing MBEVAR. The protective effect of euglycemia deserves further study in patients at risk for spinal cord ischemia. Copyright © 2016 Society for Vascular Surgery. All rights reserved.

Comparison of direct site endovascular repair utilizing expandable polytetrafluoroethylene stent grafts versus standard vascular shunts in a porcine (Sus scrofa) model.

PubMed

Davidson, Anders J; Neff, Lucas P; Grayson, J Kevin; Clement, Nathan F; DeSoucy, Erik S; Simon Logan, Meryl A; Abbot, Christopher M; Sampson, James B; Williams, Timothy K

2017-09-01

The small diameter of temporary vascular shunts for vascular trauma management may restrict flow and result in ischemia or early thrombosis. We have previously reported a clinical experience with direct, open surgical reconstruction using expandable polytetrafluoroethylene stent grafts to create a "sutureless" anastomosis as an alternative to standard temporary vascular shunts. We sought to characterize patency and flow characteristics of these grafts compared with standard shunts in a survival model of porcine vascular injury. Twelve Yorkshire-cross swine received a 2-cm-long near-circumferential defect in the bilateral iliac arteries. A 14 Fr Argyle shunt was inserted into one randomly assigned artery, with a self-expanding expandable polytetrafluoroethylene stent deployed in the other. At 72 hours, conduit patency was evaluated by angiography. Arterial flow measurements were obtained at baseline, immediately after intervention, and after 72 hours via direct measurement with perivascular flow meters. Blood pressure proximal and distal to the conduits and arterial samples for histopathology were obtained during the terminal procedure. Angiography revealed no difference in patency at 72 hours (p = 1.0). While there was no difference in baseline arterial flow between arteries (p = 0.63), the stent grafts demonstrated significantly improved blood flow compared with shunts both immediately after intervention (390 ± 36 mL/min vs. 265 ± 25 mL/min, p = 0.002) and at 72 hours (261 ± 29 mL/min vs. 170 ± 36 mL/min, p = 0.005). The pressure gradient across the shunts was greater than that of the stent grafts (11.5 mm Hg [interquartile range, 3-19 mm Hg] vs. 3 mm Hg [interquartile range, 3-5 mm Hg], p = 0.013). The speed of deployment was similar between the two devices. Open "sutureless" direct site repair using commercially available stent grafts to treat vascular injury is a technically feasible strategy for damage control management of peripheral vascular injury and offers increased blood flow when compared with temporary shunts. Furthermore, stent grafts may offer improved durability to extend the window until definitive vascular repair. The combination of these traits may improve outcomes after vascular injury. Epidemiologic/Prognostic, level III.

Clopidogrel is not associated with major bleeding complications during peripheral arterial surgery

PubMed Central

Stone, David H.; Goodney, Philip P.; Schanzer, Andres; Nolan, Brian W.; Adams, Julie E.; Powell, Richard J.; Walsh, Daniel B.; Cronenwett, Jack L.

2017-01-01

Objectives Persistent variation in practice surrounds preoperative clopidogrel management at the time of vascular surgery. While some surgeons preferentially discontinue clopidogrel citing a perceived risk of perioperative bleeding, others will proceed with surgery in patients taking clopidogrel for an appropriate indication. The purpose of this study was to determine whether preoperative clopidogrel use was associated with significant bleeding complications during peripheral arterial surgery. Methods We reviewed a prospective regional vascular surgery registry recorded by 66 surgeons from 15 centers in New England from 2003 to 2009. Preoperative clopidogrel use within 48 hours of surgery was analyzed among patients undergoing carotid endarterectomy (CEA), lower extremity bypass (LEB), endovascular abdominal aortic aneurysm repair (EVAR), and open abdominal aortic aneurysm repair (oAAA). Ruptured AAAs were excluded. Endpoints included postoperative bleeding requiring reoperation, as well as the incidence and volume of blood transfusion. Statistical analysis was performed using analysis of variance, Fisher exact, χ2, and Wilcoxon rank-sum tests. Results Over the study interval, a total of 10,406 patients underwent surgery, including 5264 CEA, 2883 LEB, 1125 EVAR, and 1134 oAAA repair. Antiplatelet use among all patients varied, with 19% (n = 2010) taking no antiplatelet agents, 69% (n = 7132) taking aspirin (ASA) alone, 2.2% (n = 229) taking clopidogrel alone, and 9.7% (n = 1017) taking both ASA and clopidogrel. Clopidogrel alone or as dual antiplatelet therapy was most frequently used prior to CEA and least frequently prior to oAAA group (CEA 16.1%, LEB 9.0%, EVAR 6.5%, oAAA 5%). Reoperation for bleeding was not significantly different among patients based on antiplatelet regimen (none 1.5%, ASA 1.3%, clopidogrel 0.9%, ASA/clopidogrel 1.5%, P = .74). When analyzed by operation type, no difference in reoperation for bleeding was seen across antiplatelet regimens. There was also no difference in the incidence of transfusion among antiplatelet treatment groups (none 18%, ASA 17%, clopidogrel 0%, ASA/clopidogrel 24%, P = .1) and none when analyzed by individual operation type. Among patients who did require transfusion, there was no significant difference in the mean number of units of packed red blood cells required (none 0.7 units, ASA 0.5 units, clopidogrel 0 units, ASA/clopidogrel 0.6 units, P = .1) or when stratified by operation type. Conclusions Patients undergoing peripheral arterial surgery in whom clopidogrel was continued either alone or as part of dual antiplatelet therapy did not have significant bleeding complications compared with patients taking no antiplatelet therapy or ASA alone at the time of surgery. These data suggest that clopidogrel can safely be continued preoperatively in patients with appropriate indications for its use, such as symptomatic carotid disease or recent drug-eluting coronary stents. PMID:21571492

Technology penetration of endovascular aortic aneurysm repair in southern California.

PubMed

Shah, Haimesh; Kumar, S Ram; Major, Kevin; Hood, Douglas; Rowe, Vincent; Weaver, Fred A

2006-11-01

Our objective was to investigate the penetration of endovascular abdominal aortic aneurysm repair (EVAR) in the large, diverse health-care market of southern California over 3 years and to study variability in the pattern of distribution of EVAR in southern California counties by analyzing available demographic, geographic, and socioeconomic data from California state health-care databases. Information abstracted from the inpatient hospital discharge data for patients undergoing AAA repair for the years 2001, 2002, and 2003, derived from the Office of Statewide Health Planning and Development, included age, gender, race, hospitals performing EVAR, and payors for the service. Per-capita income (PCI) for the year 1999 and the population size of each county for the respective years were obtained from the U.S. Census Bureau. Data pertaining to members of the Southern California Vascular Surgical Society (SCVSS) serving the southern California region were obtained from the SCVSS membership directory. Data were categorized based on 10 counties in southern California. All the above variables were analyzed using the chi-squared test, with p < 0.05 considered significant. The proportions of EVAR for the years 2001, 2002, and 2003 were 15.4% (n = 409), 20.2% (n = 492), and 25.9% (n = 566), respectively. This is a 67.8% (p < 0.0001) increase in EVAR application in southern California since 2001. However, the proportion of EVAR varied among counties (p < 0.0001), with 457 EVARs performed in Los Angeles County and eight in Imperial County during the study period. EVAR proportion was higher in patients aged > or =65 years (p < 0.0001) and male patients (p < 0.0001). The proportion of EVAR was significantly higher in counties with more than 20 vascular surgeons available (p < 0.0001) and PCI >21,000 US$ (p < 0.0001) and in Medicare, health maintenance organization, preferred provider organization, and private insurance holders (p < 0.0001). There was a trend toward increased EVARs in counties with more than eight hospitals that performed EVAR (p = 0.0545). However, no significant difference in EVAR proportion was observed among subgroups based on race (p = 0.535) and population size (p = 0.84). Although the number and proportion of EVAR increased significantly in southern California over 3 years, the penetration of the procedure varied among counties. County affluence, payor mix, and the number of vascular surgeons/county influenced the variability. These observations suggest that economic barriers may limit access to new biomedical technology. This has implications for health-care public policy directed toward providing equal access to medical care without regard to economic status.

Underlying reasons associated with hospital readmission following surgery in the United States.

PubMed

Merkow, Ryan P; Ju, Mila H; Chung, Jeanette W; Hall, Bruce L; Cohen, Mark E; Williams, Mark V; Tsai, Thomas C; Ko, Clifford Y; Bilimoria, Karl Y

2015-02-03

Financial penalties for readmission have been expanded beyond medical conditions to include surgical procedures. Hospitals are working to reduce readmissions; however, little is known about the reasons for surgical readmission. To characterize the reasons, timing, and factors associated with unplanned postoperative readmissions. Patients undergoing surgery at one of 346 continuously enrolled US hospitals participating in the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) between January 1, 2012, and December 31, 2012, had clinically abstracted information examined. Readmission rates and reasons (ascertained by clinical data abstractors at each hospital) were assessed for all surgical procedures and for 6 representative operations: bariatric procedures, colectomy or proctectomy, hysterectomy, total hip or knee arthroplasty, ventral hernia repair, and lower extremity vascular bypass. Unplanned 30-day readmission and reason for readmission. The unplanned readmission rate for the 498,875 operations was 5.7%. For the individual procedures, the readmission rate ranged from 3.8% for hysterectomy to 14.9% for lower extremity vascular bypass. The most common reason for unplanned readmission was surgical site infection (SSI) overall (19.5%) and also after colectomy or proctectomy (25.8%), ventral hernia repair (26.5%), hysterectomy (28.8%), arthroplasty (18.8%), and lower extremity vascular bypass (36.4%). Obstruction or ileus was the most common reason for readmission after bariatric surgery (24.5%) and the second most common reason overall (10.3%), after colectomy or proctectomy (18.1%), ventral hernia repair (16.7%), and hysterectomy (13.4%). Only 2.3% of patients were readmitted for the same complication they had experienced during their index hospitalization. Only 3.3% of patients readmitted for SSIs had experienced an SSI during their index hospitalization. There was no time pattern for readmission, and early (≤7 days postdischarge) and late (>7 days postdischarge) readmissions were associated with the same 3 most common reasons: SSI, ileus or obstruction, and bleeding. Patient comorbidities, index surgical admission complications, non-home discharge (hazard ratio [HR], 1.40 [95% CI, 1.35-1.46]), teaching hospital status (HR, 1.14 [95% CI 1.07-1.21]), and higher surgical volume (HR, 1.15 [95% CI, 1.07-1.25]) were associated with a higher risk of hospital readmission. Readmissions after surgery were associated with new postdischarge complications related to the procedure and not exacerbation of prior index hospitalization complications, suggesting that readmissions after surgery are a measure of postdischarge complications. These data should be considered when developing quality indicators and any policies penalizing hospitals for surgical readmission.

Associated injuries, management, and outcomes of blunt abdominal aortic injury.

PubMed

de Mestral, Charles; Dueck, Andrew D; Gomez, David; Haas, Barbara; Nathens, Avery B

2012-09-01

Blunt abdominal aortic injury (BAAI) is very rare, and current literature is limited to case series of single-center experience. Through an analysis of the National Trauma Data Bank, the largest aggregation of United States trauma registry data, our aim was to characterize the associated injury pattern, contemporary management, and in-hospital outcomes of patients with BAAI. We used a nested case-control design. The overall cohort consisted of adult patients (age ≥ 16 years) severely injured (Injury Severity Score ≥ 16) after blunt trauma who were treated at a level 1 or 2 trauma center in years 2007 to 2009. Cases were patients with BAAI and were frequency-matched by age group and mechanism to randomly selected controls at a one-to-five ratio. Multivariable matched analysis (conditional logistic regression) was used to derive adjusted measures of association between BAAI and adjacent arterial, intra-abdominal, and bony injuries. We identified 436 patients with BAAI from 180 centers. The mean Injury Severity Score was 35 ± 14, and most patients were injured in motor vehicle crashes (84%). Multivariable analysis showed injury to the thoracic aorta, renal and iliac artery, small bowel, colon, liver, pancreas, and kidney, as well as lumbar spine fractures were independently associated with BAAI. A total of 394 patients (90%) were managed nonoperatively, and 42 (10%) underwent repair. Of these 42 patients, 29 (69%) underwent endovascular repair, with 11 patients undergoing open aortic repair and two extra-anatomic bypasses. Median time from admission to repair was 1 day (interquartile range, 1-2 days). Overall mortality was 29%. A total of 271 (69%) patients managed nonoperatively survived to hospital discharge. The index of suspicion for BAAI should be raised in severely injured patients by the presence of injuries to the lumbar spine, bowel, retroperitoneal organs, and adjacent major arteries. Although endovascular repair is the most common intervention, most patients are managed nonoperatively and survive to hospital discharge. Copyright © 2012 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.

Designation as “Unfit for Open Repair” Is Associated With Poor Outcomes After Endovascular Aortic Aneurysm Repair

PubMed Central

De Martino, Randall R.; Brooke, Benjamin S.; Robinson, William; Schanzer, Andres; Indes, Jeffrey E.; Wallaert, Jessica B.; Nolan, Brian W.; Cronenwett, Jack L.; Goodney, Philip P.

2014-01-01

Background Endovascular aortic aneurysm repair (EVAR) is often offered to patients with abdominal aortic aneurysms (AAAs) considered preoperatively to be unfit for open AAA repair (oAAA). This study describes the short- and long-term outcomes of patients undergoing EVAR with AAAs <6.5 cm who are considered unfit for oAAA. Methods and Results We analyzed elective EVARs for AAAs <6.5 cm diameter in the Vascular Study Group of New England (2003–2011). Patients were designated as fit or unfit for oAAA by the treating surgeon. End points included in-hospital major adverse events and long-term mortality. We identified patient characteristics associated with being unfit for open repair and predictors of survival using multivariable analyses. Of 1653 EVARs, 309 (18.7%) patients were deemed unfit for oAAA. These patients were more likely to have advanced age, cardiac disease, chronic obstructive pulmonary disease, and larger aneurysms at the time of repair (54 versus 56 mm, P=0.001). Patients unfit for oAAA had higher rates of cardiac (7.8% versus 3.1%, P<0.01) and pulmonary (3.6 versus 1.6, P<0.01) complications and worse survival rates at 5 years (61% versus 80%; log rank P<0.01) compared with those deemed fit for oAAA. Finally, patients designated as unfit for oAAA had worse survival, even adjusting for patient characteristics and aneurysm size (hazard ratio, 1.6; 95% confidence interval, 1.2–2.2; P<0.01). Conclusions In patients with AAAs <6.5 cm, designation by the operating surgeon as unfit for oAAA provides insight into both short- and long-term efficacy of EVAR. Patients unable to tolerate oAAA may not benefit from EVAR unless their risk of AAA rupture is very high. PMID:24046399

Popliteal artery repair in massively transfused military trauma casualties: a pursuit to save life and limb.

PubMed

Fox, Charles J; Perkins, Jeremy G; Kragh, John F; Singh, Niten N; Patel, Bhavin; Ficke, James R

2010-07-01

Popliteal artery war wounds can bleed severely and historically have high rates of amputation associated with ligation (72%) and repair (32%). More than before, casualties are now surviving the initial medical evacuation and presenting with severely injured limbs that prompt immediate limb salvage decisions in the midst of life-saving maneuvers. A modern analysis of current results may show important changes because previous limb salvage strategies were limited by the resuscitation and surgical techniques of their eras. Because exact comparisons between wars are difficult, the objective of this study was to calculate a worst-case (a pulseless, fractured limb with massive hemorrhage from popliteal artery injury) amputation-free survival rate for the most severely wounded soldiers undergoing immediate reconstruction to save both life and limb. We performed a retrospective study of trauma casualties admitted to the combat support hospital at Ibn Sina Hospital in Baghdad, Iraq, between 2003 and 2007. US military casualties requiring a massive transfusion (> or = 10 blood units transfused within 24 hours of injury) were identified. We extracted data on the subset of casualties with a penetrating supra or infrageniculate popliteal arterial vascular injury. Demographics, injury mechanism, Injury Severity Score, tourniquet use, physiologic parameters, damage control adjuncts, surgical repair techniques, operative time, and outcomes (all-cause 30-day mortality, amputation rates, limb salvage failure, and graft patency) were investigated. Forty-six massively transfused male casualties, median age 24 years (range, 19-54 years; mean Injury Severity Score, 19 +/- 8.0), underwent immediate orthopedic stabilization and vascular reconstruction. There was one early death. The median operative time for the vascular repairs was 217 minutes (range, 94-630 minutes) and included all damage control procedures. Combined arterial and venous injuries occurred in 17 (37%). Ligation was performed for no arterial and 9 venous injuries. Amputations (transtibial or transfemoral) were considered limb salvage failures (14 of 48, 29.2%) and were grouped as immediate (< or = 48 hours, 5), early (>48 hours and < or = 30 days, 6), or late (>30 days, 3). Limb losses were from graft thrombosis, infection, or chronic pain. Combined arterial and venous injuries occurred in 17 (37%). Ligation was performed for no arterial and nine venous injuries. For a median follow-up (excluding death) of 48 months (range, 23-75 months), the amputation-free survival rate was 67%. This study, a worst-case study, showed comparable results to historical controls regarding limb salvage rates (71% for Iraq vs. 56-69% for the Vietnam War). Thirty-day survival (98%), 4-year amputation-free survival (67%), and complication-free rates (35%) fill knowledge gaps. Guidelines for managing popliteal artery injuries show promising results because current resuscitation practices and surgical care yielded similar amputation rates to prior conflicts despite more severe injuries. Significant transfusion requirements and injury severity may not indicate a life-over-limb strategy for popliteal arterial repairs. Future studies of limb salvage failures may help improve casualty care by reducing the complications that directly impact amputation-free survival.

Patient satisfaction with the consent discussion is not improved by showing patients their computed tomography or angiography images before they undergo vascular surgery.

PubMed

LeBlanc, Dominic; Power, Adam H; DeRose, Guy; Duncan, Audra; Dubois, Luc

2018-05-18

Patient-based decision aids and other multimedia tools have been developed to help enrich the preoperative discussion between surgeon and patient. Use of these tools, however, can be time-consuming and logistically challenging. We investigated whether simply showing patients their images from preoperative computed tomography (CT) or angiography would improve patients' satisfaction with the preoperative discussion. We also examined whether this improved the patient's understanding and trust and whether it contributed to increased preoperative anxiety. Patients undergoing either elective abdominal aortic aneurysm repair or lower limb revascularization were randomly assigned to either standard perioperative discussion or perioperative discussion and review of images (CT image or angiogram). Randomization was concealed and stratified by surgeon. Primary outcome was patient satisfaction with the preoperative discussion as measured by a validated 7-item scale (score, 0-28), with higher scores indicating improved satisfaction. Secondary outcomes included patient understanding, patient anxiety, patient trust, and length of preoperative discussion. Scores were compared using t-test. Overall, 51 patients were randomized, 25 to the intervention arm (discussion and imaging) and 26 to the control arm. Most patients were male (69%), and the average age was 70 years. Forty percent of patients underwent abdominal aortic aneurysm repair, whereas 60% underwent lower limb revascularization. Patient satisfaction with the discussion was generally high, with no added improvement when preoperative images were reviewed (mean score, 24.9 ± 3.02 vs 24.8 ± 2.93; P = .88). Similarly, there was no difference in the patient's anxiety, level of trust, or understanding when the imaging review was compared with standard discussion. There was a trend toward longer preoperative discussions in the group that underwent imaging review (8.18 vs 6.35 minutes; P = .07). Showing patients their CT or angiography images during the preoperative discussion does not improve the patient's satisfaction with the consent discussion. Similarly, there was no effect on the patient's trust, understanding, or anxiety level. Our conclusions are limited by the lack of a standardized measure of patient understanding and not measuring outcomes postoperatively, both of which should be considered in future studies. Copyright © 2018 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.

Endovascular treatment of complicated aortic aneurysms in patients with underlying arteriopathies.

PubMed

Baril, Donald T; Carroccio, Alfio; Palchik, Eugene; Ellozy, Sharif H; Jacobs, Tikva S; Teodorescu, Victoria; Marin, Michael L

2006-07-01

Patients with arteriopathies including giant cell arteritis, Marfan syndrome, and Takayasu's disease are at risk for aneurysmal degeneration of the aorta. Aortic repair has been recommended for these patients to prevent rupture. The purpose of this study was to examine outcomes following endovascular stent graft (EVSG) repair of aortic aneurysms in this patient population. Over an 8-year period, 11 patients (six men, five women) with arteriopathies underwent endovascular aortic repair. The mean age was 50 (range 15-81). Diseases included Marfan syndrome (n = 6), Takayasu's disease (n = 3), and giant cell arteritis (n = 2). Success of EVSG repair was evaluated per the reporting standards of the Society for Vascular Surgery/American Association for Vascular Surgery. Follow-up was a mean of 28.9 months (range 3-68). Six patients underwent EVSG repair of the thoracic aorta, four underwent EVSG repair of the abdominal aorta, and one underwent a staged repair of the thoracic and subsequently the abdominal aorta. Six true aneurysms and six pseudoaneurysms were repaired. Eight patients had previous aortic surgery, including four with multiple aortic operations. For the 12 aneurysms treated, technical success was achieved in 11 (91.7%). One technical failure occurred due to a small iliac access vessel, requiring an eventual iliac conduit for insertion. Early complications (<30 days) occurred in three patients. Type I or III endoleak developed following two repairs (16.7%). Aneurysm expansion occurred following one repair (8.3%). No aneurysm-related deaths occurred during follow-up. EVSG repair of aortic aneurysms is feasible and can be safely performed in patients with arteriopathies. Long-term durability in this younger group of patients who carry an ongoing risk of arterial degeneration remains to be determined.

Gender disparities in the utilization of laparoscopic groin hernia repair.

PubMed

Thiels, Cornelius A; Holst, Kimberly A; Ubl, Daniel S; McKenzie, Travis J; Zielinski, Martin D; Farley, David R; Habermann, Elizabeth B; Bingener, Juliane

2017-04-01

Clinical treatment guidelines have suggested that laparoscopic hernia repair should be the preferred approach in both men and women with bilateral or recurrent elective groin hernias. Anecdotal evidence suggests, however, that women are less likely to undergo a laparoscopic repair than men, and therefore, we aimed to delineate if these disparities persisted after controlling for patient factors and comorbidities. The American College of Surgeons National Surgical Quality Improvement Project data were abstracted for all elective groin hernia repairs between 2005 and 2014. Univariate analysis was used to compare rates of laparoscopic surgery between men and women. Multivariable analysis was performed, controlling for patient demographics, preoperative comorbidities, and year of surgery. Over the 10-y period, 141,490 patients underwent elective groin hernia repair, of which 13,325 were women (9.4%). The rate of general anesthesia utilization was high in both men (81.3%) and women (77.2%) with 75.1% of open repairs being performed under general anesthesia. Overall, 20.2% of women underwent laparoscopic repair compared with 28.0% of men (P < 0.01). Women tended to be older, had a lesser body mass index, and slightly greater American Anesthesia Association (all P < 0.05). On multivariable regression, women had decreased odds of undergoing a laparoscopic approach compared with men (odds ratio: 0.70; 95% confidence interval, 0.67-0.73, P < 0.01). In the elective setting, women were less likely to undergo laparoscopic repair of groin hernias than men. Although we are unable to ascertain underlying causes for these gender disparities, these data suggest that there remains a disparity in the management of groin hernias in women. Copyright © 2016 Elsevier Inc. All rights reserved.

Early Primary Care Provider Follow-up and Readmission After High-Risk Surgery

PubMed Central

Brooke, Benjamin S.; Stone, David H.; Cronenwett, Jack L.; Nolan, Brian; DeMartino, Randall R.; MacKenzie, Todd A.; Goodman, David C.; Goodney, Philip P.

2014-01-01

IMPORTANCE Follow-up with a primary care provider (PCP) in addition to the surgical team is routinely recommended to patients discharged after major surgery despite no clear evidence that it improves outcomes. OBJECTIVE To test whether PCP follow-up is associated with lower 30-day readmission rates after open thoracic aortic aneurysm (TAA) repair and ventral hernia repair (VHR), surgical procedures known to have a high and low risk of readmission, respectively. DESIGN, SETTING, AND PARTICIPANTS In a cohort of Medicare beneficiaries discharged to home after open TAA repair (n = 12 679) and VHR (n = 52 807) between 2003 to 2010, we compared 30-day readmission rates between patients seen and not seen by a PCP within 30 days of discharge and across tertiles of regional primary care use. We stratified our analysis by the presence of complications during the surgical (index) admission. MAIN OUTCOMES AND MEASURES Thirty-day readmission rate. RESULTS Overall, 2619 patients (20.6%) undergoing open TAA repair and 4927 patients (9.3%) undergoing VHR were readmitted within 30 days after surgery. Complications occurred in 4649 patients (36.6%) undergoing open TAA repair and 4528 patients (8.6%) undergoing VHR during their surgical admission. Early follow-up with a PCP significantly reduced the risk of readmission among open TAA patients who experienced perioperative complications, from 35.0% (without follow-up) to 20.4% (with follow-up) (P < .001). However, PCP follow-up made no significant difference in patients whose hospital course was uncomplicated (19.4% with follow-up vs 21.9% without follow-up; P = .31). In comparison, early follow-up with a PCP after VHR did not reduce the risk of readmission, regardless of complications. In adjusted regional analyses, undergoing open TAA repair in regions with high compared with low primary care use was associated with an 18% lower likelihood of 30-day readmission (odds ratio, 0.82; 95% CI, 0.71–0.96; P = .02), whereas no significant difference was found among patients after VHR. CONCLUSIONS AND RELEVANCE Follow-up with a PCP after high-risk surgery (eg, open TAA repair), especially among patients with complications, is associated with a lower risk of hospital readmission. Patients undergoing lower-risk surgery (eg, VHR) do not receive the same benefit from early PCP follow-up. Identifying high-risk surgical patients who will benefit from PCP integration during care transitions may offer a low-cost solution toward limiting readmissions. PMID:25074237

LDL-Induced Impairment of Human Vascular Smooth Muscle Cells Repair Function Is Reversed by HMG-CoA Reductase Inhibition

PubMed Central

Padró, Teresa; Lugano, Roberta; García-Arguinzonis, Maisa; Badimon, Lina

2012-01-01

Growing human atherosclerotic plaques show a progressive loss of vascular smooth muscle cells (VSMC) becoming soft and vulnerable. Lipid loaded-VSMC show impaired vascular repair function and motility due to changes in cytoskeleton proteins involved in cell-migration. Clinical benefits of statins reducing coronary events have been related to repopulation of vulnerable plaques with VSMC. Here, we investigated whether HMG-CoA reductase inhibition with rosuvastatin can reverse the effects induced by atherogenic concentrations of LDL either in the native (nLDL) form or modified by aggregation (agLDL) on human VSMC motility. Using a model of wound repair, we showed that treatment of human coronary VSMC with rosuvastatin significantly prevented (and reversed) the inhibitory effect of nLDL and agLDL in the repair of the cell depleted areas. In addition, rosuvastatin significantly abolished the agLDL-induced dephosphorylation of myosin regulatory light chain as demonstrated by 2DE-electrophoresis and mass spectrometry. Besides, confocal microscopy showed that rosuvastatin enhances actin-cytoskeleton reorganization during lipid-loaded-VSMC attachment and spreading. The effects of rosuvastatin on actin-cytoskeleton dynamics and cell migration were dependent on ROCK-signalling. Furthermore, rosuvastatin caused a significant increase in RhoA-GTP in the cytosol of VSMC. Taken together, our study demonstrated that inhibition of HMG-CoA reductase restores the migratory capacity and repair function of VSMC that is impaired by native and aggregated LDL. This mechanism may contribute to the stabilization of lipid-rich atherosclerotic plaques afforded by statins. PMID:22719992

Critical role of the axonal guidance cue EphrinB2 in lung growth, angiogenesis, and repair.

PubMed

Vadivel, Arul; van Haaften, Tim; Alphonse, Rajesh S; Rey-Parra, Gloria-Juliana; Ionescu, Lavinia; Haromy, Al; Eaton, Farah; Michelakis, Evangelos; Thébaud, Bernard

2012-03-01

Lung diseases characterized by alveolar damage currently lack efficient treatments. The mechanisms contributing to normal and impaired alveolar growth and repair are incompletely understood. Axonal guidance cues (AGC) are molecules that guide the outgrowth of axons to their targets. Among these AGCs, members of the Ephrin family also promote angiogenesis, cell migration, and organogenesis outside the nervous system. The role of Ephrins during alveolar growth and repair is unknown. We hypothesized that EphrinB2 promotes alveolar development and repair. We used in vitro and in vivo manipulation of EphrinB2 signaling to assess the role of this AGC during normal and impaired lung development. In vivo EphrinB2 knockdown using intranasal siRNA during the postnatal stage of alveolar development in rats arrested alveolar and vascular growth. In a model of O(2)-induced arrested alveolar growth in newborn rats, air space enlargement, loss of lung capillaries, and pulmonary hypertension were associated with decreased lung EphrinB2 and receptor EphB4 expression. In vitro, EphrinB2 preserved alveolar epithelial cell viability in O(2), decreased O(2)-induced alveolar epithelial cell apoptosis, and accelerated alveolar epithelial cell wound healing, maintained lung microvascular endothelial cell viability, and proliferation and vascular network formation. In vivo, treatment with intranasal EphrinB2 decreased alveolar epithelial and endothelial cell apoptosis, preserved alveolar and vascular growth in hyperoxic rats, and attenuated pulmonary hypertension. The AGC EphrinB2 may be a new therapeutic target for lung repair and pulmonary hypertension.

Early and mid-term clinical outcome in younger and elderly patients undergoing mitral valve repair with or without tricuspid valve repair.

PubMed

Renner, André; Zittermann, Armin; Aboud, Anas; Hakim-Meibodi, Kavous; Börgermann, Jochen; Gummert, Jan F

2015-01-01

Data regarding durability and midterm benefits of mitral valve (MV) repair in elderly patients are scarce. To evaluate the feasibility and safety of MV repair in elderly patients, we performed a retrospective data analysis. We compared clinical outcomes in younger patients (<75 years: n = 462) and older patients (≥75 years: n = 100) undergoing MV repair with or without tricuspid valve (TV) repair. The primary end-point was 30-day mortality. The preoperative risk profile (EuroSCORE, NYHA class, percentage pulmonary hypertension, percentage diabetes) was higher in older patients compared with younger patients. Nevertheless, operative complications such as low cardiac output syndrome, stroke, infections, the need of haemofiltration and IABP use did not differ significantly between the two groups. The thirty-day mortality rate was 0% in older patients and 1% in younger patients (P = 0.30). In the subgroup of patients with double valve repair, the 30-day mortality rate in older patients (n = 28) and younger patients (n = 46) was 0 and 4%, respectively (P = 0.27). In older and younger patients, the 6-month mortality rate was 4 and 2%, respectively (P = 0.16), and the 1-year mortality rate was 10 and 3%, respectively (P = 0.001). The propensity score-adjusted odds ratio of 1-year mortality with the group of younger patients as a reference was 2.04 (95% confidence interval: 0.77-5.40; P = 0.15) for older patients. Freedom from 1-year reoperation did not differ significantly between age groups. Data demonstrate excellent postoperative mortality rates in older patients undergoing MV repair with or without TV repair. Consequently, even in older patients with numerous comorbidities, MV repair should be considered a suitable surgical method. © The Author 2014. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.

Association Between Increased Vascular Density and Loss of Protective RAS in Early-Stage NPDR

NASA Technical Reports Server (NTRS)

Radhakrishnan, Krishnan; Raghunandan, Sneha; Vyas, Ruchi J.; Vu, Amanda C.; Bryant, Douglas; Yaqian, Duan; Knecht, Brenda E.; Grant, Maria B.; Chalam, K . V.; Parsons-Wingerter, Patricia

2016-01-01

Our hypothesis predicts that retinal blood vessels increase in density during early-stage progression to moderate nonproliferative diabetic retinopathy (NPDR). The prevailing paradigm of NPDR progression is that vessels drop out prior to abnormal, vision-impairing regrowth at late-stage proliferative diabetic retinopathy (DR). However, surprising results for our previous preliminary study 1 with NASA's VESsel GENeration Analysis (VESGEN) software showed that vessels proliferated considerably during moderate NPDR compared to drop out at both mild and severe NPDR. Validation of our hypothesis will support development of successful early-stage regenerative therapies such as vascular repair by circulating angiogenic cells (CACs). The renin-angiotensin system (RAS)is implicated in the pathogenesis of DR and in the function of CACs, a critical bone marrow-derived population that is instrumental in vascular repair.

Repair of a mandibular defect with a free vascularized coccygeal vertebra transfer in a dog.

PubMed

Yeh, L S; Hou, S M

1994-01-01

Bilateral mandibular defects in a male mongrel dog were repaired. On the left side, a free vascularized coccygeal bone graft that included the median caudal artery and caudal vein was used to correct the defect. On the right side, the defect was bridged with a bone plate and screws. For further immobilization, the muzzle was temporarily taped for 3 weeks and a pharyngostomy tube was used for nutritional support. The dog was able to eat dry commercial food satisfactorily within 2 months of surgery despite mild malocclusion. Radiographs taken 2 months and 18 months postoperatively showed bony union with graft hypertrophy in the left mandible, whereas the right mandibular defect showed protracted nonunion. The results indicate that vascularized coccygeal vertebra transfer provides an alternative for the management of canine mandibular defects.

[Progress of Masquelet technique to repair bone defect].

PubMed

Yin, Qudong; Sun, Zhenzhong; Gu, Sanjun

2013-10-01

To summarize the progress of Masquelet technique to repair bone defect. The recent literature concerning the application of Masquelet technique to repair bone defect was extensively reviewed and summarized. Masquelet technique involves a two-step procedure. First, bone cement is used to fill the bone defect after a thorough debridement, and an induced membrane structure surrounding the spacer formed; then the bone cement is removed after 6-8 weeks, and rich cancellous bone is implanted into the induced membrane. Massive cortical bone defect is repaired by new bone forming and consolidation. Experiments show that the induced membrane has vascular system and is also rich in vascular endothelial growth factor, transforming growth factor beta1, bone morphogenetic protein 2, and bone progenitor cells, so it has osteoinductive property; satisfactory results have been achieved in clinical application of almost all parts of defects, various types of bone defect and massive defect up to 25 cm long. Compared with other repair methods, Masquelet technique has the advantages of reliable effect, easy to operate, few complications, low requirements for recipient site, and wide application. Masquelet technique is an effective method to repair bone defect and is suitable for various types of bone defect, especially for bone defects caused by infection and tumor resection.

Origins of bone repair in the armour of fossil fish: response to a deep wound by cells depositing dentine instead of dermal bone.

PubMed

Johanson, Zerina; Smith, Moya; Kearsley, Anton; Pilecki, Peter; Mark-Kurik, Elga; Howard, Charles

2013-10-23

The outer armour of fossil jawless fishes (Heterostraci) is, predominantly, a bone with a superficial ornament of dentine tubercles surrounded by pores leading to flask-shaped crypts (ampullae). However, despite the extensive bone present in these early dermal skeletons, damage was repaired almost exclusively with dentine. Consolidation of bone, by dentine invading and filling the vascular spaces, was previously recognized in Psammolepis and other heterostracans but was associated with ageing and dermal shield wear (reparative). Here, we describe wound repair by deposition of dentine directly onto a bony scaffold of fragmented bone. An extensive wound response occurred from massive deposition of dentine (reactionary), traced from tubercle pulp cavities and surrounding ampullae. These structures may provide the cells to make reparative and reactionary dentine, as in mammalian teeth today in response to stimuli (functional wear or damage). We suggest in Psammolepis, repair involved mobilization of these cells in response to a local stimulatory mechanism, for example, predator damage. By comparison, almost no new bone is detected in repair of the Psammolepis shield. Dentine infilling bone vascular tissue spaces of both abraded dentine and wounded bone suggests that recruitment of this process has been evolutionarily conserved over 380 Myr and precedes osteogenic skeletal repair.

Radiation-induced senescence-like phenotype in proliferating and plateau-phase vascular endothelial cells

DOE Office of Scientific and Technical Information (OSTI.GOV)

Igarashi, Kaori; Sakimoto, Ippei; Kataoka, Keiko

The effects of ionizing radiation (IR) on tumor angiogenesis still remain largely unknown. In this study, we found that IR (8 Gy) induces a high-frequency (80-90%) senescence-like phenotype in vascular endothelial cells (ECs) undergoing exponential growth. This finding allowed us to characterize the IR-induced senescence-like (IRSL) phenotype by examining the gene expression profiles and in vitro angiogenic activities of these ECs. The expression levels of genes associated with cell cycle progression and DNA replication were remarkably reduced in the IRSL ECs. Additionally, the in vitro invasion and migration activities of these cells through Matrigel were significantly suppressed. We also foundmore » that confluent ECs exhibited a high-frequency IRSL phenotype when they were replated immediately after irradiation, whereas incubation in plateau-phase conditions reduced the induction of this phenotype and enhanced colony formation. The kinetics of DNA double-strand break repair, which showed a faster time course in confluent ECs than in growing ECs, may contribute to the protective mechanism associated with the IRSL phenotype. These results imply that the IRSL phenotype may be important for determining the angiogenic activity of ECs following irradiation. The present study should contribute to the understanding of the effects of IR on tumor angiogenesis.« less

Applications of the Amplatzer Vascular Plug to various vascular lesions

PubMed Central

Güneyli, Serkan; Çınar, Celal; Bozkaya, Halil; Parıldar, Mustafa; Oran, İsmail

2014-01-01

The Amplatzer® Vascular Plug (AVP) can be used to embolize medium-to-large high-flow vessels in various locations. Between 2009 and 2012, 41 AVPs (device size, 6–22 mm in diameter) were used to achieve occlusion in 31 patients (24 males, seven females) aged 9–92 years (mean age, 54.5 years). The locations and indications for embolotherapy were as follows: internal iliac artery embolization before stent-graft repair for aorto-iliac (n=6) and common iliac artery (n=3) aneurysms, subclavian artery embolization before stent-graft repair for thoracic aorta (n=3) and arcus aorta (n=1) aneurysms, brachiocephalic trunk embolization before stent-graft repair for a thoracic aorta aneurysm (n=1), embolization of aneurysms and pseudoaneurysms (n=5), embolization for carotid blow-out syndrome (n=3), closure of arteriovenous fistula (n=8), and closure of a portosystemic fistula (n=1). Of the 41 AVPs, 30 were AVP 2 and 11 were AVP 4. The mean follow-up duration was 4.7 months (range, 1–24 months). During follow-up, there was one migration, one insufficient embolization, and one recanalization. The remaining vascular lesions were successfully excluded from the circulation. The AVP, which can be used in a wide spectrum of pathologies, is easy to use and causes few complications. This essay presents our experience with the AVP. PMID:24047719

Risk stratification for the development of respiratory adverse events following vascular surgery using the Society of Vascular Surgery's Vascular Quality Initiative.

PubMed

Genovese, Elizabeth A; Fish, Larry; Chaer, Rabih A; Makaroun, Michel S; Baril, Donald T

2017-02-01

Postoperative respiratory adverse events (RAEs) are associated with high rates of morbidity and mortality in general surgery, however, little is known about these complications in the vascular surgery population, a frail subset with multiple comorbidities. The objective of this study was to describe the contemporary incidence of RAEs in vascular surgery patients, the risk factors for this complication, and the overall impact of RAEs on patient outcomes. The Vascular Quality Initiative was queried (2003-2014) for patients who underwent endovascular abdominal aortic repair, open abdominal aortic aneurysm repair, thoracic endovascular aortic repair, suprainguinal bypass, or infrainguinal bypass. A mixed-effects logistic regression model determined the independent risk factors for RAEs. Using a random 85% of the cohort, a risk prediction score for RAEs was created, and the score was validated using the remaining 15% of the cohort, comparing the predicted to the actual incidence of RAE and determining the area under the receiver operating characteristic curve. The independent risk of in-hospital mortality and discharge to a nursing facility associated with RAEs was determined using a mixed-effects logistic regression to control for baseline patient characteristics, operative variables, and other postoperative adverse events. The cohort consisted of 52,562 patients, with a 5.4% incidence of RAEs. The highest rates of RAEs were seen in current smokers (6.1%), recent acute myocardial infarction (10.1%), symptomatic congestive heart failure (9.9%), chronic obstructive pulmonary disease requiring oxygen therapy (11.0%), urgent and emergent procedures (6.4% and 25.9%, respectively), open abdominal aortic aneurysm repairs (17.6%), in situ suprainguinal bypasses (9.68%), and thoracic endovascular aortic repairs (9.6%). The variables included in the risk prediction score were age, body mass index, smoking status, congestive heart failure severity, chronic obstructive pulmonary disease severity, degree of renal insufficiency, ambulatory status, transfer status, urgency, and operative type. The predicted compared with the actual RAE incidence were highly correlated, with a correlation coefficient of 0.943 (P < .0001) and a c-statistic = 0.818. RAEs had a significantly higher rates of in-hospital mortality (25.4% vs 1.2%; P < .0001; adjusted odds ratio, 5.85; P < .0001), and discharge to a nursing facility (57.8% vs 19.0%; P < .0001; adjusted odds ratio, 3.14; P < .0001). RAEs are frequent and one of the strongest risk factors for in-hospital mortality and inability to be discharged home. Our risk prediction score accurately stratifies patients based on key demographics, comorbidities, presentation, and operative type that can be used to guide patient counseling, preoperative optimization, and postoperative management. Furthermore, it may be useful in developing quality benchmarks for RAE following major vascular surgery. Copyright © 2016 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.

CTP synthase 1, a smooth muscle-sensitive therapeutic target for effective vascular repair

PubMed Central

Tang, Rui; Cui, Xiao-Bing; Wang, Jia-Ning; Chen, Shi-You

2013-01-01

Objective Vascular remodeling due to smooth muscle cell (SMC) proliferation and neointima formation is a major medical challenge in cardiovascular intervention. However, anti-neointima drugs often indistinguishably block re-endothelialization, an essential step toward successful vascular repair, due to their non-specific effect on endothelial cells (EC). The objective of this study was to identify a therapeutic target that differentially regulates SMC and EC proliferation. Approach and Results By using both rat balloon-injury and mouse wire-injury models, we identified CTP synthase (CTPS) as one of the potential targets that may be used for developing therapeutics for treating neointima-related disorders. CTPS1 was induced in proliferative SMCs in vitro and neointima SMCs in vivo. Blockade of CTPS1 expression by small hairpin RNA or activity by cyclopentenyl cytosine suppressed SMC proliferation and neointima formation. Surprisingly, cyclopentenyl cytosine had much less effect on EC proliferation. Of importance, blockade of CTPS1 in vivo sustained the re-endothelialization due to induction of CTP synthesis salvage pathway enzymes nucleoside diphosphate kinase A and B in ECs. Diphosphate kinase B appeared to preserve EC proliferation via utilization of extracellular cytidine to synthesize CTP. Indeed, blockade of both CTPS1 and diphosphate kinase B suppressed EC proliferation in vitro and the re-endothelization in vivo. Conclusions Our study uncovered a fundamental difference in CTP biosynthesis between SMCs and ECs during vascular remodeling, which provided a novel strategy by using cyclopentenyl cytosine or other CTPS1 inhibitors to selectively block SMC proliferation without disturbing or even promoting re-endothelialization for effective vascular repair following injury. PMID:24008161

Iatrogenic popliteal artery injury in non arthroplasty knee surgery.

PubMed

Bernhoff, K; Björck, M

2015-02-01

We have investigated iatrogenic popliteal artery injuries (PAI) during non arthroplasty knee surgery regarding mechanism of injury, treatment and outcomes, and to identify successful strategies when injury occurs. In all, 21 iatrogenic popliteal artery injuries in 21 patients during knee surgery other than knee arthroplasty were identified from the Swedish Vascular Registry (Swedvasc) between 1987 and 2011. Prospective registry data were supplemented with case-records, including long-term follow-up. In total, 13 patients suffered PAI during elective surgery and eight during urgent surgery such as fracture fixation or tumour resection. Nine injuries were detected intra-operatively, five within 12 to 48 hours and seven > 48 hours post-operatively (two days to 23 years). There were 19 open vascular and two endovascular surgical repairs. Two patients died within six months of surgery. One patient required amputation. Only six patients had a complete recovery of whom had the vascular injury detected at time of injury and repaired by a vascular surgeon. Patients sustaining vascular injury during elective procedures are more likely to litigate (p = 0.029). We conclude that outcomes are poorer when there is a delay of diagnosis and treatment, and that orthopaedic surgeons should develop strategies to detect PAI early and ensure rapid access to vascular surgical support. ©2015 The British Editorial Society of Bone & Joint Surgery.

Effect of low-intensity whole-body vibration on bone defect repair and associated vascularization in mice.

PubMed

Matsumoto, Takeshi; Goto, Daichi

2017-12-01

Low-intensity whole-body vibration (LIWBV) may stimulate bone healing, but the involvement of vascular ingrowth, which is essential for bone regeneration, has not been well examined. We thus investigated the LIWBV effect on vascularization during early-stage bone healing. Mice aged 13 weeks were subjected to cortical drilling on tibial bone. Two days after surgery (day 0), mice were exposed daily to sine-wave LIWBV at 30 Hz and 0.1 g peak-to-peak acceleration for 20 min/day (Vib) or were sham-treated (sham). Following vascular casting with a zirconium-based contrast agent on days 6, 9, or 12 and sacrifice, vascular and bone images were obtained by K-edge subtraction micro-CT using synchrotron lights. Bone regeneration advanced more in the Vib group from days 9 to 12. The vascular volume fraction decreased from days 6 to 9 in both groups; however, from days 9 to 12, it was increased in shams, while it stabilized in the Vib group. The vascular volume fraction tended to be or was smaller in the Vib group on days 6 and 12. The vessel number density was higher on day 9 but lower on day 12 in the Vib group. These results suggest that the LIWBV-promoted bone repair is associated with the modulation of vascularization, but additional studies are needed to determine the causality of this association.

Neurotrophin-3 Induces BMP-2 and VEGF Activities and Promotes the Bony Repair of Injured Growth Plate Cartilage and Bone in Rats.

PubMed

Su, Yu-Wen; Chung, Rosa; Ruan, Chun-Sheng; Chim, Shek Man; Kuek, Vincent; Dwivedi, Prem P; Hassanshahi, Mohammadhossein; Chen, Ke-Ming; Xie, Yangli; Chen, Lin; Foster, Bruce K; Rosen, Vicki; Zhou, Xin-Fu; Xu, Jiake; Xian, Cory J

2016-06-01

Injured growth plate is often repaired by bony tissue causing bone growth defects, for which the mechanisms remain unclear. Because neurotrophins have been implicated in bone fracture repair, here we investigated their potential roles in growth plate bony repair in rats. After a drill-hole injury was made in the tibial growth plate and bone, increased injury site mRNA expression was observed for neurotrophins NGF, BDNF, NT-3, and NT-4 and their Trk receptors. NT-3 and its receptor TrkC showed the highest induction. NT-3 was localized to repairing cells, whereas TrkC was observed in stromal cells, osteoblasts, and blood vessel cells at the injury site. Moreover, systemic NT-3 immunoneutralization reduced bone volume at injury sites and also reduced vascularization at the injured growth plate, whereas recombinant NT-3 treatment promoted bony repair with elevated levels of mRNA for osteogenic markers and bone morphogenetic protein (BMP-2) and increased vascularization and mRNA for vascular endothelial growth factor (VEGF) and endothelial cell marker CD31 at the injured growth plate. When examined in vitro, NT-3 promoted osteogenesis in rat bone marrow stromal cells, induced Erk1/2 and Akt phosphorylation, and enhanced expression of BMPs (particularly BMP-2) and VEGF in the mineralizing cells. It also induced CD31 and VEGF mRNA in rat primary endothelial cell culture. BMP activity appears critical for NT-3 osteogenic effect in vitro because it can be almost completely abrogated by co-addition of the BMP inhibitor noggin. Consistent with its angiogenic effect in vivo, NT-3 promoted angiogenesis in metatarsal bone explants, an effect abolished by co-treatment with anti-VEGF. This study suggests that NT-3 may be an osteogenic and angiogenic factor upstream of BMP-2 and VEGF in bony repair, and further studies are required to investigate whether NT-3 may be a potential target for preventing growth plate faulty bony repair or for promoting bone fracture healing. © 2016 American Society for Bone and Mineral Research. © 2016 American Society for Bone and Mineral Research.

National trends in utilization and outcome of thoracic endovascular aortic repair for traumatic thoracic aortic injuries.

PubMed

Ultee, Klaas H J; Soden, Peter A; Chien, Victor; Bensley, Rodney P; Zettervall, Sara L; Verhagen, Hence J M; Schermerhorn, Marc L

2016-05-01

Endovascular repair of traumatic thoracic aortic injuries (TTAI) is an alternative to conventional open surgical repair. Single-institution studies have shown a survival benefit with thoracic endovascular aortic repair (TEVAR), but whether this is being realized nationally is not clear. The purpose of our study was to document trends in the increase in use of TEVAR and its effect on outcomes of TTAI nationally. Patients admitted with a TTAI between 2005 and 2011 were identified in the National Inpatient Sample. Patients were grouped by treatment into TEVAR, open repair, or nonoperative management. Primary outcomes were relative use over time and in-hospital mortality. Secondary outcomes included postoperative complications and length of stay. Multivariable logistic regression was performed to identify independent predictors of mortality. Included were 8384 patients, with 2492 (29.7%) undergoing TEVAR, 848 (10.1%) open repair, and 5044 (60.2%) managed nonoperatively. TEVAR became the dominant treatment option for TTAI during the study period, starting at 6.5% of interventions in 2005 and accounting for 86.5% of interventions in 2011 (P < .001). Nonoperative management declined concurrently with the widespread of adoption TEVAR (79.8% to 53.7%; P < .001). In-hospital mortality after TEVAR decreased during the study period from 33.3% in 2005 to 4.9% in 2011 (P < .001), and an increase in mortality was observed for open repair from 13.9% to 19.2% (P < .001). Procedural mortality (TEVAR or open repair) decreased from 14.9% to 6.7% (P < .001), and mortality after any TTAI admission declined from 24.5% to 13.3% during the study period (P < .001). In addition to lower mortality, TEVAR was followed by fewer cardiac complications (4.1% vs 8.5%; P < .001), respiratory complications (47.5% vs 54.8%; P < .001), and shorter length of stay (18.4 vs 20.2 days; P = .012) compared with open repair. In adjusted mortality analyses, open repair proved to be associated with twice the mortality risk compared with TEVAR (odds ratio, 2.1; 95% confidence interval, 1.6-2.7), and nonoperative management was associated with more than a fourfold increase in mortality (odds ratio, 4.5; 95% confidence interval, 3.8-5.3). TEVAR is now the dominant surgical approach in TTAI, with substantial perioperative morbidity and mortality benefits over open aortic repair. Overall mortality after admission for TTAI has declined, which is most likely the result of the replacement of open repair by TEVAR as well as the broadened eligibility for operative repair. Copyright © 2016 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.

Comparison of implant cost and surgical time in arthroscopic transosseous and transosseous equivalent rotator cuff repair.

PubMed

Black, Eric M; Austin, Luke S; Narzikul, Alexa; Seidl, Adam J; Martens, Kelly; Lazarus, Mark D

2016-09-01

We investigated the cost savings associated with arthroscopic transosseous (anchorless) double-row rotator cuff repair compared with double-row anchored (transosseous-equivalent [TOE]) repair. All patients undergoing double-row arthroscopic rotator cuff repair from 2009 to 2012 by a single surgeon were eligible for inclusion. The study included 2 consecutive series of patients undergoing anchorless or TOE repair. Excluded from the study were revision repairs, subscapularis repairs, patients with poor tendon quality or excursion requiring medialized repair, and partial repairs. Rotator cuff implant costs (paid by the institution) and surgical times were compared between the 2 groups, controlling for rotator cuff tear size and additional procedures performed. The study included 344 patients, 178 with TOE repairs and 166 with anchorless repairs. Average implant cost for TOE repairs was $1014.10 ($813.00 for small, $946.67 for medium, $1104.56 for large, and $1507.29 for massive tears). This was significantly more expensive compared with anchorless repairs, which averaged $678.05 ($659.75 for small, $671.39 for medium, $695.55 for large, and $716.00 for massive tears). Average total operative time in TOE and anchorless groups was not significantly different (99 vs. 98 minutes). There was larger (although not statistically significant) case time variation in the TOE group. Compared with TOE repair, anchorless rotator cuff repair provides substantial implant-related cost savings, with no significant differences in surgical time for medium and large rotator cuff tears. Case time for TOE repair varied more with extremes in tear size. Copyright © 2016 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.

Brain-peripheral cell crosstalk in white matter damage and repair.

PubMed

Hayakawa, Kazuhide; Lo, Eng H

2016-05-01

White matter damage is an important part of cerebrovascular disease and may be a significant contributing factor in vascular mechanisms of cognitive dysfunction and dementia. It is well accepted that white matter homeostasis involves multifactorial interactions between all cells in the axon-glia-vascular unit. But more recently, it has been proposed that beyond cell-cell signaling within the brain per se, dynamic crosstalk between brain and systemic responses such as circulating immune cells and stem/progenitor cells may also be important. In this review, we explore the hypothesis that peripheral cells contribute to damage and repair after white matter damage. Depending on timing, phenotype and context, monocyte/macrophage can possess both detrimental and beneficial effects on oligodendrogenesis and white matter remodeling. Endothelial progenitor cells (EPCs) can be activated after CNS injury and the response may also influence white matter repair process. These emerging findings support the hypothesis that peripheral-derived cells can be both detrimental or beneficial in white matter pathology in cerebrovascular disease. This article is part of a Special Issue entitled: Vascular Contributions to Cognitive Impairment and Dementia, edited by M. Paul Murphy, Roderick A. Corriveau and Donna M. Wilcock. Copyright © 2015 Elsevier B.V. All rights reserved.

X-ray irradiation has positive effects for the recovery of peripheral nerve injury maybe through the vascular smooth muscle contraction signaling pathway.

PubMed

Jiang, Bo; Zhang, Yong; She, Chang; Zhao, Jiaju; Zhou, Kailong; Zuo, Zhicheng; Zhou, Xiaozhong; Wang, Peiji; Dong, Qirong

2017-09-01

It is well known that moderate to high doses of ionizing radiation have a toxic effect on the organism. However, there are few experimental studies on the mechanisms of LDR ionizing radiation on nerve regeneration after peripheral nerve injury. We established the rats' peripheral nerve injury model via repaired Peripheral nerve injury nerve, vascular endothelial growth factor a and Growth associated protein-43 were detected from different treatment groups. We performed transcriptome sequencing focusing on investigating the differentially expressed genes and gene functions between the control group and 1Gy group. Sequencing was done by using high-throughput RNA-sequencing (RNA-seq) technologies. The results showed the 1Gy group to be the most effective promoting repair. RNA-sequencing identified 619 differently expressed genes between control and treated groups. A Gene Ontology analysis of the differentially expressed genes revealed enrichment in the functional pathways. Among them, candidate genes associated with nerve repair were identified. Pathways involved in cell-substrate adhesion, vascular smooth muscle contraction and cell adhesion molecule signaling may be involved in recovery from peripheral nerve injury. Copyright © 2017. Published by Elsevier B.V.

Molecular Pathways of Notch Signaling in Vascular Smooth Muscle Cells

PubMed Central

Boucher, Joshua; Gridley, Thomas; Liaw, Lucy

2012-01-01

Notch signaling in the cardiovascular system is important during embryonic development, vascular repair of injury, and vascular pathology in humans. The vascular smooth muscle cell (VSMC) expresses multiple Notch receptors throughout its life cycle, and responds to Notch ligands as a regulatory mechanism of differentiation, recruitment to growing vessels, and maturation. The goal of this review is to provide an overview of the current understanding of the molecular basis for Notch regulation of VSMC phenotype. Further, we will explore Notch interaction with other signaling pathways important in VSMC. PMID:22509166

Percutaneous Tricuspid Valve Regurgitation Repair With the MitraClip Device Using an Edge-to-Edge Bicuspidization Technique.

PubMed

Gafoor, Sameer; Petrescu, O Madalina; Lehr, Eric J; Puls, Charles; Zhang, Ming; Petersen, John L; Olsen, John V; Penev, Irina; Agrawal, Mayank; Sharma, Rahul; Barnhart, Glenn

2017-03-01

Patients who present with both severe mitral and tricuspid regurgitation who are symptomatic despite optimal medical therapy and at prohibitive risk for surgery pose a significant therapeutic challenge. The MitraClip device (Abbott Vascular) is approved for percutaneous mitral valve repair in high-risk and non-operative patients, and has also been used for tricuspid valve repair. Imaging support for percutaneous edge-to-edge tricuspid valve repair has not been reported and is a vital part of the procedure. Here, we present a periprocedural imaging strategy for percutaneous tricuspid valve repair with the MitraClip device using a bicuspidization technique.

Umbilical hernia repair in pregnant patients: review of the American College of Surgeons National Surgical Quality Improvement Program.

PubMed

Haskins, I N; Rosen, M J; Prabhu, A S; Amdur, R L; Rosenblatt, S; Brody, F; Krpata, D M

2017-10-01

Umbilical hernias present commonly during pregnancy secondary to increased intra-abdominal pressure. As a result, umbilical hernia incarceration or strangulation may affect pregnant females. The purpose of this study is to detail the operative management and 30-day outcomes of umbilical hernias in pregnant patients using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP). All female patients undergoing umbilical hernia repair during pregnancy were identified within the ACS-NSQIP. Preoperative patient variables, intraoperative variables, and 30-day patient morbidity and mortality outcomes were investigated using a variety of statistical tests. A total of 126 pregnant patients underwent umbilical hernia repair from 2005 to 2014; 73 (58%) had incarceration or strangulation at the time of surgical intervention. The majority of patients (95%) underwent open umbilical hernia repair. Superficial surgical site infection was the most common morbidity in patients undergoing open umbilical hernia repair. Based on review of the ACS-NSQIP database, the incidence of umbilical hernia repair during pregnancy is very low; however, the majority of patients required repair for incarceration of strangulation. When symptoms develop, these hernias can be repaired with minimal 30-day morbidity to the mother. Additional studies are needed to determine the long-term recurrence rate of umbilical hernia repairs performed in pregnant patients and the effects of surgical intervention and approach on the fetus.

Combined flaps based on the superficial temporal vascular system for reconstruction of facial defects.

PubMed

Zhou, Renpeng; Wang, Chen; Qian, Yunliang; Wang, Danru

2015-09-01

Facial defects are multicomponent deficiencies rather than simple soft-tissue defects. Based on different branches of the superficial temporal vascular system, various tissue components can be obtained to reconstruct facial defects individually. From January 2004 to December 2013, 31 patients underwent reconstruction of facial defects with composite flaps based on the superficial temporal vascular system. Twenty cases of nasal defects were repaired with skin and cartilage components, six cases of facial defects were treated with double island flaps of the skin and fascia, three patients underwent eyebrow and lower eyelid reconstruction with hairy and hairless flaps simultaneously, and two patients underwent soft-tissue repair with auricular combined flaps and cranial bone grafts. All flaps survived completely. Donor-site morbidity is minimal, closed primarily. Donor areas healed with acceptable cosmetic results. The final outcome was satisfactory. Combined flaps based on the superficial temporal vascular system are a useful and versatile option in facial soft-tissue reconstruction. Copyright © 2015 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.

Vascular Ageing and Exercise: Focus on Cellular Reparative Processes.

PubMed

Ross, Mark D; Malone, Eva; Florida-James, Geraint

2016-01-01

Ageing is associated with an increased risk of developing noncommunicable diseases (NCDs), such as diabetes and cardiovascular disease (CVD). The increased risk can be attributable to increased prolonged exposure to oxidative stress. Often, CVD is preceded by endothelial dysfunction, which carries with it a proatherothrombotic phenotype. Endothelial senescence and reduced production and release of nitric oxide (NO) are associated with "vascular ageing" and are often accompanied by a reduced ability for the body to repair vascular damage, termed "reendothelialization." Exercise has been repeatedly shown to confer protection against CVD and diabetes risk and incidence. Regular exercise promotes endothelial function and can prevent endothelial senescence, often through a reduction in oxidative stress. Recently, endothelial precursors, endothelial progenitor cells (EPC), have been shown to repair damaged endothelium, and reduced circulating number and/or function of these cells is associated with ageing. Exercise can modulate both number and function of these cells to promote endothelial homeostasis. In this review we look at the effects of advancing age on the endothelium and these endothelial precursors and how exercise appears to offset this "vascular ageing" process.

Current concepts in repair of extremity venous injury.

PubMed

Williams, Timothy K; Clouse, W Darrin

2016-04-01

Extremity venous injury management remains controversial. The purpose of this communication is to offer perspective as well as experiential and technical insight into extremity venous injury repair. Available literature is reviewed and discussed. Historical context is provided. Indication, the decision process for repair, including technical conduct, is delineated. In particular, the authors' experiences in both civilian and wartime injury are used for perspective. Extremity venous injury repair was championed within data from the Vietnam Vascular Registry. However, patterns of extremity venous injury differ between combat and civilian settings. Since Vietnam, civilian descriptive series opine the benefits and potential complications associated with both venous injury repair and ligation. These surround extremity edema, chronic venous insufficiency, thromboembolism, and limb loss. Whereas no clear superiority in either approach has been identified to date, there appears to be no increased risk of pulmonary embolism or chronic venous changes with repair. Newer data from the wars in Iraq and Afghanistan and meta-analysis have reinforced this and also have suggested limb salvage benefit for extremity venous repair in combined arterial and venous injuries in modern settings. The patient's physiologic state and associated injury drive five triage categories suggesting vein injury management. Vein repair thrombosis occurs in a significant proportion, yet many recanalize and possibly have a positive impact on limb venous return. Further, early decompression favors reduced blood loss, acute edema, and inflammation, supporting collateral development. Large soft tissue injury minimizing collateral capacity increases the importance of repair. Constructs of repair are varied with modest differences in patency. Venous shunting is feasible, but specific roles remain nebulous. An aggressive posture toward extremity venous injury repair seems justified today because of the likely role in reducing venous hypertensive sequelae as well as a potential role in limb salvage. Appropriate triage selection for extremity vein repair is essential. Copyright © 2016 Society for Vascular Surgery. All rights reserved.

Direct Leukocyte Migration across Pulmonary Arterioles and Venules into the Perivascular Interstitium of Murine Lungs during Bleomycin Injury and Repair

PubMed Central

Wang, Ping M.; Kachel, Diane L.; Cesta, Mark F.; Martin, William J.

2011-01-01

During acute lung injury and repair, leukocytes are thought to enter the lung primarily across alveolar capillaries and postcapillary venules. We hypothesized that leukocytes also migrate across pulmonary arterioles and venules, which serve as alternative sites for leukocyte influx into the lung during acute lung injury and repair. Lung sections from C57BL/6J mice up to 14 days after intratracheal bleomycin (3.33 U/kg) or saline instillation were assessed by light, fluorescence, confocal, and transmission electron microscopy for evidence of inflammatory cell sequestration and transmigration at these sites. After bleomycin treatment, large numbers of leukocytes (including neutrophils, eosinophils, and monocytes) were present in the vascular lumina and in perivascular interstitia of pulmonary arterioles and venules, as well as within the vascular walls. Leukocytes were observed within well-defined pathways in arteriolar walls and much less structured pathways in venular walls, apparently in the process of transmigration. Intercellular adhesion molecule-1 (ICAM-1) and vascular cell adhesion molecule-1 (VCAM-1) were expressed at sites of leukocyte interaction with the luminal surface, especially in arterioles. Leukocytes appeared to exit from the vessels near collagen fibers into the perivascular interstitium. Results indicate that leukocytes can directly migrate across arteriolar and venular walls into the perivascular interstitium, which may represent an important but under-recognized pathway for leukocyte influx into the lung during injury and repair. PMID:21641381

Immediate costs of mini-open versus arthroscopic rotator cuff repair in an Asian population.

PubMed

Hui, Yik Jing; Teo, Alex Quok An; Sharma, Siddharth; Tan, Bryan Hsi Ming; Kumar, V Prem

2017-01-01

While there has been increasing interest in minimally invasive surgery, the expenses incurred by patients undergoing this form of surgery have not been comprehensively studied. The authors compared the costs borne by patients undergoing arthroscopic rotator cuff repair with the standard mini-open repair at a tertiary hospital in an Asian population. This was a retrospective cohort study. The authors studied the inpatient hospital bills of patients following rotator cuff tear repair between January 2010 and October 2014 via the hospital electronic medical records system. 148 patients had arthroscopic repair and 78 had mini-open repair. The cost of implants, consumables, and the total cost of hospitalization were analyzed. Operative times and length of stay for both procedures were also studied. Constant scores and American Shoulder Elbow Scores (ASES) were recorded preoperatively and at 1 year postoperatively. Three fellowship-trained surgeons performed arthroscopic repairs and one performed the mini-open repair. The cost of implants and consumables was significantly higher with arthroscopic repair. The duration of surgery was also significantly longer with that technique. There was no difference in length of stay between the two techniques. There was also no difference in Constant scores or ASES scores, both preoperatively and at 1 year postoperatively. The immediate costs of mini-open repair of rotator cuff tears are significantly less than that of arthroscopic repair. Most of the difference arises from the cost of implants and consumables. Equivalent functional outcomes from both techniques suggest that mini-open repair may be more cost-effective.

Sports Hernia Treatment

PubMed Central

Economopoulos, Kostas J.; Milewski, Matthew D.; Hanks, John B.; Hart, Joseph M.; Diduch, David R.

2013-01-01

Background: The minimal repair technique for sports hernias repairs only the weak area of the posterior abdominal wall along with decompressing the genitofemoral nerve. This technique has been shown to return athletes to competition rapidly. This study compares the clinical outcomes of the minimal repair technique with the traditional modified Bassini repair. Hypothesis: Athletes undergoing the minimal repair technique for a sports hernia would return to play more rapidly compared with athletes undergoing the traditional modified Bassini repair. Methods: A retrospective study of 28 patients who underwent sports hernia repair at the authors’ institution was performed. Fourteen patients underwent the modified Bassini repair, and a second group of 14 patients underwent the minimal repair technique. The 2 groups were compared with respect to time to return to sport, return to original level of competition, and clinical outcomes. Results: Patients in the minimal repair group returned to sports at a median of 5.6 weeks (range, 4-8 weeks), which was significantly faster compared with the modified Bassini repair group, with a median return of 25.8 weeks (range, 4-112 weeks; P = 0.002). Thirteen of 14 patients in the minimal repair group returned to sports at their previous level, while 9 of 14 patients in the Bassini group were able to return to their previous level of sport (P = 0.01). Two patients in each group had recurrent groin pain. One patient in the minimal repair group underwent revision hernia surgery for recurrent pain, while 1 patient in the Bassini group underwent hip arthroscopy for symptomatic hip pain. Conclusion: The minimal repair technique allows athletes with sports hernias to return to play faster than patients treated with the modified Bassini. PMID:24427419

Redo thoracic endovascular aortic repair due to endoleak with celiac artery snorkeling.

PubMed

Planer, David; Bliagos, Dimitrios; Gray, William A

2011-10-01

Reintervention due to endoleak of aortic endograft repair is often challenging. Herein, we report endovascular endoleak repair in a patient with previous thoracic and abdominal endovascular grafts with extensive coverage of the aorta. The present technique included snorkeling of the celiac trunk to preserve antegrade flow in the celiac artery and to maintain future options for reintervention. Copyright © 2011 Annals of Vascular Surgery Inc. Published by Elsevier Inc. All rights reserved.

Vascular Repair After Menstruation Involves Regulation of Vascular Endothelial Growth Factor-Receptor Phosphorylation by sFLT-1

PubMed Central

Graubert, Michael D.; Asuncion Ortega, Maria; Kessel, Bruce; Mortola, Joseph F.; Iruela-Arispe, M. Luisa

2001-01-01

Regeneration of the endometrium after menstruation requires a rapid and highly organized vascular response. Potential regulators of this process include members of the vascular endothelial growth factor (VEGF) family of proteins and their receptors. Although VEGF expression has been detected in the endometrium, the relationship between VEGF production, receptor activation, and endothelial cell proliferation during the endometrial cycle is poorly understood. To better ascertain the relevance of VEGF family members during postmenstrual repair, we have evaluated ligands, receptors, and activity by receptor phosphorylation in human endometrium throughout the menstrual cycle. We found that VEGF is significantly increased at the onset of menstruation, a result of the additive effects of hypoxia, transforming growth factor-α, and interleukin-1β. Both VEGF receptors, FLT-1 and KDR, followed a similar pattern. However, functional activity of KDR, as determined by phosphorylation studies, revealed activation in the late menstrual and early proliferative phases. The degree of KDR phosphorylation was inversely correlated with the presence of sFLT-1. Endothelial cell proliferation analysis in endometrium showed a peak during the late menstrual and early proliferative phases in concert with the presence of VEGF, VEGF receptor phosphorylation, and decrease of sFLT-1. Together, these results suggest that VEGF receptor activation and the subsequent modulation of sFLT-1 in the late menstrual phase likely contributes to the onset of angiogenesis and endothelial repair in the human endometrium. PMID:11290558

Repair of congenital heart disease with associated pulmonary hypertension in children: what are the minimal investigative procedures? Consensus statement from the Congenital Heart Disease and Pediatric Task Forces, Pulmonary Vascular Research Institute (PVRI).

PubMed

Lopes, Antonio Augusto; Barst, Robyn J; Haworth, Sheila Glennis; Rabinovitch, Marlene; Al Dabbagh, Maha; Del Cerro, Maria Jesus; Ivy, Dunbar; Kashour, Tarek; Kumar, Krishna; Harikrishnan, S; D'Alto, Michele; Thomaz, Ana Maria; Zorzanelli, Leína; Aiello, Vera D; Mocumbi, Ana Olga; Santana, Maria Virginia T; Galal, Ahmed Nasser; Banjar, Hanaa; Tamimi, Omar; Heath, Alexandra; Flores, Patricia C; Diaz, Gabriel; Sandoval, Julio; Kothari, Shyam; Moledina, Shahin; Gonçalves, Rilvani C; Barreto, Alessandra C; Binotto, Maria Angélica; Maia, Margarida; Al Habshan, Fahad; Adatia, Ian

2014-06-01

Standardization of the diagnostic routine for children with congenital heart disease associated with pulmonary arterial hypertension (PAH-CHD) is crucial, in particular since inappropriate assignment to repair of the cardiac lesions (e.g., surgical repair in patients with elevated pulmonary vascular resistance) may be detrimental and associated with poor outcomes. Thus, members of the Congenital Heart Disease and Pediatric Task Forces of the Pulmonary Vascular Research Institute decided to conduct a survey aimed at collecting expert opinion from different institutions in several countries, covering many aspects of the management of PAH-CHD, from clinical recognition to noninvasive and invasive diagnostic procedures and immediate postoperative support. In privileged communities, the vast majority of children with congenital cardiac shunts are now treated early in life, on the basis of noninvasive diagnostic evaluation, and have an uneventful postoperative course, with no residual PAH. However, a small percentage of patients (older at presentation, with extracardiac syndromes or absence of clinical features of increased pulmonary blood flow, thus suggesting elevated pulmonary vascular resistance) remain at a higher risk of complications and unfavorable outcomes. These patients need a more sophisticated diagnostic approach, including invasive procedures. The authors emphasize that decision making regarding operability is based not only on cardiac catheterization data but also on the complete diagnostic picture, which includes the clinical history, physical examination, and all aspects of noninvasive evaluation.

Loss of transcription factor early growth response gene 1 results in impaired endochondral bone repair

PubMed Central

Reumann, Marie K.; Strachna, Olga; Yagerman, Sarah; Torrecilla, Daniel; Kim, Jihye; Doty, Steven B.; Lukashova, Lyudmila; Boskey, Adele L.; Mayer-Kuckuk, Philipp

2011-01-01

Transcription factors that play a role in ossification during development are expected to participate in postnatal fracture repair since the endochondral bone formation that occurs in embryos is recapitulated during fracture repair. However, inherent differences exist between bone development and fracture repair, including a sudden disruption of tissue integrity followed by an inflammatory response. This raises the possibility that repair-specific transcription factors participate in bone healing. Here, we assessed the consequence of loss of early growth response gene 1 (EGR-1) on endochondral bone healing because this transcription factor has been shown to modulate repair in vascularized tissues. Model fractures were created in ribs of wild type (wt) and EGR-1−/− mice. Differences in tissue morphology and composition between these two animal groups were followed over 28 post fracture days (PFDs). In wt mice, bone healing occurred in healing phases characteristic of endochondral bone repair. A similar healing sequence was observed in EGR-1−/− mice but was impaired by alterations. A persistent accumulation of fibrin between the disconnected bones was observed on PFD7 and remained pronounced in the callus on PFD14. Additionally, the PFD14 callus was abnormally enlarged and showed increased deposition of mineralized tissue. Cartilage ossification in the callus was associated with hyper-vascularity and -proliferation. Moreover, cell deposits located in proximity to the callus within skeletal muscle were detected on PFD14. Despite these impairments, repair in EGR-1−/− callus advanced on PFD28, suggesting EGR-1 is not essential for healing. Together, this study provides genetic evidence that EGR-1 is a pleiotropic regulator of endochondral fracture repair. PMID:21726677

Loss of transcription factor early growth response gene 1 results in impaired endochondral bone repair.

PubMed

Reumann, Marie K; Strachna, Olga; Yagerman, Sarah; Torrecilla, Daniel; Kim, Jihye; Doty, Stephen B; Lukashova, Lyudmila; Boskey, Adele L; Mayer-Kuckuk, Philipp

2011-10-01

Transcription factors that play a role in ossification during development are expected to participate in postnatal fracture repair since the endochondral bone formation that occurs in embryos is recapitulated during fracture repair. However, inherent differences exist between bone development and fracture repair, including a sudden disruption of tissue integrity followed by an inflammatory response. This raises the possibility that repair-specific transcription factors participate in bone healing. Here, we assessed the consequence of loss of early growth response gene 1 (EGR-1) on endochondral bone healing because this transcription factor has been shown to modulate repair in vascularized tissues. Model fractures were created in ribs of wild type (wt) and EGR-1(-/-) mice. Differences in tissue morphology and composition between these two animal groups were followed over 28 post fracture days (PFDs). In wt mice, bone healing occurred in healing phases characteristic of endochondral bone repair. A similar healing sequence was observed in EGR-1(-/-) mice but was impaired by alterations. A persistent accumulation of fibrin between the disconnected bones was observed on PFD7 and remained pronounced in the callus on PFD14. Additionally, the PFD14 callus was abnormally enlarged and showed increased deposition of mineralized tissue. Cartilage ossification in the callus was associated with hyper-vascularity and -proliferation. Moreover, cell deposits located in proximity to the callus within skeletal muscle were detected on PFD14. Despite these impairments, repair in EGR-1(-/-) callus advanced on PFD28, suggesting EGR-1 is not essential for healing. Together, this study provides genetic evidence that EGR-1 is a pleiotropic regulator of endochondral fracture repair. Copyright © 2011 Elsevier Inc. All rights reserved.

Does application of moderately concentrated platelet-rich plasma improve clinical and structural outcome after arthroscopic repair of medium-sized to large rotator cuff tear? A randomized controlled trial.

PubMed

Pandey, Vivek; Bandi, Atul; Madi, Sandesh; Agarwal, Lipisha; Acharya, Kiran K V; Maddukuri, Satish; Sambhaji, Charudutt; Willems, W Jaap

2016-08-01

Platelet-rich plasma (PRP) has the potential to improve tendon-bone healing. The evidence is still controversial as to whether PRP application after repair of medium-sized to large cuff tears leads to superior structural and clinical outcome, especially after single-row repair. In a randomized study, 102 patients (PRP group, 52 patients; control group, 50 patients) with medium-sized and large degenerative posterosuperior tears were included for arthroscopic repair with a minimum follow-up of 2 years. Patients were evaluated with clinical scores (visual analog scale score, Constant-Murley score, University of California-Los Angeles score, and American Shoulder and Elbow Surgeons score) and ultrasound to assess retear and vascularity pattern of the cuff. Visual analog scale scores were significantly lower in the PRP group than in controls at 1 month, 3 months, and 6 months but not later. Constant-Murley scores were significantly better in the PRP group compared with controls at 12 and 24 months, whereas University of California-Los Angeles scores were significantly higher in the PRP group at 6 and 12 months (P < .05). The American Shoulder and Elbow Surgeons score in both groups was comparable at all the times. At 24 months, retear in the PRP group (n = 2; 3.8%) was significantly lower than in the control group (n = 10; 20%; P = .01). The retear difference was significant only for large tears (PRP:control group, 1:6; P = .03). Doppler ultrasound examination showed significant vascularity in the PRP group repair site at 3 months postoperatively (P < .05) and in peribursal tissue until 12 months. Application of moderately concentrated PRP improves clinical and structural outcome in large cuff tears. PRP also enhances vascularity around the repair site in the early phase. Copyright © 2016 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.

Endovascular repair of abdominal aortic aneurysms in patients with congenital renal vascular anomalies.

PubMed

Kaplan, D B; Kwon, C C; Marin, M L; Hollier, L H

1999-09-01

The endovascular repair of abdominal aortic aneurysms (AAAs) has been suggested as an alternative to conventional aortic reconstruction. The presence of anomalous renal vascular anatomy frequently necessitates special planning during conventional aortic replacement and may also create unique challenges for endovascular repair. We analyzed our experience with 24 patients with variant renal vascular anatomies who underwent treatment with aortic endografts to determine the safety and efficacy of this technique in this population. During a 6-year period, 204 patients underwent aortic endograft procedures, 24 (11.8%) of whom had variations in renal vascular anatomy. There were 19 men and five women. Each of the 24 patients had variant renal vascular anatomy, which was defined by the presence of multiple renal arteries (n = 32), with or without a renal parenchymal anomaly (horseshoe or solitary pelvic kidney). Twenty patients underwent aneurysm repair with balloon expandable polytetrafluoroethylene grafts, and the remaining patients underwent endograft placement with self-expanding attachment systems. Eighteen patients underwent exclusion and presumed thrombosis of anomalous renal branches to effectively attach the aortic endograft. The decision to sacrifice a supernumerary artery was made on the basis of the vessel size (<3 mm), the absence of coexisting renal insufficiency, and the expectation for successful aneurysm exclusion. The successful exclusion of the AAAs was achieved in all the patients, with the loss of a total of 17 renal artery branches in 12 patients. Small segmental renal infarcts (<20%) were detected in only six of the 12 patients with follow-up computed tomographic scan results, despite angiographic evidence of vessel occlusion at the time of endografting. No evidence of new onset hypertension or changes in antihypertensive medication was seen in this group. No retrograde endoleaks were detected through the excluded renal branches on late follow-up computed tomographic scans. Serum creatinine levels before and after endografting were unchanged after the exclusion of the AAA in all but one patient with multiple renal branches. One patient had a transient rise in serum creatinine level presumed to be caused by contrast nephropathy. On the basis of this experience, we recommend the consideration of endovascular grafting for patients with AAAs and anomalous renal vessels when the main renal vascular anatomy can be preserved and when the loss of only small branches (<3 mm) is necessitated in patients with otherwise normal renal functions.

A registry-based randomized trial comparing radial and femoral approaches in women undergoing percutaneous coronary intervention: the SAFE-PCI for Women (Study of Access Site for Enhancement of PCI for Women) trial.

PubMed

Rao, Sunil V; Hess, Connie N; Barham, Britt; Aberle, Laura H; Anstrom, Kevin J; Patel, Tejan B; Jorgensen, Jesse P; Mazzaferri, Ernest L; Jolly, Sanjit S; Jacobs, Alice; Newby, L Kristin; Gibson, C Michael; Kong, David F; Mehran, Roxana; Waksman, Ron; Gilchrist, Ian C; McCourt, Brian J; Messenger, John C; Peterson, Eric D; Harrington, Robert A; Krucoff, Mitchell W

2014-08-01

This study sought to determine the effect of radial access on outcomes in women undergoing percutaneous coronary intervention (PCI) using a registry-based randomized trial. Women are at increased risk of bleeding and vascular complications after PCI. The role of radial access in women is unclear. Women undergoing cardiac catheterization or PCI were randomized to radial or femoral arterial access. Data from the CathPCI Registry and trial-specific data were merged into a final study database. The primary efficacy endpoint was Bleeding Academic Research Consortium type 2, 3, or 5 bleeding or vascular complications requiring intervention. The primary feasibility endpoint was access site crossover. The primary analysis cohort was the subgroup undergoing PCI; sensitivity analyses were conducted in the total randomized population. The trial was stopped early for a lower than expected event rate. A total of 1,787 women (691 undergoing PCI) were randomized at 60 sites. There was no significant difference in the primary efficacy endpoint between radial or femoral access among women undergoing PCI (radial 1.2% vs. 2.9% femoral, odds ratio [OR]: 0.39; 95% confidence interval [CI]: 0.12 to 1.27); among women undergoing cardiac catheterization or PCI, radial access significantly reduced bleeding and vascular complications (0.6% vs. 1.7%; OR: 0.32; 95% CI: 0.12 to 0.90). Access site crossover was significantly higher among women assigned to radial access (PCI cohort: 6.1% vs. 1.7%; OR: 3.65; 95% CI: 1.45 to 9.17); total randomized cohort: (6.7% vs. 1.9%; OR: 3.70; 95% CI: 2.14 to 6.40). More women preferred radial access. In this pragmatic trial, which was terminated early, the radial approach did not significantly reduce bleeding or vascular complications in women undergoing PCI. Access site crossover occurred more often in women assigned to radial access. (SAFE-PCI for Women; NCT01406236). Copyright © 2014 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

Aortic valve insufficiency in the teenager and young adult: the role of prosthetic valve replacement.

PubMed

Bradley, Scott M

2013-10-01

The contents of this article were presented in the session "Aortic insufficiency in the teenager" at the congenital parallel symposium of the 2013 Society of Thoracic Surgeons (STS) annual meeting. The accompanying articles detail the approaches of aortic valve repair and the Ross procedure.(1,2) The current article focuses on prosthetic valve replacement. For many young patients requiring aortic valve surgery, either aortic valve repair or a Ross procedure provides a good option. The advantages include avoidance of anticoagulation and potential for growth. In other patients, a prosthetic valve is an appropriate alternative. This article discusses the current state of knowledge regarding mechanical and bioprosthetic valve prostheses and their specific advantages relative to valve repair or a Ross procedure. In current practice, young patients requiring aortic valve surgery frequently undergo valve replacement with a prosthetic valve. In STS adult cardiac database, among patients ≤30 years of age undergoing aortic valve surgery, 34% had placement of a mechanical valve, 51% had placement of a bioprosthetic valve, 9% had aortic valve repair, and 2% had a Ross procedure. In the STS congenital database, among patients 12 to 30 years of age undergoing aortic valve surgery, 21% had placement of a mechanical valve, 18% had placement of a bioprosthetic valve, 30% had aortic valve repair, and 24% had a Ross procedure. In the future, the balance among these options may be altered by design improvements in prosthetic valves, alternatives to warfarin, the development of new patch materials for valve repair, and techniques to avoid Ross autograft failure.

Superficial Dorsal Venous Rupture of the Penis: False Penile Fracture That Needs to be Treated as a True Urologic Emergency.

PubMed

Truong, Hong; Ferenczi, Basil; Cleary, Ryan; Healy, Kelly A

2016-11-01

A 38-year-old man with history of repaired penile fracture presented with rapid detumescence, penile pain, and ecchymosis during vaginal sexual intercourse concerning for recurrent fracture. Surgical exploration revealed ruptured superficial dorsal vein of the penis, which was subsequently ligated. Patients with traumatic penile vascular injuries often present with clinical features indistinguishable from a true penile fracture. Gradual detumescence and an absence of characteristic popping sound may indicate a vascular injury but they cannot safely rule out a true penile fracture. Both true and false penile fractures require emergent surgical exploration and repair to prevent long-term complications. Copyright © 2016 Elsevier Inc. All rights reserved.

Concomitant Posterior Hip Dislocation, Ipsilateral Intertrochanteric- and Proximal Tibial- Fractures with Popliteal Artery Injury: A Challenging Trauma Mélange.

PubMed

Chotai, Pranit N; Ebraheim, Nabil A; Hart, Ryan; Wassef, Andrew

2015-11-05

Constellation of ipsilateral posterior hip dislocation, intertrochanteric- and proximal tibial fracture with popliteal artery injury is rare. Management of this presentation is challenging. A motor vehicle accident victim presented with these injuries, but without any initial signs of vascular compromise. Popliteal artery injury was diagnosed intra-operatively and repaired. This was followed by external fixation of tibial fracture, open reduction of dislocated hip and internal fixation of intertrochanteric fracture. Patient regained bilateral complete weight bearing and returned to pre-accident activity level. Apt surgical management including early repair of vascular injury in such a trauma mélange allows for a positive postoperative outcome.

Modified classification and single-stage microsurgical repair of posttraumatic infected massive bone defects in lower extremities.

PubMed

Yang, Yun-fa; Xu, Zhong-he; Zhang, Guang-ming; Wang, Jian-wei; Hu, Si-wang; Hou, Zhi-qi; Xu, Da-chuan

2013-11-01

Posttraumatic infected massive bone defects in lower extremities are difficult to repair because they frequently exhibit massive bone and/or soft tissue defects, serious bone infection, and excessive scar proliferation. This study aimed to determine whether these defects could be classified and repaired at a single stage. A total of 51 cases of posttraumatic infected massive bone defect in lower extremity were included in this study. They were classified into four types on the basis of the conditions of the bone defects, soft tissue defects, and injured limb length, including Type A (without soft tissue defects), Type B (with soft tissue defects of 10 × 20 cm or less), Type C (with soft tissue defects of 10 × 20 cm or more), and Type D (with the limb shortening of 3 cm or more). Four types of single-stage microsurgical repair protocols were planned accordingly and implemented respectively. These protocols included the following: Protocol A, where vascularized fibular graft was implemented for Type A; Protocol B, where vascularized fibular osteoseptocutaneous graft was implemented for Type B; Protocol C, where vascularized fibular graft and anterior lateral thigh flap were used for Type C; and Protocol D, where limb lengthening and Protocols A, B, or C were used for Type D. There were 12, 33, 4, and 2 cases of Types A, B, C, and D, respectively, according to this classification. During the surgery, three cases of planned Protocol B had to be shifted into Protocol C; however, all microsurgical repairs were completed. With reference to Johner-Wruhs evaluation method, the total percentage of excellent and good results was 82.35% after 6 to 41 months of follow-up. It was concluded that posttraumatic massive bone defects could be accurately classified into four types on the basis of the conditions of bone defects, soft tissue coverage, and injured limb length, and successfully repaired with the single-stage repair protocols after thorough debridement. Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

75 FR 9422 - Orthopaedic and Rehabilitation Devices Panel of the Medical Devices Advisory Committee; Notice of...

Federal Register 2010, 2011, 2012, 2013, 2014

2010-03-02

... repair of soft tissue injuries of the medial meniscus. In repairing and reinforcing medial meniscal... zone of the meniscus to provide sufficient vascularization. The CS reinforces soft tissue and provides a resorbable scaffold that is replaced by the patient's own soft tissue. The CS is not a prosthetic...

Trend, Risk Factors, and Costs of Clostridium difficile Infections in Vascular Surgery.

PubMed

Egorova, Natalia N; Siracuse, Jeffrey J; McKinsey, James F; Nowygrod, Roman

2015-01-01

Starting in December 2013, the Hospital Inpatient Quality Reporting Program included Clostridium difficile infection (CDI) rates as a new publically reported quality measure. Our goal was to review the trend, hospital variability in CDI rates, and associated risk factors and costs in vascular surgery. The rates of CDI after major vascular procedures including aortic abdominal aneurysm (AAA) repair, carotid endarterectomy or stenting, lower extremity revascularization (LER), and LE amputation were identified using Nationwide Inpatient Sample database for 2000-2011. Risk factors associated with CDI were analyzed with hierarchical multivariate logistic regression. Extra costs, length of stay (LOS), and mortality were assessed for propensity-matched hospitalizations with and without CDI. During the study period, the rates of CDI after vascular procedures had increased by 74% from 0.6 in 2000 to 1.05% in 2011, whereas the case fatality rate was stable at 9-11%. In 2011, the highest rates were after ruptured aortic abdominal aneurysm (rAAA) repair (3.3%), followed by lower extremity amputations (2.3%) and elective open AAA (1.3%). The rates of CDI increased after all vascular procedures during the 12 years. The highest increase was after endovascular LER (151.8%) and open rAAA repair (135.7%). In 2011, patients who had experienced CDI had median LOS of 15 days (interquartile range, 9-25 days) compared with 8.3 days for matched patients without CDI, in-hospital mortality 9.1% (compared with 5.0%), and $13,471 extra cost per hospitalization. The estimated cost associated with CDI in vascular surgery in the United States was ∼$98 million in 2011. Hospital rates of CDI varied from 0 to 50% with 3.5% of hospitals having infection rates ≥5%. Factors associated with CDI included multiple chronic conditions, female gender, surgery type, emergent and weekend hospitalizations, hospital transfers, and urban locations. Despite potential reduction of infection rates as evidenced by the experience of hospitals with effective interventions, CDI is increasing among vascular surgery patients. It is associated with prolonged LOS, increased mortality, and higher costs. Copyright © 2015 Elsevier Inc. All rights reserved.

Engineering clinically relevant volumes of vascularized bone

PubMed Central

Roux, Brianna M; Cheng, Ming-Huei; Brey, Eric M

2015-01-01

Vascularization remains one of the most important challenges that must be overcome for tissue engineering to be consistently implemented for reconstruction of large volume bone defects. An extensive vascular network is needed for transport of nutrients, waste and progenitor cells required for remodelling and repair. A variety of tissue engineering strategies have been investigated in an attempt to vascularize tissues, including those applying cells, soluble factor delivery strategies, novel design and optimization of bio-active materials, vascular assembly pre-implantation and surgical techniques. However, many of these strategies face substantial barriers that must be overcome prior to their ultimate translation into clinical application. In this review recent progress in engineering vascularized bone will be presented with an emphasis on clinical feasibility. PMID:25877690

Hedgehog and Resident Vascular Stem Cell Fate

PubMed Central

Mooney, Ciaran J.; Hakimjavadi, Roya; Fitzpatrick, Emma; Kennedy, Eimear; Walls, Dermot; Morrow, David; Redmond, Eileen M.; Cahill, Paul A.

2015-01-01

The Hedgehog pathway is a pivotal morphogenic driver during embryonic development and a key regulator of adult stem cell self-renewal. The discovery of resident multipotent vascular stem cells and adventitial progenitors within the vessel wall has transformed our understanding of the origin of medial and neointimal vascular smooth muscle cells (SMCs) during vessel repair in response to injury, lesion formation, and overall disease progression. This review highlights the importance of components of the Hh and Notch signalling pathways within the medial and adventitial regions of adult vessels, their recapitulation following vascular injury and disease progression, and their putative role in the maintenance and differentiation of resident vascular stem cells to vascular lineages from discrete niches within the vessel wall. PMID:26064136

Association Between Increased Vascular Density and Loss of Protective RAS in Early-stage NPDR

NASA Technical Reports Server (NTRS)

Radhakrishnan, Krishnan; Raghunandan, Sneha; Vyas, Ruchi J.; Vu, Amanda C.; Bryant, Douglas; Yaqian, Duan; Knecht, Brenda E.; Grant, Maria B.; Chalam, K. V.; Parsons-Wingerter, Patricia

2016-01-01

Our hypothesis predicts that retinal blood vessels increase in density during early-stage progression to moderate nonproliferative diabetic retinopathy (NPDR). The renin-angiotensin system (RAS) is implicated in the pathogenesis of DR and in the function of circulating angiogenic cells (CACs), a critical bone marrow-derived population that is instrumental in vascular repair.

Effects of PDGF-BB delivery from heparinized collagen sutures on the healing of lacerated chicken flexor tendon in vivo.

PubMed

Younesi, Mousa; Knapik, Derrick M; Cumsky, Jameson; Donmez, Baris Ozgur; He, Ping; Islam, Anowarul; Learn, Greg; McClellan, Philip; Bohl, Michael; Gillespie, Robert J; Akkus, Ozan

2017-11-01

Flexor tendon lacerations are traditionally repaired by using non-absorbable monofilament sutures. Recent investigations have explored to improve the healing process by growth factor delivery from the sutures. However, it is difficult to conjugate growth factors to nylon or other synthetic sutures. This study explores the performance of a novel electrochemically aligned collagen suture in a flexor tendon repair model with and without platelet derived growth factor following complete tendon laceration in vivo. Collagen suture was fabricated via electrochemical alignment process. Heparin was covalently bound to electrochemically aligned collagen sutures (ELAS) to facilitate affinity bound delivery of platelet-derived growth factor-BB (PDGF-BB). Complete laceration of the flexor digitorum profundus in the third digit of the foot was performed in 36 skeletally mature White Leghorn chickens. The left foot was used as the positive control. Animals were randomly divided into three groups: control specimens treated with standard nylon suture (n=12), specimens repaired with heparinated ELAS suture without PDGF-BB (n=12) and specimens repaired with heparinated ELAS suture with affinity bound PDGF-BB (n=12). Specimens were harvested at either 4weeks or 12weeks following tendon repair. Differences between groups were evaluated by the degree of gross tendon excursion, failure load/stress, stiffness/modulus, absorbed energy at failure, elongation/strain at failure. Quantitative histological scoring was performed to assess cellularity and vascularity. Closed flexion angle measurements demonstrated no significant differences in tendon excursion between the study groups at 4 or 12weeks. Biomechanical testing showed that the group treated with PDGF-BB bound heparinated ELAS suture had significantly higher stiffness and failure load (p<0.05) at 12-weeks relative to both heparinated ELAS suture and nylon suture. Similarly, the group treated with PDGF-BB bound suture had significantly higher ultimate tensile strength and Young's modulus (p<0.05) at 12-weeks relative to both ELAS suture and nylon suture. Compared to nylon controls, heparinized ELAS with PDGF-BB improved biomechanics and vascularity during tendon healing by 12-weeks following primary repair. The ability of ELAS to deliver PDGF-BB to the lacerated area of tendon presents investigators with a functional bioinductive platform to improve repair outcomes following flexor tendon repair. A high strength aligned collagen suture was fabricated via linear electrocompaction and heparinized for prolonged delivery of PDFG-BB. When it was used to suture a complete lacerated flexor tendon in a chicken model controlled release of the PDGF-BB improved the strength of treated tendon after 12 weeks compared to tendon sutured with commercial nylon suture. Furthermore, Collagen suture with affinity bound PDGF-BB enhanced the vascularization and remodeling of lacerated tendon when it compare to synthetic nylon suture. Overall, electrocompacted collagen sutures holds potential to improve repair outcome in flexor tendon surgeries by improving repair strength and stiffness, vascularity, and remodeling via sustained delivery of the PDGF-BB. The bioinductive collagen suture introduces a platform for sustained delivery of other growth factors for a wide-array of applications. Copyright © 2017 Acta Materialia Inc. Published by Elsevier Ltd. All rights reserved.

[Repairing of soft tissue defect in leg by free vascularized thoracoumbilical flap with reversed flow].

PubMed

Xu, Y Q; Li, Z Y; Li, J

2000-11-01

To investigate the clinical effect of free vascularized thoracoumbilical flap with reversal flow in repairing the soft tissue defect in leg with tibia exposure. Forty-four casting mould specimens of leg arteries were studied firstly. Then 25 cases with soft tissue defect and tibia exposure in the proximal-middle segment of leg were adopted in this study. Among them, 18 cases had long distance thrombosis of the anterior tibial vessels or posterior tibial vessels due to traumatic lesion. The maximal size of defect was 28 cm x 11 cm and the minimal size of defect was 11 cm x 9 cm. In operation, the thoracoumbilical flap which was based on the inferior epigastric vessels was anastomosed to the distal end of the anterior tibial vessels or posterior tibial vessels. Anterior tibial artery, posterior tibial artery and fibular artery had rich communication branches in foot and ankle. All the flaps survived, the color and cosmetic result of them were good. The free vascularized thoracoumbilical flap with reversed flow is practical in repairing the soft tissue defect of leg with tibia exposure. Either the anterior tibial vessels or the posterior tibial vessels is normal, and the distal end of injured blood vessels is available, this technique can be adopted.

Absence of CD9 reduces endometrial VEGF secretion and impairs uterine repair after parturition

PubMed Central

Kawano, Natsuko; Miyado, Kenji; Yoshii, Noriko; Kanai, Seiya; Saito, Hidekazu; Miyado, Mami; Inagaki, Noboru; Odawara, Yasushi; Hamatani, Toshio; Umezawa, Akihiro

2014-01-01

In mammals, uterine epithelium is remodeled cyclically throughout adult life for pregnancy. Despite the expression of CD9 in the uterine epithelium, its role in maternal reproduction is unclear. Here, we addressed this issue by examining uterine secretions collected from patients undergoing fertility treatment and fertilization-competent Cd9−/− mice expressing CD9-GFP in their eggs (Cd9−/−TG). CD9 in uterine secretions was observed as extracellular matrix-like feature, and its amount of the secretions associated with repeated pregnancy failures. We also found that the litter size of Cd9−/−TG female mice was significantly reduced after their first birth. Severely delayed re-epithelialization of the endometrium was then occurred. Concomitantly, vascular endothelial growth factor (VEGF) was remarkably reduced in the uterine secretions of Cd9−/−TG female mice. These results provide the first evidence that CD9-mediated VEGF secretion plays a role in re-epithelialization of the uterus. PMID:24736431

Muscle atrophy and fatty infiltration after an acute rotator cuff repair in a sheep model

PubMed Central

Luan, Tammy; Liu, Xuhui; Easley, Jeremiah T.; Ravishankar, Bharat; Puttlitz, Christian; Feeley, Brian T.

2015-01-01

Summary Introduction rotator cuff tears (RCTs) are the most common tendon injury seen in orthopedic patients. Muscle atrophy and fatty infiltration of the muscle are crucial factors that dictate the outcome following rotator cuff surgery. Though less studied in humans, rotator cuff muscle fibrosis has been seen in animal models as well and may influence outcomes as well. The purpose of this study was to determine if the rotator cuff would develop muscle changes even in the setting of an acute repair in a sheep model. We hypothesized that fatty infiltration and fibrosis would be present even after an acute repair six months after initial surgery. Methods twelve female adult sheep underwent an acute rotator cuff tear and immediate repair on the right shoulder. The left shoulder served as a control and did not undergo a tear or a repair. Six months following acute rotator cuff repairs, sheep muscles were harvested to study atrophy, fatty infiltration, and fibrosis by histological analysis, western blotting, and reverse transcription polymerase chain reaction (RT-PCR). Results the repair group demonstrated an increase expression of muscle atrophy, fatty infiltration, and fibrosis related genes. Significantly increased adipocytes, muscle fatty infiltration, and collagen deposition was observed in rotator cuff muscles in the tendon repair group compared to the control group. Conclusions rotator cuff muscle undergoes degradation changes including fatty infiltration and fibrosis even after the tendons are repair immediately after rupture. Level of Evidence Basic Science Study. PMID:26261789

Management of mitral regurgitation in Marfan syndrome: Outcomes of valve repair versus replacement and comparison with myxomatous mitral valve disease.

PubMed

Helder, Meghana R K; Schaff, Hartzell V; Dearani, Joseph A; Li, Zhuo; Stulak, John M; Suri, Rakesh M; Connolly, Heidi M

2014-09-01

The study objective was to evaluate patients with Marfan syndrome and mitral valve regurgitation undergoing valve repair or replacement and to compare them with patients undergoing repair for myxomatous mitral valve disease. We reviewed the medical records of consecutive patients with Marfan syndrome treated surgically between March 17, 1960, and September 12, 2011, for mitral regurgitation and performed a subanalysis of those with repairs compared with case-matched patients with myxomatous mitral valve disease who had repairs (March 14, 1995, to July 5, 2013). Of 61 consecutive patients, 40 underwent mitral repair and 21 underwent mitral replacement (mean [standard deviation] age, 40 [18] vs 31 [19] years; P = .09). Concomitant aortic surgery was performed to a similar extent (repair, 45% [18/40] vs replacement, 43% [9/21]; P = .87). Ten-year survival was significantly better in patients with Marfan syndrome with mitral repair than in those with replacement (80% vs 41%; P = .01). Mitral reintervention did not differ between mitral repair and replacement (cumulative risk of reoperation, 27% vs 15%; P = .64). In the matched cohort, 10-year survival after repair was similar for patients with Marfan syndrome and myxomatous mitral disease (84% vs 78%; P = .63), as was cumulative risk of reoperation (17% vs 12%; P = .61). Patients with Marfan syndrome and mitral regurgitation have better survival with repair than with replacement. Survival and risk of reoperation for patients with Marfan syndrome were similar to those for patients with myxomatous mitral disease. These results support the use of mitral valve repair in patients with Marfan syndrome and moderate or more mitral regurgitation, including those having composite replacement of the aortic root. Copyright © 2014 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.

Therapeutic strategy for functional tricuspid regurgitation in patients undergoing mitral valve repair for severe mitral regurgitation.

PubMed

Kitai, Takeshi; Furukawa, Yutaka; Murotani, Kenta; Krittanawong, Chayakrit; Kaji, Shuichiro; Koyama, Tadaaki; Okada, Yukikatsu

2017-01-15

The aim of this study was to determine optimal patient selection and selection of a prosthetic ring size for tricuspid valve (TV) repair at the time of mitral valve (MV) repair. We prospectively enrolled 167 consecutive patients undergoing MV repair. TV repair was indicated if patients had at least one of the following conditions representing tricuspid annular dilatation: (1) tricuspid regurgitation (TR)≥moderate, (2) history of right heart failure, (3) atrial fibrillation, and (4) pulmonary hypertension. The size of the ring was targeted to a normal-sized systolic tricuspid annuls in relation to the patient's body surface area (BSA). Serial echocardiographic studies were performed preoperatively, at discharge, and at 1, 3, and 5years postoperatively. Overall, 100 (60%) patients required TV repair, while it was not indicated for 67 (40%) patients. During follow-up, 26 patients showed progression or recurrent TR≥moderate. The TR grade at 5years after MV surgery was 0.8±0.9 in patients with TV repair and 0.9±0.7 in those without TV repair (P=0.69). There were no significant differences between patients with and without TV repair in a composite endpoint of death from any cause, re-do MV or TV surgery, and recurrence or progression of TR≥moderate (P=0.46). Patient selection for TV repair considering not only the grade of TR but clinical signs representing tricuspid annular dilatation is feasible at the time of MV repair. TV repair targeting a normal systolic size in relation to the BSA is a simple and reproducible procedure. Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.

Ticagrelor for Neuroendovascular Procedures: A Case Series.

PubMed

Davis, Kyle; Morrison, Christopher

2018-02-01

The development of thromboembolism is one of the most common complications of neuroendovascular procedures. Although several small studies have deemed clopidogrel safe and effective in the prevention of intracranial stent thrombosis, ticagrelor has yet to be assessed in this setting. The objective of this study was to retrospectively evaluate the safety and efficacy of ticagrelor in patients undergoing neuroendovascular procedures. A retrospective review of patients receiving ticagrelor following neuroendovascular aneurysm repair. A total of 5 patients undergoing neuroendovascular aneurysm repair received ticagrelor for a median of 5 days while hospitalized. Three patients were treated with stent-assisted coiling, while 2 received pipeline embolization devices. All patients received additional low-dose aspirin therapy. One patient received ticagrelor after experiencing a thrombotic event on clopidogrel, while a second patient was treated with ticagrelor after developing a dermatologic reaction to clopidogrel. Three (60%) patients were successfully treated and discharged on ticagrelor therapy. Two patients experienced cerebrovascular accidents following aneurysm repair while receiving ticagrelor, one of which was potentially due to medication omission. One (20%) patient receiving ticagrelor experienced a small retroperitoneal hematoma; however, ticagrelor therapy was continued without further complication. Therapy with ticagrelor may be a safe and effective treatment option for patients undergoing neuroendovascular aneurysm repair. However, future studies are warranted to substantiate these findings.

Confirmation of the safety and accuracy of physical examination in the evaluation of knee dislocation for injury of the popliteal artery: a prospective study.

PubMed

Miranda, Fernando E; Dennis, James W; Veldenz, Henry C; Dovgan, Peter S; Frykberg, Eric R

2002-02-01

Knee dislocation, which poses a significant risk for injury of the popliteal artery, prompts many surgeons to evaluate these patients with arteriography routinely. Our hypothesis was that physical examination alone (without arteriography) accurately confirms or excludes surgically significant vascular injuries associated with knee dislocation. All patients diagnosed with a knee dislocation by an attending orthopedic surgeon between January 1990 and January 2000 were prospectively managed by protocol at our Level I trauma center according to their physical examination. Those with hard signs (active hemorrhage, expanding hematoma, absent pulse, distal ischemia, bruit/thrill) underwent arteriography followed immediately by surgical repair if indicated. Patients with no hard signs (negative physical examination) were admitted for 23 hours, underwent serial physical examination, and then followed as outpatients. There were 35 knee dislocations in 35 patients during this 10-year period. The average age was 31 years; 18 dislocations were on the right knee and 17 were on the left. Two patients died from closed head injuries and multisystem trauma. Eight patients were found to have hard signs (positive physical examination) either at presentation (six patients) or during their hospitalization after reduction of their dislocation (two patients). All eight patients demonstrated a loss of pulses only. Six of these patients showed occlusion of the popliteal artery on arteriography and underwent surgical repair without complication (five vein grafts, one primary repair), one demonstrated spasm of the popliteal artery, and one showed a normal artery that required no treatment. None of the 27 patients with negative physical examination during their hospitalization ever developed limb ischemia, needed an operation for vascular injury, or experienced limb loss. Sixteen patients were available for follow-up (46%). Twelve patients with negative physical examination (44%) were contacted (mean, 13 months; range, 2-35 months), and four of the eight patients with positive physical examination (50%) and surgical repair were contacted (mean, 19 months; range, 6-49 months). None of the patients in either group developed any vascular-related symptoms or suffered from a vascular repair complication over the follow-up interval. This limited series suggests that the presence or absence of an injury of the popliteal artery after knee dislocation can be safely and reliably predicted, with a 94.3% positive predictive value and 100% negative predictive value. Arteriography appears to be unnecessary when physical examination is negative but may avert negative vascular exploration when physical examination is positive. This approach substantially reduces cost and resource use without adverse impact on the patient.

Preconditioning Shields Against Vascular Events in Surgery (SAVES), a multicentre feasibility trial of preconditioning against adverse events in major vascular surgery: study protocol for a randomised control trial.

PubMed

Healy, Donagh; Clarke-Moloney, Mary; Gaughan, Brendan; O'Daly, Siobhan; Hausenloy, Derek; Sharif, Faisal; Newell, John; O'Donnell, Martin; Grace, Pierce; Forbes, John F; Cullen, Walter; Kavanagh, Eamon; Burke, Paul; Cross, Simon; Dowdall, Joseph; McMonagle, Morgan; Fulton, Greg; Manning, Brian J; Kheirelseid, Elrasheid A H; Leahy, Austin; Moneley, Daragh; Naughton, Peter; Boyle, Emily; McHugh, Seamus; Madhaven, Prakash; O'Neill, Sean; Martin, Zenia; Courtney, Donal; Tubassam, Muhammed; Sultan, Sherif; McCartan, Damian; Medani, Mekki; Walsh, Stewart

2015-04-23

Patients undergoing vascular surgery procedures constitute a 'high-risk' group. Fatal and disabling perioperative complications are common. Complications arise via multiple aetiological pathways. This mechanistic redundancy limits techniques to reduce complications that target individual mechanisms, for example, anti-platelet agents. Remote ischaemic preconditioning (RIPC) induces a protective phenotype in at-risk tissue, conferring protection against ischaemia-reperfusion injury regardless of the trigger. RIPC is induced by repeated periods of upper limb ischaemia-reperfusion produced using a blood pressure cuff. RIPC confers some protection against cardiac and renal injury during major vascular surgery in proof-of-concept trials. Similar trials suggest benefit during cardiac surgery. Several uncertainties remain in advance of a full-scale trial to evaluate clinical efficacy. We propose a feasibility trial to fully evaluate arm-induced RIPC's ability to confer protection in major vascular surgery, assess the incidence of a proposed composite primary efficacy endpoint and evaluate the intervention's acceptability to patients and staff. Four hundred major vascular surgery patients in five Irish vascular centres will be randomised (stratified for centre and procedure) to undergo RIPC or not immediately before surgery. RIPC will be induced using a blood pressure cuff with four cycles of 5 minutes of ischaemia followed by 5 minutes of reperfusion immediately before the start of operations. There is no sham intervention. Participants will undergo serum troponin measurements pre-operatively and 1, 2, and 3 days post-operatively. Participants will undergo 12-lead electrocardiograms pre-operatively and on the second post-operative day. Predefined complications within one year of surgery will be recorded. Patient and staff experiences will be explored using qualitative techniques. The primary outcome measure is the proportion of patients who develop elevated serum troponin levels in the first 3 days post-operatively. Secondary outcome measures include length of hospital and critical care stay, unplanned critical care admissions, death, myocardial infarction, stroke, mesenteric ischaemia and need for renal replacement therapy (within 30 days of surgery). RIPC is novel intervention with the potential to significantly improve perioperative outcomes. This trial will provide the first evaluation of RIPC's ability to reduce adverse clinical events following major vascular surgery. www.clinicaltrials.gov NCT02097186 Date Registered: 24 March 2014.

Chitosan-glycerol phosphate/blood implants elicit hyaline cartilage repair integrated with porous subchondral bone in microdrilled rabbit defects.

PubMed

Hoemann, C D; Sun, J; McKee, M D; Chevrier, A; Rossomacha, E; Rivard, G-E; Hurtig, M; Buschmann, M D

2007-01-01

We have previously shown that microfractured ovine defects are repaired with more hyaline cartilage when the defect is treated with in situ-solidified implants of chitosan-glycerol phosphate (chitosan-GP) mixed with autologous whole blood. The objectives of this study were (1) to characterize chitosan-GP/blood clots in vitro, and (2) to develop a rabbit marrow stimulation model in order to determine the effects of the chitosan-GP/blood implant and of debridement on the formation of incipient cartilage repair tissue. Blood clots were characterized by histology and in vitro clot retraction tests. Bilateral 3.5 x 4 mm trochlear defects debrided into the calcified layer were pierced with four microdrill holes and filled with a chitosan-GP/blood implant or allowed to bleed freely as a control. At 1 day post-surgery, initial defects were characterized by histomorphometry (n=3). After 8 weeks of repair, osteochondral repair tissues between or through the drill holes were evaluated by histology, histomorphometry, collagen type II expression, and stereology (n=16). Chitosan-GP solutions structurally stabilized the blood clots by inhibiting clot retraction. Treatment of drilled defects with chitosan-GP/blood clots led to the formation of a more integrated and hyaline repair tissue above a more porous and vascularized subchondral bone plate compared to drilling alone. Correlation analysis of repair tissue between the drill holes revealed that the absence of calcified cartilage and the presence of a porous subchondral bone plate were predictors of greater repair tissue integration with subchondral bone (P<0.005), and of a higher total O'Driscoll score (P<0.005 and P<0.01, respectively). Chitosan-GP/blood implants applied in conjunction with drilling, compared to drilling alone, elicited a more hyaline and integrated repair tissue associated with a porous subchondral bone replete with blood vessels. Concomitant regeneration of a vascularized bone plate during cartilage repair could provide progenitors, anabolic factors and nutrients that aid in the formation of hyaline cartilage.

Sleep disturbance associated with rotator cuff tear: correction with arthroscopic rotator cuff repair.

PubMed

Austin, Luke; Pepe, Matthew; Tucker, Bradford; Ong, Alvin; Nugent, Robert; Eck, Brandon; Tjoumakaris, Fotios

2015-06-01

Sleep disturbance is a common complaint of patients with a rotator cuff tear. Inadequate and restless sleep, along with pain, is often a driving symptom for patients to proceed with rotator cuff repair. To date, no studies have examined sleep disturbance in patients undergoing rotator cuff repair, and there is no evidence that surgery improves sleep disturbance. Sleep disturbance is prevalent in patients with a symptomatic rotator cuff tear, and sleep disturbance improves after arthroscopic rotator cuff repair. Case series; Level of evidence, 4. A total of 56 patients undergoing arthroscopic rotator cuff repair for full-thickness tears were enrolled in a prospective study. Patients were surveyed preoperatively and postoperatively at intervals of 2, 6, 12, 18, and 24 weeks. Patient outcomes were scored using the Pittsburgh Sleep Quality Index (PSQI), Simple Shoulder Test (SST), visual analog scale for pain (VAS), and single assessment numeric evaluation (SANE). Demographic and surgical factors were also collected for analysis. Preoperative PSQI scores indicative of sleep disturbance were reported in 89% of patients. After surgery, a statistically significant improvement in PSQI was achieved at 3 months (P = .0012; 91% follow-up) and continued through 6 months (P = .0179; 93% follow-up). Six months after surgery, only 38% of patients continued to have sleep disturbance. Multivariable linear regression of all surgical and demographic factors versus PSQI was performed and demonstrated that preoperative and prolonged postoperative narcotic use negatively affected sleep. Sleep disturbance is common in patients undergoing rotator cuff repair. After surgery, sleep disturbance improves to levels comparable with those of the general public. Preoperative and prolonged postoperative use of narcotic pain medication negatively affects sleep. © 2015 The Author(s).

Management of combined pancreatoduodenal injuries.

PubMed Central

Feliciano, D V; Martin, T D; Cruse, P A; Graham, J M; Burch, J M; Mattox, K L; Bitondo, C G; Jordan, G L

1987-01-01

From 1969 to 1985, 129 patients with combined pancreatoduodenal injuries were treated at one urban trauma center. A total of 104 patients (80.6%) had penetrating wounds, and multiple visceral and vascular injuries were usually associated with the pancreatoduodenal injury. Primary repair or resection of one or both organs coupled with pyloric exclusion and gastrojejunostomy (68 patients) and drainage was used in 79 patients (61.2%) in the entire study and in 59% (36 of 61) of all patients treated since 1976. Simple primary repair of one or both organs and drainage was performed in 31 patients (24%), whereas the remaining 19 patients (14.8%) had pancreatoduodenectomies (13 patients) or no repair before exsanguination (six patients). Major pancreatoduodenal complications occurring in the 108 patients surviving more than 48 hours included pancreatic fistulas (25.9%), intra-abdominal abscess formation (16.6%), and duodenal fistulas (6.5%). The overall mortality rate for the study was 29.5% (38 of 129). The acute mortality rate with these injuries will remain high secondary to injuries to associated organs and vascular structures. The morbidity and late mortality rates related to the moderate to severe pancreatoduodenal injury itself can be decreased by the addition of pyloric exclusion and gastrojejunostomy to the primary repairs. PMID:3592810

Three-Dimensional Printing and Cell Therapy for Wound Repair.

PubMed

van Kogelenberg, Sylvia; Yue, Zhilian; Dinoro, Jeremy N; Baker, Christopher S; Wallace, Gordon G

2018-05-01

Significance: Skin tissue damage is a major challenge and a burden on healthcare systems, from burns and other trauma to diabetes and vascular disease. Although the biological complexities are relatively well understood, appropriate repair mechanisms are scarce. Three-dimensional bioprinting is a layer-based approach to regenerative medicine, whereby cells and cell-based materials can be dispensed in fine spatial arrangements to mimic native tissue. Recent Advances: Various bioprinting techniques have been employed in wound repair-based skin tissue engineering, from laser-induced forward transfer to extrusion-based methods, and with the investigation of the benefits and shortcomings of each, with emphasis on biological compatibility and cell proliferation, migration, and vitality. Critical issues: Development of appropriate biological inks and the vascularization of newly developed tissues remain a challenge within the field of skin tissue engineering. Future Directions: Progress within bioprinting requires close interactions between material scientists, tissue engineers, and clinicians. Microvascularization, integration of multiple cell types, and skin appendages will be essential for creation of complex skin tissue constructs.

Ultrasound-guided transversus abdominis plane block in patients undergoing open inguinal hernia repair: 0.125% bupivacaine provides similar analgesic effect compared to 0.25% bupivacaine.

PubMed

Erdoğan Arı, Dilek; Yıldırım Ar, Arzu; Karadoğan, Firdevs; Özcabı, Yetkin; Koçoğlu, Ayşegül; Kılıç, Fatih; Akgün, Fatma Nur

2016-02-01

To evaluate the effectiveness of 0.125% bupivacaine compared to 0.25% bupivacaine for ultrasound-guided transversus abdominis plane (TAP) block in patients undergoing open inguinal hernia repair. Randomized, double-blind study. Educational and research hospital. Forty adult patients of American Society of Anesthesiologists physical status I-III undergoing elective primary unilateral open inguinal hernia repair under spinal anesthesia. Patients in group I received 20 mL of 0.25% bupivacaine, whereas patients in group II received 20 mL of 0.125% bupivacaine for TAP block at the end of the surgery. Pain intensity was assessed at rest and during coughing using 10-cm visual analog scale score at 5, 15, 30, and 45 minutes and 1, 2, 4, 6, 12, and 24 hours after TAP block. Morphine consumption and time to first morphine requirement were recorded. Visual analog scale scores at rest and during coughing were not significantly different between groups at all time points measured. Twenty-four hours of morphine consumption (7.72±7.33 mg in group I and 6.06±5.20 mg in group II; P=.437) and time to first morphine requirement (182.35±125.16 minutes in group I and 143.21±87.28 minutes in group II; P=.332) were not different between groups. 0.125% Bupivacaine provides similar analgesic effect compared to 0.25% bupivacaine for ultrasound-guided TAP block in patients undergoing open inguinal hernia repair. Copyright © 2016 Elsevier Inc. All rights reserved.

Endothelial insulin receptor restoration rescues vascular function in male insulin receptor haploinsufficient mice.

PubMed

Sengupta, Anshuman; Patel, Peysh A; Yuldasheva, Nadira Y; Mughal, Romana S; Galloway, Stacey; Viswambharan, Hema; Walker, Andrew M N; Aziz, Amir; Smith, Jessica; Ali, Noman; Mercer, Ben N; Imrie, Helen; Sukumar, Piruthivi; Wheatcroft, Stephen B; Kearney, Mark T; Cubbon, Richard M

2018-05-15

Reduced systemic insulin signaling promotes endothelial dysfunction and diminished endogenous vascular repair. We asked whether restoration of endothelial insulin receptor expression could rescue this phenotype. Insulin receptor haploinsufficient mice (IRKO) were crossed with mice expressing a human insulin receptor transgene in the endothelium (hIRECO), to produce IRKO-hIRECO progeny. No metabolic differences were noted between IRKO and IRKO-hIRECO in glucose- and insulin-tolerance tests. In contrast with control IRKO littermates, IRKO-hIRECO exhibited normal blood pressure and aortic vasodilatation in response to acetylcholine, comparable to parameters noted in wild-type littermates. These phenotypic changes were associated with enhanced basal- and insulin-stimulated nitric oxide production. IRKO-hIRECO also demonstrated normalized endothelial repair after denuding arterial injury, which was associated with rescued endothelial cell migration in vitro, but not with changes in circulating progenitor populations or culture-derived myeloid angiogenic cells. These data show that restoration of endothelial insulin receptor expression alone is sufficient to prevent the vascular dysfunction caused by systemically reduced insulin signaling.

Intra-Abdominal Hypertension and Abdominal Compartment Syndrome in Association with Ruptured Abdominal Aortic Aneurysm in the Endovascular Era: Vigilance Remains Critical

PubMed Central

Bozeman, Matthew C.; Ross, Charles B.

2012-01-01

Intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) are common complications of ruptured abdominal aortoiliac aneurysms (rAAAs) and other abdominal vascular catastrophes even in the age of endovascular therapy. Morbidity and mortality due to systemic inflammatory response syndrome (SIRS) and multiple organ failure (MOF) are significant. Recognition and management of IAH are key critical care measures which may decrease morbidity and improve survival in these vascular patients. Two strategies have been utilized: expectant management with prompt decompressive laparotomy upon diagnosis of threshold levels of IAH versus prophylactic, delayed abdominal closure based upon clinical parameters at the time of initial repair. Competent management of the abdominal wound with preservation of abdominal domain is also an important component of the care of these patients. In this review, we describe published experience with IAH and ACS complicating abdominal vascular catastrophes, experience with ACS complicating endovascular repair of rAAAs, and techniques for management of the abdominal wound. Vigilance and appropriate management of IAH and ACS remains critically important in decreasing morbidity and optimizing survival following catastrophic intra-abdominal vascular events. PMID:22454763

RhBMP-2 loaded 3D-printed mesoporous silica/calcium phosphate cement porous scaffolds with enhanced vascularization and osteogenesis properties

NASA Astrophysics Data System (ADS)

Li, Cuidi; Jiang, Chuan; Deng, Yuan; Li, Tao; Li, Ning; Peng, Mingzheng; Wang, Jinwu

2017-01-01

A major limitation in the development of effective scaffolds for bone regeneration has been the limited vascularization of the regenerating tissue. Here, we propose the development of a novel calcium phosphate cement (CPC)-based scaffold combining the properties of mesoporous silica (MS) with recombinant human bone morphogenic protein-2 (rhBMP-2) to facilitate vascularization and osteogenesis. Specifically, the development of a custom MS/CPC paste allowed the three-dimensional (3D) printing of scaffolds with a defined macroporous structure and optimized silicon (Si) ions release profile to promote the ingrowth of vascular tissue at an early stage after implantation in support of tissue viability and osteogenesis. In addition, the scaffold microstructure allowed the prolonged release of rhBMP-2, which in turn significantly stimulated the osteogenesis of human bone marrow stromal cells in vitro and of bone regeneration in vivo as shown in a rabbit femur defect repair model. Thus, the combination MS/CPC/rhBMP-2 scaffolds might provide a solution to issues of tissue necrosis during the regeneration process and therefore might be able to be readily developed into a useful tool for bone repair in the clinic.

Intra-abdominal hypertension and abdominal compartment syndrome in association with ruptured abdominal aortic aneurysm in the endovascular era: vigilance remains critical.

PubMed

Bozeman, Matthew C; Ross, Charles B

2012-01-01

Intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) are common complications of ruptured abdominal aortoiliac aneurysms (rAAAs) and other abdominal vascular catastrophes even in the age of endovascular therapy. Morbidity and mortality due to systemic inflammatory response syndrome (SIRS) and multiple organ failure (MOF) are significant. Recognition and management of IAH are key critical care measures which may decrease morbidity and improve survival in these vascular patients. Two strategies have been utilized: expectant management with prompt decompressive laparotomy upon diagnosis of threshold levels of IAH versus prophylactic, delayed abdominal closure based upon clinical parameters at the time of initial repair. Competent management of the abdominal wound with preservation of abdominal domain is also an important component of the care of these patients. In this review, we describe published experience with IAH and ACS complicating abdominal vascular catastrophes, experience with ACS complicating endovascular repair of rAAAs, and techniques for management of the abdominal wound. Vigilance and appropriate management of IAH and ACS remains critically important in decreasing morbidity and optimizing survival following catastrophic intra-abdominal vascular events.

Infrainguinal arterial reconstructions in patients with aortoiliac occlusive disease: the influence of iliac stenting.

PubMed

Timaran, C H; Stevens, S L; Freeman, M B; Goldman, M H

2001-12-01

Iliac artery angioplasty (IAA) is an effective adjunct when combined with infrainguinal arterial reconstructions (IARs) in appropriate patients with multilevel occlusive disease. However, the effect of iliac artery stenting (IAS) on the outcome of patients undergoing distal bypass procedures is not defined. The purpose of this study was to estimate the influence of previous IAS for iliac occlusive disease on the outcome of IARs, compared with those after IAA alone or aortofemoral bypass grafting procedures (AFBs). During a 5-year period (1995-2000), 105 patients with previous intervention for iliac occlusive disease underwent 120 IARs. The criteria prepared by the Ad Hoc Committee on Reporting Standards (Society for Vascular Surgery/International Society for Cardiovascular Surgery) were followed to define the variables. The TransAtlantic Inter-Society Consensus classification was used to characterize the type of iliac lesions. Univariate (Kaplan-Meier) and multivariate analyses (Cox proportional hazards model) were used to determine the association between preoperative variables and cumulative primary patency. Forty-five IARs were performed in patients with an earlier IAS repair, 33 in patients with an earlier IAA repair, and 42 in patients with an earlier AFB repair. There were not significant differences between patients in the IAS and IAA groups, except for a more frequent use of polytetrafluoroethylene grafts for IARs in the IAS group (40% vs 15%; chi(2) test, P = .03). The 5-year primary patency rate for IARs was 68% in the IAS group, 46% in the IAA group, and 61% in the AFB group. Univariate analyses revealed that primary patency rates for IARs in patients with previous IAS were significantly higher than those in the IAA group (Kaplan-Meier, log-rank test, P = .02). Previous IAA repair was associated with a two-fold increased risk of IAR graft failure (relative risk, 2.2; 95% CI, 1.1-4.8; P = .04). IARs in patients with previous IAS have significantly improved graft patency, compared with those in patients with previous IAA alone. Such graft patency for IAR after IAS is similar to that obtained after AFB repair.

Short-term complications associated with the use of transvaginal mesh in pelvic floor reconstructive surgery: Results from a multi-institutional prospectively maintained dataset.

PubMed

Caveney, Maxx; Haddad, Devin; Matthews, Catherine; Badlani, Gopal; Mirzazadeh, Majid

2017-11-01

Vaginal reconstructive surgery can be performed with or without mesh. We sought to determine comparative rates of perioperative complications of native tissue versus vaginal mesh repairs for pelvic organ prolapse. Using the National Surgical Quality Improvement Program (NSQIP) database, we concatenated surgical data from vaginal procedures for prolapse repair, including anterior and posterior colporrhaphy, paravaginal defect repair, enterocele repair, and vaginal colpopexy using Current Procedural Terminology (CPT) coding. We stratified this data by the modifier associated with mesh usage at the time of the procedure. We then compared 30-day perioperative outcomes, postoperative complications (bleeding, infection, etc), and readmission rates between women with and without mesh-based repairs. We identified 10 657 vaginal reconstructive procedures without mesh and 959 mesh-based repairs from 2009 through 2013. Patients undergoing mesh repair were more likely to experience at least one complication than native tissue repair (9.28% vs 6.15%, P < 0.001), with the overall complication rate also being higher in the mesh group (11.37% vs 9.39%, P = 0.03). Procedures with mesh had a higher rate of perioperative bleeding requiring transfusion than native tissue repair (2.3% vs 0.49%, P < 0.001), and organ surgical site infection (SSI) (0.52% vs 0.17%, P = 0.02). There were no significant differences in rates of readmission, superficial, or deep SSIs, pneumonia, urinary tract infection, sepsis, or renal failure. The use of vaginal mesh for pelvic organ prolapse repair appears to result in a higher rate of perioperative complications than native tissue repair. Patients undergoing these procedures should be counselled preoperatively concerning these risks. © 2017 Wiley Periodicals, Inc.

A simulator for training in endovascular aneurysm repair: The use of three dimensional printers.

PubMed

Torres, I O; De Luccia, N

2017-08-01

To develop an endovascular aneurysm repair (EVAR) simulation system using three dimensional (3D) printed aneurysms, and to evaluate the impact of patient specific training prior to EVAR on the surgical performance of vascular surgery residents in a university hospital in Brazil. This was a prospective, controlled, single centre study. During 2015, the aneurysms of patients undergoing elective EVAR at São Paulo University Medical School were 3D printed and used in training sessions with vascular surgery residents. The 3D printers Stratasys-Connex 350, Formlabs-Form1+, and Makerbot were tested. Ten residents were enrolled in the control group (five residents and 30 patients in 2014) or the training group (five residents and 25 patients in 2015). The control group performed the surgery under the supervision of a senior vascular surgeon (routine procedure, without simulator training). The training group practised the surgery in a patient specific simulator prior to the routine procedure. Objective parameters were analysed, and a subjective questionnaire addressing training utility and realism was answered. Patient specific training reduced fluoroscopy time by 30% (mean 48 min, 95% confidence interval [CI] 40-58 vs. 33 min, 95% CI 26-42 [p < .01]), total procedure time by 29% (mean 292 min [95% CI 235-336] vs. 207 [95% CI 173-247]; p < .01), and volume of contrast used by 25% (mean 87 mL [95% CI 73-103] vs. 65 mL [95% CI 52-81]; p = .02). The residents considered the training useful and realistic, and reported that it increased their self confidence. The 3D printers Form1+ (using flexible resin) and Makerbot (using silicone) provided the best performance based on simulator quality and cost. An EVAR simulation system using 3D printed aneurysms was feasible. The best results were obtained with the 3D printers Form1+ (using flexible resin) and Makerbot (using silicone). Patient specific training prior to EVAR at a university hospital in Brazil improved residents' surgical performance (based on fluoroscopy time, surgery time, and volume of contrast used) and increased their self confidence. Copyright © 2017 The Authors. Published by Elsevier Ltd.. All rights reserved.

Paraesophageal Hernia Repair: Techniques for Success.

PubMed

Cohn, Tyler D; Soper, Nathaniel J

2017-01-01

With the introduction of laparoscopy, the outcomes of patients undergoing paraesophageal hernia repair have improved dramatically. When the fundamentals of a proper repair are followed, patients can expect to have improvement in gastroesophageal reflux symptoms, including heartburn, regurgitation, chest pain, dysphagia, and dyspnea. Adhering to these principles will alleviate patients' symptoms and avoid reoperation. This article describes the approach to paraesophageal hernia repair, including patient evaluation, operative technique, and postoperative management. Esophageal lengthening and crural reinforcement with mesh are addressed as well. Adhering to the basic techniques outlined in this article should lead to successful and durable patient outcomes following a paraesophageal hernia repair.

Risk Stratification for the Development of Respiratory Adverse Events Following Vascular Surgery Using the Society of Vascular Surgery’s Vascular Quality Initiative

PubMed Central

Genovese, Elizabeth A; Fish, Larry; Chaer, Rabih A; Makaroun, Michel S; Baril, Donald T

2017-01-01

Objective Post-operative respiratory adverse events (RAEs) are associated with high rates of morbidity and mortality in general surgery, however little is known about these complications in the vascular surgery population, a frail subset with multiple comorbidities. The objective of this study was to describe the contemporary incidence of RAEs in vascular surgery patients, the risk factors for this complication and the overall impact of RAEs on patient outcomes. Methods The Vascular Quality Initiative was queried (2003–2014) for patients who underwent endovascular abdominal aortic repair, open abdominal aortic aneurysm (AAA) repair, thoracic endovascular aortic repair (TEVAR), suprainguinal bypass or infrainguinal bypass. A mixed-effects logistic regression model determined the independent risk factors for RAEs. Using a random 85% of the cohort, a risk prediction score for RAEs was created and the score was validated using the remaining 15% of the cohort, comparing the predicted to the actual incidence of RAE and determining the area under the receiver operating characteristic curve. The independent risk of in-hospital mortality and discharge to a nursing facility associated with RAEs was determined using a mixed-effects logistic regression to control for baseline patient characteristics, operative variables and other post-operative adverse events. Results The cohort consisted of 52,562 patients, with a 5.4% incidence of RAEs. The highest rates of RAEs were seen in current smokers (6.1%), recent acute myocardial infarction (10.1%), symptomatic congestive heart failure (CHF) (9.9%), chronic obstructive pulmonary disease (COPD) requiring oxygen therapy (11.0%), urgent and emergent procedures (6.4% and 25.9%, respectively), open AAA repairs (17.6%), in-situ suprainguinal bypasses (9.68%) and TEVARs (9.6%). The variables included in the risk prediction score were age, body mass index, smoking status, CHF severity, COPD severity, degree of renal insufficiency, ambulatory status, transfer status, urgency and operative type. The predicted compared to the actual RAE incidence were highly correlated, with a correlation coefficient of 0.943 (P<.0001) and a c-statistic=0.818. RAEs had a significantly higher rates of in-hospital mortality (25.4% vs. 1.2%, P<.0001, adjusted OR=5.85, P<.0001) and discharge to a nursing facility (57.8% vs. 19.0%, P<.0001, adjusted OR=3.14, P<.0001). Conclusions RAEs are frequent and one of the strongest risk factors for in-hospital mortality and inability to be discharged home. Our risk prediction score accurately stratifies patients based on key demographics, comorbidities, presentation, and operative type that can be used to guide patient counseling, preoperative optimization, and post-operative management. Furthermore, it may be useful in developing quality benchmarks for RAE following major vascular surgery. PMID:27832989

Comparison of Revision Rates of Anterior- and Posterior-Approach Ptosis Surgery: A Retrospective Review of 1519 Cases.

PubMed

Chou, Eva; Liu, Jun; Seaworth, Cathleen; Furst, Meredith; Amato, Malena M; Blaydon, Sean M; Durairaj, Vikram D; Nakra, Tanuj; Shore, John W

To compare revision rates for ptosis surgery between posterior-approach and anterior-approach ptosis repair techniques. This is the retrospective, consecutive cohort study. All patients undergoing ptosis surgery at a high-volume oculofacial plastic surgery practice over a 4-year period. A retrospective chart review was conducted of all patients undergoing posterior-approach and anterior-approach ptosis surgery for all etiologies of ptosis between 2011 and 2014. Etiology of ptosis, concurrent oculofacial surgeries, revision, and complications were analyzed. The main outcome measure is the ptosis revision rate. A total of 1519 patients were included in this study. The mean age was 63 ± 15.4 years. A total of 1056 (70%) of patients were female, 1451 (95%) had involutional ptosis, and 1129 (74.3%) had concurrent upper blepharoplasty. Five hundred thirteen (33.8%) underwent posterior-approach ptosis repair, and 1006 (66.2%) underwent anterior-approach ptosis repair. The degree of ptosis was greater in the anterior-approach ptosis repair group. The overall revision rate for all patients was 8.7%. Of the posterior group, 6.8% required ptosis revision; of the anterior group, 9.5% required revision surgery. The main reason for ptosis revision surgery was undercorrection of one or both eyelids. Concurrent brow lifting was associated with a decreased, but not statistically significant, rate of revision surgery. Patients who underwent unilateral ptosis surgery had a 5.1% rate of Hering's phenomenon requiring ptosis repair in the contralateral eyelid. Multivariable logistic regression for predictive factors show that, when adjusted for gender and concurrent blepharoplasty, the revision rate in anterior-approach ptosis surgery is higher than posterior-approach ptosis surgery (odds ratio = 2.08; p = 0.002). The overall revision rate in patients undergoing ptosis repair via posterior-approach or anterior-approach techniques is 8.7%. There is a statistically higher rate of revision with anterior-approach ptosis repair.

[Evaluation of upper urinary tract function in patients undergoing autoplastic surgery for hydronphrosis of the intrarenal pelvis].

PubMed

Kurbanaliev, R M; Usupbaev, A Ch; Kolesnichenko, I V; Sadyrbekov, N Zh; Sultanov, B M

2018-05-01

To investigate the functional state of the upper urinary tract in patients undergoing autoplastic surgery for a hydronophrosis of the intrarenal pelvis. The study comprised 78 patients with the intrarenal pelvis and impaired urinary outflow due to stricture of the ureteropelvic junction and vascular conflict (interatrial and arteriovenous narrowing), who underwent pyeloplasty using autologous tunica vaginalis. All patients underwent an incision of ureteropelvic stricture and resection of the parietal layer of the tunica vaginalis which was used to repair the obstruction site and internal stenting of the upper urinary tract. The patients were examined at baseline and during follow-up ranging from 3 months to 3 years. At three months after surgery, there was a decrease in the size of the renal pelvis and calyces with an improvement of all parameters of uro- and hemodynamics. At three years after surgery, the structural and functional parameters of the upper urinary tract were completely restored. Obstructive uropathy, resulting from the intrarenal pelvis, leads to persistently impaired urinary outflow from the upper urinary tract. Surgical intervention is the only curative treatment able to restore the urinary flow. In men with the intrarenal pelvis, the autoplastic surgery of the ureteropelvic junction obstruction using a parietal layer of the tunica vaginalis is an effective surgical modality improving renal pelvis capacity and contributing to the recovery of urinary outflow from the upper urinary tract.

MACULAR HOLE FORMATION FOLLOWED BY SPONTANEOUS CLOSURE AFTER PNEUMATIC RETINOPEXY IN A PATIENT WITH DIABETIC MACULAR EDEMA.

PubMed

Cohen, Michael N; Baumal, Caroline R

2018-05-10

To report early formation and spontaneous closure of a full-thickness macular hole that developed after successful pneumatic retinopexy in a patient who had been undergoing treatment for diabetic macular edema. Case report of a 68-year-old man with bilateral nonproliferative diabetic retinopathy who was currently undergoing anti-vascular endothelial growth factor treatment for bilateral diabetic macular edema. On presentation, visual acuity was 20/200 in the left eye, and examination revealed a bullous, macula-off retinal detachment with a single horseshoe tear at 12 o'clock in the left eye. Pneumatic retinopexy was performed followed by laser augmentation 3 days later. Three weeks postoperatively, he returned with visual acuity of 20/50 and a full-thickness macular hole in the left eye. Although he elected for initial observation, he returned 2 weeks later with visual acuity of 20/50 in both eyes and a retinal detachment with a single break at 10 o'clock in the right eye. The macular hole in the left eye had spontaneously resolved. Pneumatic retinopexy was performed to the right eye. Over 1 year after bilateral pneumatic retinopexy, his retina remains without recurrence of a macular hole in the left eye. In the early postoperative period after pneumatic retinopexy to repair a retinal detachment, a macular hole can form and spontaneously close.

The utility of 64 channel multidetector CT angiography for evaluating the renal vascular anatomy and possible variations: a pictorial essay.

PubMed

Kumar, Sheo; Neyaz, Zafar; Gupta, Archna

2010-01-01

The increased use of laparoscopic nephrectomy and nephron-sparing surgery has prompted the need for a more detailed radiological evaluation of the renal vascular anatomy. Multidetector CT angiography is a fast and accurate modality for assessing the precise anatomy of the renal vessels. In this pictorial review, we present the multidetector CT angiography appearances of the normal renal vascular anatomy and a spectrum of various anomalies that require accurate vascular depiction before undergoing surgical treatment.

Tissue Engineering Research

DTIC Science & Technology

2002-01-01

al. 1999; Petersen et al. 1999); the differentiation (Pittenger et al. 1999) and clinical use of mesenchymal stem cells (Osiris Therapeutics...endothelialization of vascular prostheses, and use of mesenchymal stem cells for bone repair. Current Condition Factors determining cell source and design...the use of mesenchymal stem cells for bone repair. The UK has taken an active interest in further research on the use of ES cells . This is aided by

A practical method to rapidly dissolve metallic stents.

PubMed

Bradshaw, Scott H; Kennedy, Lloyd; Dexter, David F; Veinot, John P

2009-01-01

Metallic stents are commonly used in many clinical applications including peripheral vascular disease intervention, biliary obstruction, endovascular repair of aneurysms, and percutaneous coronary interventions. In the examination of vascular stent placement, it is important to determine if the stent is open or has become obstructed. This is increasingly important in the era of drug-eluting stent usage in coronary arteries. We describe a practical, rapid and cost-effective method to dissolve most metallic stents leaving the vascular and luminal tissues intact. This practical method may replace the laborious and expensive plastic embedding methods currently utilized.

An Evaluation of Parastomal Hernia Repair Using the Americas Hernia Society Quality Collaborative.

PubMed

Fox, Sarah S; Janczyk, Randy; Warren, Jeremy A; Carbonell, Alfredo M; Poulose, Benjamin K; Rosen, Michael J; Hope, William W

2017-08-01

The purpose of this review was to evaluate outcomes relating to parastomal hernia repair. Data from the Americas Hernia Society Quality Collaborative were used to identify patients undergoing parastomal hernia repair from 2013 to 2016. Parastomal hernia repairs were compared with other repairs using Pearson's test and Wilcoxon test with a P value <0.05 considered significant. Parastomal hernia repairs were performed in 311 patients. Techniques of repair include open in 85 per cent and laparoscopic in 15 per cent. Mesh was used in 92 per cent with keyhole in 34 per cent, flat mesh in 33 per cent, and Sugarbaker in 25 per cent. Mesh types were permanent synthetic in 79 per cent, biologic in 13 per cent, absorbable synthetic in 6 per cent, and hybrid synthetic/biologic in 2 per cent. Most common location for mesh was sublay in 84 per cent followed by onlay in 14 per cent and inlay in 2 per cent with 59 per cent of patients undergoing a myofascial release. Ostomy disposition included ostomy left in situ (47%), moved to a new site (18%), taken down (22%), and rematured in same location in (13%). Outcomes related to parastomal hernia repair included 10 per cent surgical site infection, 24 per cent surgical site occurrence, and 12 per cent surgical site occurrences requiring procedural interventions with a 13 per cent readmission rate and 6 per cent reoperation rate. When comparing parastomal hernias with other ventral hernia repairs, parastomal hernias had a significantly higher surgical site infection, surgical site occurrence, surgical site occurrences requiring procedural intervention, readmission, reoperation rate, and length of stay, and were less commonly performed laparoscopically (P < 0.05). Most parastomal hernias are being repaired open with synthetic mesh in the sublay position. Less favorable outcomes of parastomal hernia repair when compared with other ventral hernia repairs are likely related to the complexity of parastomal hernia repair.

Dimer monomer transition and dimer re-formation play important role for ATM cellular function during DNA repair

DOE Office of Scientific and Technical Information (OSTI.GOV)

Du, Fengxia; Zhang, Minjie; University of Chinese Academy of Sciences, Beijing 100049

2014-10-03

Highlights: • ATM phosphorylates the opposite strand of the dimer in response to DNA damage. • The PETPVFRLT box of ATM plays a key role in its dimer dissociation in DNA repair. • The dephosphorylation of ATM is critical for dimer re-formation after DNA repair. - Abstract: The ATM protein kinase, is a serine/threonine protein kinase that is recruited and activated by DNA double-strand breaks, mediates responses to ionizing radiation in mammalian cells. Here we show that ATM is held inactive in unirradiated cells as a dimer and phosphorylates the opposite strand of the dimer in response to DNA damage.more » Cellular irradiation induces rapid intermolecular autophosphorylation of serine 1981 that causes dimer dissociation and initiates cellular ATM kinase activity. ATM cannot phosphorylate the substrates when it could not undergo dimer monomer transition. After DNA repair, the active monomer will undergo dephosphorylation to form dimer again and dephosphorylation is critical for dimer re-formation. Our work reveals novel function of ATM dimer monomer transition and explains why ATM dimer monomer transition plays such important role for ATM cellular activity during DNA repair.« less

Lower Mortality for Abdominal Aortic Aneurysm Repair in High-Volume Hospitals Is Contingent upon Nurse Staffing

PubMed Central

Wiltse Nicely, Kelly L; Sloane, Douglas M; Aiken, Linda H

2013-01-01

Objective To determine whether and to what extent the lower mortality rates for patients undergoing abdominal aortic aneurysm (AAA) repair in high-volume hospitals is explained by better nursing. Data Sources State hospital discharge data, Multi-State Nursing Care and Patient Safety Survey, and hospital characteristics from the AHA Annual Survey. Study Design Cross-sectional analysis of linked patient outcomes for individuals undergoing AAA repair in four states. Data Collection Secondary data sources. Principal Findings Favorable nursing practice environments and higher hospital volumes of AAA repair are associated with lower mortality and fewer failures-to-rescue in main-effects models. Furthermore, nurse staffing interacts with volume such that there is no mortality advantage observed in high-volume hospitals with poor nurse staffing. When hospitals have good nurse staffing, patients in low-volume hospitals are 3.4 times as likely to die and 2.6 times as likely to die from complications as patients in high-volume hospitals (p < .001). Conclusions Nursing is part of the explanation for lower mortality after AAA repair in high-volume hospitals. Importantly, lower mortality is not found in high-volume hospitals if nurse staffing is poor. PMID:23088426

Progressive shortfall in open aneurysm experience for vascular surgery trainees with the impact of fenestrated and branched endovascular technology.

PubMed

Dua, Anahita; Koprowski, Steven; Upchurch, Gilbert; Lee, Cheong J; Desai, Sapan S

2017-01-01

In 2014, we published a series of articles in the Journal of Vascular Surgery that detailed the decrease in volume of open aneurysm repair (OAR) completed for abdominal aortic aneurysm (AAA) by vascular surgery trainees. At that time, only data points from 2000 through 2011 were available, and reliable predictions could only be made through 2015. Lack of data on endovascular aneurysm repair (EVAR) using fenestrated (FEVAR) and branched (BrEVAR) endografts also affected our findings. Despite these limitations, our predictions for OAR completed by vascular trainees were accurate for 2012 to 2014. This report uses updated data points through 2014 in conjunction with data on FEVAR and BrEVAR obtained from industry to predict trends in OAR and how it will affect vascular surgery training through 2020. An S-curve modified logistic function was used to model the effect of introducing new technologies (EVAR, FEVAR, BrEVAR) on the standard management of AAA with OAR starting in the year 2000, similar to the technique that we have previously described. Weighted samples and data from the United States Census Bureau were used in conjunction with volume estimates derived from the National Inpatient Sample, State Inpatient Databases, and industry sources to determine trends in OAR and EVAR. The number of cases completed at teaching hospitals was calculated using the National Inpatient Sample, and Accreditation Council for Graduate Medical Education case logs were used to forecast the number of cases completed by vascular surgery trainees through 2020. Sensitivity analysis and trend analysis were completed. Approximately 45,000 AAA repairs are completed annually in the United States, but only 15% of these are now completed using OAR compared with >50% just a decade ago. Further, with the accelerating adoption of FEVAR and BrEVAR, and expanding indications for standard EVAR, our model predicts that <3000 OARs will be completed annually by 2020. Because only a subset of these cases are completed at teaching institutions, our model predicts that a vascular surgery trainee in a fellowship program will complete only one to two OARs, whereas trainees in a 0+5 program may complete two to three OARs. Our initial prediction in the 2014 report was that vascular trainees would complete approximately five OARs by 2020. After incorporating new data on BrEVAR, FEVAR, and the accelerating pace of EVAR use between 2012 and 2014, it now appears that vascular trainees will complete one to three OARs during their training. Copyright © 2016 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.

Extensive traumatic anterior skull base fractures with cerebrospinal fluid leak: classification and repair techniques using combined vascularized tissue flaps.

PubMed

Archer, Jacob B; Sun, Hai; Bonney, Phillip A; Zhao, Yan Daniel; Hiebert, Jared C; Sanclement, Jose A; Little, Andrew S; Sughrue, Michael E; Theodore, Nicholas; James, Jeffrey; Safavi-Abbasi, Sam

2016-03-01

This article introduces a classification scheme for extensive traumatic anterior skull base fracture to help stratify surgical treatment options. The authors describe their multilayer repair technique for cerebrospinal fluid (CSF) leak resulting from extensive anterior skull base fracture using a combination of laterally pediculated temporalis fascial-pericranial, nasoseptal-pericranial, and anterior pericranial flaps. Retrospective chart review identified patients treated surgically between January 2004 and May 2014 for anterior skull base fractures with CSF fistulas. All patients were treated with bifrontal craniotomy and received pedicled tissue flaps. Cases were classified according to the extent of fracture: Class I (frontal bone/sinus involvement only); Class II (extent of involvement to ethmoid cribriform plate); and Class III (extent of involvement to sphenoid bone/sinus). Surgical repair techniques were tailored to the types of fractures. Patients were assessed for CSF leak at follow-up. The Fisher exact test was applied to investigate whether the repair techniques were associated with persistent postoperative CSF leak. Forty-three patients were identified in this series. Thirty-seven (86%) were male. The patients' mean age was 33 years (range 11-79 years). The mean overall length of follow-up was 14 months (range 5-45 months). Six fractures were classified as Class I, 8 as Class II, and 29 as Class III. The anterior pericranial flap alone was used in 33 patients (77%). Multiple flaps were used in 10 patients (3 salvage) (28%)--1 with Class II and 9 with Class III fractures. Five (17%) of the 30 patients with Class II or III fractures who received only a single anterior pericranial flap had persistent CSF leak (p < 0.31). No CSF leak was found in patients who received multiple flaps. Although postoperative CSF leak occurred only in high-grade fractures with single anterior flap repair, this finding was not significant. Extensive anterior skull base fractures often require aggressive treatment to provide the greatest long-term functional and cosmetic benefits. Several vascularized tissue flaps can be used, either alone or in combination. Vascularized flaps are an ideal substrate for cranial base repair. Dual and triple flap techniques that combine the use of various anterior, lateral, and nasoseptal flaps allow for a comprehensive arsenal in multilayered skull base repair and salvage therapy for extensive and severe fractures.

Macrophages control vascular stem/progenitor cell plasticity through tumor necrosis factor-α-mediated nuclear factor-κB activation.

PubMed

Wong, Mei Mei; Chen, Yikuan; Margariti, Andriani; Winkler, Bernhard; Campagnolo, Paola; Potter, Claire; Hu, Yanhua; Xu, Qingbo

2014-03-01

Vascular lineage differentiation of stem/progenitor cells can contribute to both tissue repair and exacerbation of vascular diseases such as in vein grafts. The role of macrophages in controlling vascular progenitor differentiation is largely unknown and may play an important role in graft development. This study aims to identify the role of macrophages in vascular stem/progenitor cell differentiation and thereafter elucidate the mechanisms that are involved in the macrophage- mediated process. We provide in vitro evidence that macrophages can induce endothelial cell (EC) differentiation of the stem/progenitor cells while simultaneously inhibiting their smooth muscle cell differentiation. Mechanistically, both effects were mediated by macrophage-derived tumor necrosis factor-α (TNF-α) via TNF-α receptor 1 and canonical nuclear factor-κB activation. Although the overexpression of p65 enhanced EC (or attenuated smooth muscle cell) differentiation, p65 or TNF-α receptor 1 knockdown using lentiviral short hairpin RNA inhibited EC (or rescued smooth muscle cell) differentiation in response to TNF-α. Furthermore, TNF-α-mediated EC differentiation was driven by direct binding of nuclear factor-κB (p65) to specific VE-cadherin promoter sequences. Subsequent experiments using an ex vivo decellularized vessel scaffold confirmed an increase in the number of ECs and reduction in smooth muscle cell marker expression in the presence of TNF-α. The lack of TNF-α in a knockout mouse model of vein graft decreased endothelialization and significantly increased thrombosis formation. Our study highlights the role of macrophages in directing vascular stem/progenitor cell lineage commitment through TNF-α-mediated TNF-α receptor 1 and nuclear factor-κB activation that is likely required for endothelial repair in vascular diseases such as vein graft.

Knee dislocations with vascular injury: outcomes in the Lower Extremity Assessment Project (LEAP) Study.

PubMed

Patterson, Brendan M; Agel, Julie; Swiontkowski, Marc F; Mackenzie, Ellen J; Bosse, Michael J

2007-10-01

The purpose of this study is to report the clinical and functional results of a cohort of patients with knee dislocations associated with vascular injury. Patients with knee dislocation and associated vascular injury were prospectively assessed for outcome of severe lower extremity trauma during 2 years. The Sickness Impact Profile was used to assess the functional recovery of the patient. Surgeon and therapist assessments documented clinical metrics and treatment, including salvage or amputation, neurologic recovery, knee stability, and knee motion. Eighteen patients sustained a knee dislocation and an associated popliteal artery injury. Seven patients were found to have an additional vascular injury. All patients underwent repair of the vascular injury. At the time of final follow-up, 14 knees were successfully salvaged and four required amputation (1 below knee amputation, 2 through knee amputation, and 1 above knee amputation). Eighteen patients had at least a popliteal injury and underwent repair of the vascular injury. The patients with a limb-threatening knee dislocation that was successfully reconstructed had Sickness Impact Profile scores of 20.12 at 3 months, 13.18 at 6 months, 12.08 at 1 year, and 7.0 at 2 years after injury. Patients who sustain a limb-threatening knee dislocation have a moderate to high level of disability 2 years after injury. Nearly one in five patients who present to a Level I trauma center with a dysvascular limb associated with a knee dislocation will require amputation. Prolonged warm ischemia time was associated with a high rate of amputation. Patients who sustain vascular injuries associated with a knee dislocation need immediate transport to a trauma hospital, rapid assessment and diagnosis at presentation, and revascularization. Patients with these injuries can be effectively treated without angiography before surgery.

Engineering clinically relevant volumes of vascularized bone.

PubMed

Roux, Brianna M; Cheng, Ming-Huei; Brey, Eric M

2015-05-01

Vascularization remains one of the most important challenges that must be overcome for tissue engineering to be consistently implemented for reconstruction of large volume bone defects. An extensive vascular network is needed for transport of nutrients, waste and progenitor cells required for remodelling and repair. A variety of tissue engineering strategies have been investigated in an attempt to vascularize tissues, including those applying cells, soluble factor delivery strategies, novel design and optimization of bio-active materials, vascular assembly pre-implantation and surgical techniques. However, many of these strategies face substantial barriers that must be overcome prior to their ultimate translation into clinical application. In this review recent progress in engineering vascularized bone will be presented with an emphasis on clinical feasibility. © 2015 The Authors. Journal of Cellular and Molecular Medicine published by John Wiley & Sons Ltd and Foundation for Cellular and Molecular Medicine.

Discrepancy between the clinical and histopathologic diagnosis of soft tissue vascular malformations.

PubMed

Horbach, Sophie E R; Utami, Amalia M; Meijer-Jorna, Lorine B; Sillevis Smitt, J H; Spuls, Phyllis I; van der Horst, Chantal M A M; van der Wal, Allard C

2017-11-01

Soft tissue vascular malformations are generally diagnosed clinically, according to the International Society for the Study of Vascular Anomalies (ISSVA) classification. Diagnostic histopathologic examination is rarely performed. We sought to evaluate the validity of the current diagnostic workup without routinely performed diagnostic histopathology. We retrospectively determined whether there were discrepancies between clinical and histopathologic diagnoses of patients with clinically diagnosed vascular malformations undergoing therapeutic surgical resections in our center (2000-2015). Beforehand, a pathologist revised the histopathologic diagnoses according to the ISSVA classification. Clinical and histopathologic diagnoses were discrepant in 57% of 142 cases. In these cases, the pathologist indicated the diagnosis was not at all a vascular malformation (n = 24; 17%), a completely different type of vascular malformation (n = 26; 18%), or a partially different type with regard to the combination of vessel-types involved (n = 31; 22%). Possible factors associated with the discrepancies were both clinician-related (eg, diagnostic uncertainty) and pathology-related (eg, lack of immunostaining). Retrospective analysis of a subgroup of patients undergoing surgery. The large discrepancy between clinical and histopathologic diagnoses raises doubt about the validity of the current diagnostic workup for vascular malformations. Clear clinical and histopathologic diagnostic criteria might be essential for a uniform diagnosis. Copyright © 2017 American Academy of Dermatology, Inc. Published by Elsevier Inc. All rights reserved.

Pre-vascularization Enhances Therapeutic Effects of Human Mesenchymal Stem Cell Sheets in Full Thickness Skin Wound Repair.

PubMed

Chen, Lei; Xing, Qi; Zhai, Qiyi; Tahtinen, Mitchell; Zhou, Fei; Chen, Lili; Xu, Yingbin; Qi, Shaohai; Zhao, Feng

2017-01-01

Split thickness skin graft (STSG) implantation is one of the standard therapies for full thickness wound repair when full thickness autologous skin grafts (FTG) or skin flap transplants are inapplicable. Combined transplantation of STSG with dermal substitute could enhance its therapeutic effects but the results remain unsatisfactory due to insufficient blood supply at early stages, which causes graft necrosis and fibrosis. Human mesenchymal stem cell (hMSC) sheets are capable of accelerating the wound healing process. We hypothesized that pre-vascularized hMSC sheets would further improve regeneration by providing more versatile angiogenic factors and pre-formed microvessels. In this work, in vitro cultured hMSC cell sheets (HCS) and pre-vascularized hMSC cell sheets (PHCS) were implanted in a rat full thickness skin wound model covered with an autologous STSG. Results demonstrated that the HCS and the PHCS implantations significantly reduced skin contraction and improved cosmetic appearance relative to the STSG control group. The PHCS group experienced the least hemorrhage and necrosis, and lowest inflammatory cell infiltration. It also induced the highest neovascularization in early stages, which established a robust blood micro-circulation to support grafts survival and tissue regeneration. Moreover, the PHCS grafts preserved the largest amount of skin appendages, including hair follicles and sebaceous glands, and developed the smallest epidermal thickness. The superior therapeutic effects seen in PHCS groups were attributed to the elevated presence of growth factors and cytokines in the pre-vascularized cell sheet, which exerted a beneficial paracrine signaling during wound repair. Hence, the strategy of combining STSG with PHCS implantation appears to be a promising approach in regenerative treatment of full thickness skin wounds.

Investigation on laser-assisted tissue repair with NIR millisecond-long light pulses and Indocyanine Green-biopolymeric patches

NASA Astrophysics Data System (ADS)

Matteini, Paolo; Banchelli, Martina; Cottat, Maximilien; Osticioli, Iacopo; de Angelis, Marella; Rossi, Francesca; Pini, Roberto

2016-03-01

In previous works a minimally invasive laser-assisted technique for vascular repair was presented. The technique rests on the photothermal adhesion of a biocompatible and bioresorbable patch containing Indocyanine Green that is brought into contact with the site to be repaired. Afterward the use of NIR millisecond-long light pulses generates a strong welding effect between the patch and the underlying tissue and in turn the repair of the wound. This technique was shown to be effective in animal model and provides several advantages over conventional suturing methods. Here we investigate and discuss the optical stability of the ICG-biopolymeric patches and the photothermal effects induced to the irradiated tissue.

Interventional radiology in living donor liver transplant

PubMed Central

Cheng, Yu-Fan; Ou, Hsin-You; Yu, Chun-Yen; Tsang, Leo Leung-Chit; Huang, Tung-Liang; Chen, Tai-Yi; Hsu, Hsien-Wen; Concerjero, Allan M; Wang, Chih-Chi; Wang, Shih-Ho; Lin, Tsan-Shiun; Liu, Yueh-Wei; Yong, Chee-Chien; Lin, Yu-Hung; Lin, Chih-Che; Chiu, King-Wah; Jawan, Bruno; Eng, Hock-Liew; Chen, Chao-Long

2014-01-01

The shortage of deceased donor liver grafts led to the use of living donor liver transplant (LDLT). Patients who undergo LDLT have a higher risk of complications than those who undergo deceased donor liver transplantation (LT). Interventional radiology has acquired a key role in every LT program by treating the majority of vascular and non-vascular post-transplant complications, improving graft and patient survival and avoiding, in the majority of cases, surgical revision and/or re-transplant. The aim of this paper is to review indications, diagnostic modalities, technical considerations, achievements and potential complications of interventional radiology procedures after LDLT. PMID:24876742

Methylene Blue for Vasoplegia When on Cardiopulmonary Bypass During Double-Lung Transplantation.

PubMed

Carley, Michelle; Schaff, Jacob; Lai, Terrance; Poppers, Jeremy

2015-10-15

Vasoplegia syndrome, characterized by hypotension refractory to fluid resuscitation or high-dose vasopressors, low systemic vascular resistance, and normal-to-increased cardiac index, is associated with increased morbidity and mortality after cardiothoracic surgery. Methylene blue inhibits inducible nitric oxide synthase and guanylyl cyclase, and has been used to treat vasoplegia during cardiopulmonary bypass. However, because methylene blue is associated with increased pulmonary vascular resistance, its use in patients undergoing lung transplantion has been limited. Herein, we report the use of methylene blue to treat refractory vasoplegia during cardiopulmonary bypass in a patient undergoing double-lung transplantation.

Rationale, scope, and 20-year experience of vascular surgical training with lifelike pulsatile flow models.

PubMed

Eckstein, Hans-Henning; Schmidli, Jürg; Schumacher, Hardy; Gürke, Lorenz; Klemm, Klaus; Duschek, Nikolaus; Meile, Toni; Assadian, Afshin

2013-05-01

Vascular surgical training currently has to cope with various challenges, including restrictions on work hours, significant reduction of open surgical training cases in many countries, an increasing diversity of open and endovascular procedures, and distinct expectations by trainees. Even more important, patients and the public no longer accept a "learning by doing" training philosophy that leaves the learning curve on the patient's side. The Vascular International (VI) Foundation and School aims to overcome these obstacles by training conventional vascular and endovascular techniques before they are applied on patients. To achieve largely realistic training conditions, lifelike pulsatile models with exchangeable synthetic arterial inlays were created to practice carotid endarterectomy and patch plasty, open abdominal aortic aneurysm surgery, and peripheral bypass surgery, as well as for endovascular procedures, including endovascular aneurysm repair, thoracic endovascular aortic repair, peripheral balloon dilatation, and stenting. All models are equipped with a small pressure pump inside to create pulsatile flow conditions with variable peak pressures of ~90 mm Hg. The VI course schedule consists of a series of 2-hour modules teaching different open or endovascular procedures step-by-step in a standardized fashion. Trainees practice in pairs with continuous supervision and intensive advice provided by highly experienced vascular surgical trainers (trainer-to-trainee ratio is 1:4). Several evaluations of these courses show that tutor-assisted training on lifelike models in an educational-centered and motivated environment is associated with a significant increase of general and specific vascular surgical technical competence within a short period of time. Future studies should evaluate whether these benefits positively influence the future learning curve of vascular surgical trainees and clarify to what extent sophisticated models are useful to assess the level of technical skills of vascular surgical residents at national or international board examinations. This article gives an overview of our experiences of >20 years of practical training of beginners and advanced vascular surgeons using lifelike pulsatile vascular surgical training models. Copyright © 2013 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.

Strength and Persistence of Energy-Based Vessel Seals Rely on Tissue Water and Glycosaminoglycan Content.

PubMed

Kramer, Eric A; Cezo, James D; Fankell, Douglas P; Taylor, Kenneth D; Rentschler, Mark E; Ferguson, Virginia L

2016-11-01

Vessel ligation using energy-based surgical devices is steadily replacing conventional closure methods during minimally invasive and open procedures. In exploring the molecular nature of thermally-induced tissue bonds, novel applications for surgical resection and repair may be revealed. This work presents an analysis of the influence of unbound water and hydrophilic glycosaminoglycans on the formation and resilience of vascular seals via: (a) changes in pre-fusion tissue hydration, (b) the enzymatic digestion of glycosaminoglycans (GAGs) prior to fusion and (c) the rehydration of vascular seals following fusion. An 11% increase in pre-fusion unbound water led to an 84% rise in vascular seal strength. The digestion of GAGs prior to fusion led to increases of up to 82% in seal strength, while the rehydration of native and GAG-digested vascular seals decreased strengths by 41 and 44%, respectively. The effects of increased unbound water content prior to fusion combined with the effects of seal rehydration after fusion suggest that the heat-induced displacement of tissue water is a major contributor to tissue adhesion during energy-based vessel sealing. The effects of pre-fusion GAG-digestion on seal integrity indicate that GAGs are inhibitory to the bond formation process during thermal ligation. GAG digestion may allow for increased water transport and protein interaction during the fusion process, leading to the formation of stronger bonds. These findings provide insight into the physiochemical nature of the fusion bond, its potential for optimization in vascular closure and its application to novel strategies for vascular resection and repair.

40 CFR 90.1207 - Entry and access.

Code of Federal Regulations, 2012 CFR

2012-07-01

... the following places: (1) Any facility where engines undergo or are undergoing aging, maintenance, repair, preparation for aging, selection for aging or emission testing. (2) Any facility where records or... (b) and also to inspect and make copies of records related to engine aging (service accumulation) and...

40 CFR 90.1207 - Entry and access.

Code of Federal Regulations, 2013 CFR

2013-07-01

... the following places: (1) Any facility where engines undergo or are undergoing aging, maintenance, repair, preparation for aging, selection for aging or emission testing. (2) Any facility where records or... (b) and also to inspect and make copies of records related to engine aging (service accumulation) and...

40 CFR 90.1207 - Entry and access.

Code of Federal Regulations, 2010 CFR

2010-07-01

... the following places: (1) Any facility where engines undergo or are undergoing aging, maintenance, repair, preparation for aging, selection for aging or emission testing. (2) Any facility where records or... (b) and also to inspect and make copies of records related to engine aging (service accumulation) and...

40 CFR 90.1207 - Entry and access.

Code of Federal Regulations, 2014 CFR

2014-07-01

... the following places: (1) Any facility where engines undergo or are undergoing aging, maintenance, repair, preparation for aging, selection for aging or emission testing. (2) Any facility where records or... (b) and also to inspect and make copies of records related to engine aging (service accumulation) and...

40 CFR 90.1207 - Entry and access.

Code of Federal Regulations, 2011 CFR

2011-07-01

... the following places: (1) Any facility where engines undergo or are undergoing aging, maintenance, repair, preparation for aging, selection for aging or emission testing. (2) Any facility where records or... (b) and also to inspect and make copies of records related to engine aging (service accumulation) and...

Primary proximal tubule injury leads to epithelial cell cycle arrest, fibrosis, vascular rarefaction, and glomerulosclerosis

PubMed Central

Bonventre, Joseph V

2014-01-01

Tubular injury has a major etiological role in fibrosis. For many years, this relationship has been dominated by the perception that epithelial cells are transformed into myofibroblasts that proliferate and generate fibrotic matrix—the so-called epithelial-to-mesenchymal transition. Here we focus on mechanisms by which injury to the tubule results in fibrosis because of paracrine mechanisms. Specific injury to the proximal tubule results in inflammation, reversible injury, and adaptive repair if the insult is mild, self-limited in time, and occurs in a background of a normal kidney. Repeated injury, in contrast, leads to maladaptive repair with sustained tubule injury, chronic inflammation, proliferation of interstitial myofibroblasts, vascular rarefaction, interstitial fibrosis, and glomerular sclerosis. During the maladaptive repair process after the renal insult, many tubular cells become arrested in the G2/M phase of the cell cycle. This results in activation of the DNA repair response with the resultant synthesis and secretion of pro-fibrotic factors. Pharmacologic interventions that enhance the movement through G2/M or facilitate apoptosis of cells that otherwise would be blocked in G2/M may reduce the development of fibrosis after kidney injury and reduce the progression of chronic kidney disease. PMID:26310195

Repair of Avascular Meniscus Tears with Electrospun Collagen Scaffolds Seeded with Human Cells

PubMed Central

Baek, Jihye; Sovani, Sujata; Glembotski, Nicholas E.; Du, Jiang; Jin, Sungho; Grogan, Shawn P.

2016-01-01

The self-healing capacity of an injured meniscus is limited to the vascularized regions and is especially challenging in the inner avascular regions. As such, we investigated the use of human meniscus cell-seeded electrospun (ES) collagen type I scaffolds to produce meniscal tissue and explored whether these cell-seeded scaffolds can be implanted to repair defects created in meniscal avascular tissue explants. Human meniscal cells (derived from vascular and avascular meniscal tissue) were seeded on ES scaffolds and cultured. Constructs were evaluated for cell viability, gene expression, and mechanical properties. To determine potential for repair of meniscal defects, human meniscus avascular cells were seeded and cultured on aligned ES collagen scaffolds for 4 weeks before implantation. Surgical defects resembling “longitudinal tears” were created in the avascular zone of bovine meniscus and implanted with cell-seeded collagen scaffolds and cultured for 3 weeks. Tissue regeneration and integration were evaluated by histology, immunohistochemistry, mechanical testing, and magentic resonance imaging. Ex vivo implantation with cell-seeded collagen scaffolds resulted in neotissue that was significantly better integrated with the native tissue than acellular collagen scaffolds or untreated defects. Human meniscal cell-seeded ES collagen scaffolds may therefore be useful in facilitating meniscal repair of avascular meniscus tears. PMID:26842062

Vascular access complications in patients undergoing percutaneous procedures in hemodynamics: a scoping review.

PubMed

Reich, Rejane; Rabelo-Silva, Eneida Rejane; Santos, Simone Marques Dos; Almeida, Miriam de Abreu

2018-06-07

To map the production of knowledge on vascular access complications in patients undergoing percutaneous procedures in hemodynamic laboratories. Scoping review study. The search strategy was developed in three stages, considering the period from July 2005 to July 2015 in the PubMed, CINAHL, Scopus, and LILACS databases. The collected data were analyzed and summarized in a narrative form. One-hundred twenty-eight publications that made it possible to map the contexts of study of complications, occurrence according to access routes, as well as an understanding of diagnosis and clinical management, were included. Three theme categories were identified: complications; predictive factors; and diagnosis/treatment. Vascular access site complications range according to the access route used. Knowledge of factors that permeate the occurrence of these events may contribute to early detection, planning, and monitoring of the care implemented.

Inguinal hernia repair in women: is the laparoscopic approach superior?

PubMed

Ashfaq, A; McGhan, L J; Chapital, A B; Harold, K L; Johnson, D J

2014-06-01

Laparoscopic inguinal hernia repair is associated with reduced post-operative pain and earlier return to work in men. However, the role of laparoscopic hernia repair in women is not well reported. The aim of this study was to review the outcomes of the laparoscopic versus open repair of inguinal hernias in women and to discuss patients' considerations when choosing the approach. A retrospective chart review of all consecutive patients undergoing inguinal hernia repair from January 2005 to December 2009 at a single institution was conducted. Presentation characteristics and outcome measures including recurrence rates, post-operative pain and complications were compared in women undergoing laparoscopic versus open hernia repair. A total of 1,133 patients had an inguinal herniorrhaphy. Of these, 101 patients were female (9 %), with a total of 111 hernias. A laparoscopic approach was chosen in 44 % of patients. The majority of women (56 %) presented with groin pain as the primary symptom. Neither the mode of presentation nor the presenting symptoms significantly influenced the surgical approach. There were no statistically significant differences in hernia recurrence, post-operative neuralgia, seroma/hematoma formation or urinary retention between the two approaches (p < 0.05). A greater proportion of patients with bilateral hernias had a laparoscopic approach rather than an open technique (12 vs. 2 %, p = 0.042). Laparoscopic herniorrhaphy is as safe and efficacious as open repair in women, and should be considered when the diagnosis is in question, for management of bilateral hernias or when concomitant abdominal pathology is being addressed.

How can a vascular surgeon help in kidney transplantation.

PubMed

Lejay, Anne; Thaveau, Fabien; Caillard, Sophie; Georg, Yannick; Moulin, Bruno; Wolf, Philippe; Geny, Bernard; Chakfe, Nabil

2017-04-01

Kidney transplantation is a surgical procedure involving both vascular and ureteric anastomoses. As a matter of fact, it can be performed either by urologists or vascular surgeons. However, vascular surgeon's expertise can be helpful at different times. In the present paper we describe how can vascular surgeons help at the different stages of kidney transplantation process in modern care: 1) before kidney transplantation for recipient preparation in order to allow subsequent graft implantation, either by performing percutaneous embolization of renal arteries in the setting of polycystic kidney disease or treatment of aneurysmal or occlusive lesions that would contra-indicate graft implantation; 2) at the time of surgery graft back table preparation and repair; and 3) after surgery for long-term follow-up, including transplant renal artery stenosis treatment or transplant nephrectomy.

Endovascular closure of ascending aortic pseudoaneurysm with a type II Amplatzer vascular plug.

PubMed

De Boo, Diederick W; Mott, Nigel; Kavnoudias, Helen; Walton, Antony; Lyon, Stuart M

2014-05-01

A 71-year-old man initially presented with an asymptomatic, incidentally detected ascending aortic pseudoaneurysm 25 years following aortic root repair with mechanical aortic valve replacement. This pseudoaneurysm was previously treated with coil embolization but due to coil impaction it reopened 8 years later. Endovascular closure of the pseudoaneurysm was achieved with the off-label use of a type II Amplatzer vascular plug.

Renal artery and vein injury following blunt trauma.

PubMed Central

Sturm, J T; Perry, J F; Cass, A S

1975-01-01

Blunt injuries of the renal vascular pedicle occur infrequently. The experience with fourteen cases of blunt renal vascular trauma is presented. Most patients were injured in motor vehicle accidents. The diagnosis was made immediately after admission in 6 patients, delayed in 5, and at autopsy in 3. Most patients presented with gross or microscopic hematuria. The diagnosis of renal vascular injury was suggested by IVP in most instances. Surgical management was used in the 6 patients in whom the immediate diagnosis of renal pedicle injury was made; primary vascular repair was carried out in 4 patients and nephrectomy in two. Conservative management was used in 4 of the 5 patients with delayed diagnosis, and nephrectomy was required in the fifth. Three patients received no treatment as two were dead on arrival and one die during laparotomy. Seven patients died (50%). One of the 7 survivors has a functioning kidney following repair of a renal vein laceration. Three patients with devascularized kidneys have been followed long term and have not developed hypertension. An IVP should be mandatory following severe blunt trauma, especially when hematuria is present. Renal arteriography is indicated with distortion of calyces, extravasation or nonfunction seen on IVP and allows a definitive diagnosis of renal vessel injury to be made. PMID:1190872

Bio-enhanced repair of the anterior cruciate ligament

PubMed Central

Proffen, Benedikt L.; Sieker, Jakob T.; Murray, Martha

2015-01-01

Suture repair of the ACL has been widely abandoned in favor of ACL reconstruction, largely due to the high rates of failure and unreliability of the outcomes following suture repair. However, there have been recent basic science studies which suggest that combining a suture repair with a biologic adjunct may improve the results of suture repair of the ACL, with several studies in large animal models showing equivalent strength of an ACL treated with bio-enhanced repaired with that of an ACL graft at 3, 6 and 12 months after surgery. In addition, the groups treated with bio-enhanced repair had significantly less osteoarthritis when compared with the animals undergoing ACL reconstruction. These findings have led to a renewed interest in bio-enhanced primary repair as a way to make repair of the ACL a viable option for a select group of patients in the future. PMID:25595694

Arthroscopic Double-Row Transosseous Equivalent Rotator Cuff Repair with a Knotless Self-Reinforcing Technique.

PubMed

Mook, William R; Greenspoon, Joshua A; Millett, Peter J

2016-01-01

Rotator cuff tears are a significant cause of shoulder morbidity. Surgical techniques for repair have evolved to optimize the biologic and mechanical variables critical to tendon healing. Double-row repairs have demonstrated superior biomechanical advantages to a single-row. The preferred technique for rotator cuff repair of the senior author was reviewed and described in a step by step fashion. The final construct is a knotless double row transosseous equivalent construct. The described technique includes the advantages of a double-row construct while also offering self reinforcement, decreased risk of suture cut through, decreased risk of medial row overtensioning and tissue strangulation, improved vascularity, the efficiency of a knotless system, and no increased risk for subacromial impingement from the burden of suture knots. Arthroscopic knotless double row rotator cuff repair is a safe and effective method to repair rotator cuff tears.

Arthroscopic Double-Row Transosseous Equivalent Rotator Cuff Repair with a Knotless Self-Reinforcing Technique

PubMed Central

Mook, William R.; Greenspoon, Joshua A.; Millett, Peter J.

2016-01-01

Background: Rotator cuff tears are a significant cause of shoulder morbidity. Surgical techniques for repair have evolved to optimize the biologic and mechanical variables critical to tendon healing. Double-row repairs have demonstrated superior biomechanical advantages to a single-row. Methods: The preferred technique for rotator cuff repair of the senior author was reviewed and described in a step by step fashion. The final construct is a knotless double row transosseous equivalent construct. Results: The described technique includes the advantages of a double-row construct while also offering self reinforcement, decreased risk of suture cut through, decreased risk of medial row overtensioning and tissue strangulation, improved vascularity, the efficiency of a knotless system, and no increased risk for subacromial impingement from the burden of suture knots. Conclusion: Arthroscopic knotless double row rotator cuff repair is a safe and effective method to repair rotator cuff tears. PMID:27733881

Treatment of a Common Iliac Aneurysm by Endovascular Exclusion Using the Amplatzer Vascular Plug and Femorofemoral Crossover Graft

DOE Office of Scientific and Technical Information (OSTI.GOV)

Coupe, Nicholas J., E-mail: optimus2050@hotmail.com; Ling, Lynn; Cowling, Mark G.

2009-07-15

We report our initial experience using the Amplatzer Vascular Plug II (AVP2) in the treatment of a left common iliac aneurysm. Following investigation by computerized tomographic angiography and catheter angiography, a 79-year-old man was found to have a markedly tortuous iliac system, with a left common iliac artery aneurysm that measured 48 mm in maximal diameter. Due to the patient's age and comorbidities the surgical opinion was that conventional open repair was not suitable. However, due to the tortuous nature of the aneurysm and iliac vessels, standard endovascular repair, using either a bifurcated or an aorto-uni-iliac stent graft, was alsomore » not possible. A combined approach was used by embolizing the ipsilateral internal iliac artery using coils and excluding the aneurysm using two AVP2 occlusion devices, followed by femorofemoral crossover grafting. Total aneurysm occlusion was achieved using this method and this allowed the patient to have a much less invasive surgical procedure than with conventional open repair of common iliac aneurysms, thus avoiding potential comorbidity and mortality.« less

Characterization of the Mechanical Strength, Resorption Properties, and Histologic Characteristics of a Fully Absorbable Material (Poly-4-hydroxybutyrate—PHASIX Mesh) in a Porcine Model of Hernia Repair

PubMed Central

Deeken, Corey R.; Matthews, Brent D.

2013-01-01

Purpose. Poly-4-hydroxybutyrate (P4HB) is a naturally derived, absorbable polymer. P4HB has been manufactured into PHASIX Mesh and P4HB Plug designs for soft tissue repair. The objective of this study was to evaluate mechanical strength, resorption properties, and histologic characteristics in a porcine model. Methods. Bilateral defects were created in the abdominal wall of n = 20 Yucatan minipigs and repaired in a bridged fashion with PHASIX Mesh or P4HB Plug fixated with SorbaFix or permanent suture, respectively. Mechanical strength, resorption properties, and histologic characteristics were evaluated at 6, 12, 26, and 52 weeks (n = 5 each). Results. PHASIX Mesh and P4HB Plug repairs exhibited similar burst strength, stiffness, and molecular weight at all time points, with no significant differences detected between the two devices (P > 0.05). PHASIX Mesh and P4HB Plug repairs also demonstrated significantly greater burst strength and stiffness than native abdominal wall at all time points (P < 0.05), and material resorption increased significantly over time (P < 0.001). Inflammatory infiltrates were mononuclear, and both devices exhibited mild to moderate granulation tissue/vascularization. Conclusions. PHASIX Mesh and P4HB Plug demonstrated significant mechanical strength compared to native abdominal wall, despite significant material resorption over time. Histological assessment revealed a comparable mild inflammatory response and mild to moderate granulation tissue/vascularization. PMID:23781348

Urinary function after Snodgrass repair of distal hypospadias: comparison with the Mathieu repair.

PubMed

Scarpa, Maria Grazia; Castagnetti, Marco; Berrettini, Alfredo; Rigamonti, Waifro; Musi, Luciano

2010-05-01

To evaluate urinary function in patients with distal hypospadias undergoing repair by the tubularized incised-plate urethroplasty (TIP or Snodgrass), compare the results with those in patients treated by the Mathieu technique, and show the potential issues inherent to the evaluation of such results. A cross-sectional assessment was performed of uncomplicated distal hypospadias operated on during a 3-year period, already toilet trained, and able to void volitionally. Evaluation included clinical assessment urinary symptoms and urinary stream, and uroflowmetry. Out of 83 patients operated on during the study period, 10 (12%) developed complication and 32 were not toilet trained or refused to participate in the study. Median follow-up in the remaining 41 patients included in the study was 20 (3-36) months. None of these patients presented voiding symptoms or urinary stream abnormalities. Uroflowmetry was normal in 30 cases and obstructive in 11 (27%). An obstructive flow pattern was more common in patients undergoing TIP versus Mathieu repair, 8 of 19 (42%) versus 3 of 22 (14%), respectively (P = 0.07). Four TIP cases with an obstructive uroflow pattern were managed conservatively. Although both the TIP and the Mathieu repair allow good results in terms of urinary function after distal hypospadias repairs, the TIP technique seems more likely to be associated with urine flow pattern abnormalities. The actual clinical relevance of this finding remains ill defined.

Endovascular repair of an iliac arteriovenous fistula secondary to perforation from a common iliac aneurysm in a patient with Ehler-Danlos syndrome.

PubMed

Sala Almonacil, Vicente Andrés; Zaragozá García, José Miguel; Gómez Palonés, Francisco Julián; Plaza Martínez, Ángel; Ortíz Monzón, Eduardo

2012-08-01

Type IV Ehler-Danlos syndrome (EDS) patients are prone to life-threatening vascular complications. Surgical management of those complications is challenging owing to vessel wall fragility, which may result in hemorrhagic events and high mortality rates. Here we report a case of left common iliac aneurysm perforation of the ipsilateral iliac vein repaired using endovascular technique in a patient with EDS. A 54-year-old patient presented with heart failure symptoms that evolved over 1 week in association with left leg edema and steal syndrome due to a perforation of the left iliac vein caused by a left common iliac aneurysm. A thrombosed right common iliac aneurysm and several other visceral and peripheral aneurysms were discovered on computed tomographic scan at admission. An aortouniiliac stent graft was used to seal the fistula. After 18 months of follow-up, the patient remained asymptomatic. We suggest that endovascular therapy is useful to manage vascular complications in patients with EDS. Copyright © 2012 Annals of Vascular Surgery Inc. Published by Elsevier Inc. All rights reserved.

Calculating when elective abdominal aortic aneurysm repair improves survival for individual patients: development of the Aneurysm Repair Decision Aid and economic evaluation.

PubMed

Grant, Stuart W; Sperrin, Matthew; Carlson, Eric; Chinai, Natasha; Ntais, Dionysios; Hamilton, Matthew; Dunn, Graham; Buchan, Iain; Davies, Linda; McCollum, Charles N

2015-04-01

Abdominal aortic aneurysm (AAA) repair aims to prevent premature death from AAA rupture. Elective repair is currently recommended when AAA diameter reaches 5.5 cm (men) and 5.0 cm (women). Applying population-based indications may not be appropriate for individual patient decisions, as the optimal indication is likely to differ between patients based on age and comorbidities. To develop an Aneurysm Repair Decision Aid (ARDA) to indicate when elective AAA repair optimises survival for individual patients and to assess the cost-effectiveness and associated uncertainty of elective repair at the aneurysm diameter recommended by the ARDA compared with current practice. The UK Vascular Governance North West and National Vascular Database provided individual patient data to develop predictive models for perioperative mortality and survival. Data from published literature were used to model AAA growth and risk of rupture. The cost-effectiveness analysis used data from published literature and from local and national databases. A combination of systematic review methods and clinical registries were used to provide data to populate models and inform the structure of the ARDA. Discrete event simulation (DES) was used to model the patient journey from diagnosis to death and synthesised data were used to estimate patient outcomes and costs for elective repair at alternative aneurysm diameters. Eight patient clinical scenarios (vignettes) were used as exemplars. The DES structure was validated by clinical and statistical experts. The economic evaluation estimated costs, quality-adjusted life-years (QALYs) and incremental cost-effectiveness ratios (ICERs) from the NHS, social care provider and patient perspective over a lifetime horizon. Cost-effectiveness acceptability analyses and probabilistic sensitivity analyses explored uncertainty in the data and the value for money of ARDA-based decisions. The ARDA outcome measures include perioperative mortality risk, annual risk of rupture, 1-, 5- and 10-year survival, postoperative long-term survival, median life expectancy and predicted time to current threshold for aneurysm repair. The primary economic measure was the ICER using the QALY as the measure of health benefit. The analysis demonstrated it is feasible to build and run a complex clinical decision aid using DES. The model results support current guidelines for most vignettes but suggest that earlier repair may be effective in younger, fitter patients and ongoing surveillance may be effective in elderly patients with comorbidities. The model adds information to support decisions for patients with aneurysms outside current indications. The economic evaluation suggests that using the ARDA compared with current guidelines could be cost-effective but there is a high level of uncertainty. Lack of high-quality long-term data to populate all sections of the model meant that there is high uncertainty about the long-term clinical and economic consequences of repair. Modelling assumptions were necessary and the developed survival models require external validation. The ARDA provides detailed information on the potential consequences of AAA repair or a decision not to repair that may be helpful to vascular surgeons and their patients in reaching informed decisions. Further research is required to reduce uncertainty about key data, including reintervention following AAA repair, and assess the acceptability and feasibility of the ARDA for use in routine clinical practice. The National Institute for Health Research Health Technology Assessment programme.

Management of Iatrogenic Pseudoaneurysms in Patients Undergoing Coronary Artery Bypass Grafting.

PubMed

Stone, Patrick A; Thompson, Stephanie N; Hanson, Brent; Masinter, David

2016-05-01

A plethora of papers have been written regarding postcatheterization femoral pseudoaneurysms. However, literature is lacking on pseudoaneurysmal management in patients undergoing coronary artery bypass grafting (CABG). Thus, we examined if pseudoaneurysms with subsequent CABG can be managed with the same strategies as those not exposed to the intense anticoagulation accompanying CABGs. During a 14-year study period, we retrospectively examined femoral iatrogenic pseudoaneurysms (IPSAs) diagnosed postheart catheterization in patients having a subsequent CABG. Patient information was obtained from electronic medical records and included pseudoaneurysm characteristics, treatment, and resolution. Outcomes of interest included the occurrence of IPSA treatment failures and complications. In the 66 patients (mean age, 66 ± 11 years, 46% male) meeting inclusion criteria, mean dose of heparin received during the CABG procedure was 34 000 ± 23 000 units. The IPSA size distribution was the following: 17% of IPSAs measured <1 cm, 55% between 1 and 3 cm, and 21% measured >3 cm. Pseudoaneurysms were managed with compression, duplex-guided thrombin injection, and surgical repair (1%, 27%, and 26% of cases, respectively). Thrombin injection and surgical repair were 100% effective at treating pseudoaneurysms, with 1 patient experiencing a surgical site infection postsurgical repair. Observation-only management was employed in 30 (45%) patients. Nine of 30 patients with no intervention beyond observation had duplex documented resolution/thrombosis during follow-up. One patient initially managed by observation required readmission and surgical repair of an enlarging pseudoaneurysm (6 cm growth) following CABG. Management of pseudoaneurysms in patients prior to CABG should be similar to those patients not undergoing intense anticoagulation. In appropriate cases, small aneurysms can be safely observed, while thrombin injections are effective and safe as well. Thus, routine open surgical repair is not routinely required in patients with femoral pseudoaneurysms at time of CABG. © The Author(s) 2016.

Vascular Surgery in the Pacific Theaters of World War II: The Persistence of Ligation Amid Unique Military Medical Conditions.

PubMed

Barr, Justin; Cherry, Kenneth J; Rich, Norman M

2018-06-18

: Although multiple sources chronicle the practice of vascular surgery in the North African, Mediterranean, and European theaters of World War II, that of the Pacific campaign remains undescribed. Relying on primary source documents from the war, this article provides the first discussion of the management of vascular injuries in the island-hopping battles of the Pacific. It explains how the particular military, logistic, and geographic conditions of this theater influenced medical and surgical care, prompting a continued emphasis on ligation when surgeons in Europe had already transitioned to repairing arteries.

Infection Rates in Arthroscopic Versus Open Rotator Cuff Repair.

PubMed

Hughes, Jonathan D; Hughes, Jessica L; Bartley, Justin H; Hamilton, William P; Brennan, Kindyle L

2017-07-01

The prevalence of rotator cuff repair continues to rise, with a noted transition from open to arthroscopic techniques in recent years. One reported advantage of arthroscopic repair is a lower infection rate. However, to date, the infection rates of these 2 techniques have not been directly compared with large samples at a single institution with fully integrated medical records. To retrospectively compare postoperative infection rates between arthroscopic and open rotator cuff repair. Cohort study; Level of evidence, 3. From January 2003 until May 2011, a total of 1556 patients underwent rotator cuff repair at a single institution. These patients were divided into an arthroscopic repair group and an open group. A Pearson chi-square test and Fisher exact test were used, with a subgroup analysis to segment the open repair group into mini-open and open procedures. The odds ratio and 95% CI of developing a postoperative infection was calculated for the 2 groups. A multiple-regressions model was then utilized to identify predictors of the presence of infection. Infection was defined as only those treated with surgical intervention, thus excluding superficial infections treated with antibiotics alone. A total of 903 patients had an arthroscopic repair, while 653 had open repairs (600 mini-open, 53 open). There were 4 confirmed infections in the arthroscopic group and 16 in the open group (15 mini-open, 1 open), resulting in postoperative infection rates of 0.44% and 2.45%, respectively. Subgroup analysis of the mini-open and open groups demonstrated a postoperative infection rate of 2.50% and 1.89%, respectively. The open group had an odds ratio of 5.645 (95% CI, 1.9-17.0) to develop a postoperative infection compared with the arthroscopic group. Patients undergoing open rotator cuff repair had a significantly higher rate of postoperative infection compared with those undergoing arthroscopic rotator cuff repair.

Suture repair of umbilical hernia during caesarean section: a case-control study.

PubMed

Steinemann, D C; Limani, P; Ochsenbein, N; Krähenmann, F; Clavien, P-A; Zimmermann, R; Hahnloser, D

2013-08-01

The objective of this study was to investigate the additional burdens in terms of pain, prolongation of surgery and morbidity which is added to elective caesarean section if umbilical hernia suture repair is performed simultaneously. Secondly, patient's satisfaction and hernia recurrence rate were assessed. Consecutive women with symptomatic umbilical hernia undergoing internal or external suture repair during elective caesarean were included in this retrospective cohort-control study. Data on post-operative pain, duration of surgery and morbidity of a combined procedure were collected. These patients were matched 1:10 to women undergoing caesarean section only. Additionally, two subgroups were assessed separately: external and internal suture hernia repair. These subgroups were compared for patient's satisfaction, cosmesis, body image and recurrence rate. Fourteen patients with a mean age of 37 years were analysed. Internal suture repair (n = 7) prolonged caesarean section by 20 min (p = 0.001) and external suture repair (n = 7) by 34 min (p < 0.0001). Suture repair did not increase morphine use (0.38 ± 0.2 vs. 0.4 ± 02 mg/kg body weight), had no procedure-related morbidity and prolonged hospitalization by 0.5 days (p = 0.01). At a median follow-up of 37 (5-125) months, two recurrences in each surgical technique, internal and external suture repair, occurred (28 %). Body image and cosmesis score showed a higher level of functioning in internal suture repair (p = 0.02; p = 0.04). Despite a high recurrence rate, internal suture repair of a symptomatic umbilical hernia during elective caesarean section should be offered to women if requested. No additional morbidity or scar is added to caesarean section. Internal repair is faster, and cosmetic results are better, additional skin or fascia dissection is avoided, and it seems to be as effective as an external approach. Yet, women must be informed on the high recurrence rate.

A comparison of efficacy of endovascular versus surgical repair for the treatment of arteriovenous fistula stenosis in Taiwan.

PubMed

Fan, Szu-Shan; Chen, Chien-Wen; Lu, Kuo-Cheng; Mao, Hung-Chung; Chen, Miao-Pei; Chou, Chu-Lin

2017-05-15

Percutaneous transluminal angioplasty (PTA) and fistula reconstruction surgery are therapeutic options for vascular access occlusion in hemodialysis patients. However, owing to its convenience, PTA has gradually become the preferred therapeutic option for fistula stenosis or occlusion. This study investigated the effects of the two therapeutic methods on the vascular access maintenance duration (number of days) and maintenance costs of fistula in dialysis patients from different dialysis units. In this study, 544 hemodialysis patients from 2 dialysis units in a teaching hospital in the southern area of Taiwan were included in the analysis of the frequency of PTA or revascularization surgery and the use of related medical resources by conducting a retrospective chart review. The frequency of PTA in the patients undergoing long-term hemodialysis was not significantly associated with their demographic characteristics. The efficacy of PTA has declined with shorter maintenance duration with increasing PTA frequency. The cost profile of PTA was more expensive than that of fistula revascularization surgery. In this study, PTA was found to be just a temporary solution for fistula thrombosis, whereas fistula reconstruction surgery is inexpensive and improves survival time. Therefore, dialysis units should establish an appropriate standard of care to avoid over-reliance on PTA in order to reduce the fistula failure rate, improve the dialysis efficacy, and reduce the psychological stress in patients, as well as to reduce the maintenance costs and rationalize the medical expenses.

The association between caudal anesthesia and increased risk of postoperative surgical complications in boys undergoing hypospadias repair.

PubMed

Taicher, Brad M; Routh, Jonathan C; Eck, John B; Ross, Sherry S; Wiener, John S; Ross, Allison K

2017-07-01

Recent reports have suggested that caudal anesthesia may be associated with an increased risk of postoperative surgical complications. We examined our experience with caudal anesthesia in hypospadias repair to evaluate for increased risk of urethrocutaneous fistula or glanular dehiscence. All hypospadias repairs performed by a single surgeon in 2001-2014 were reviewed. Staged or revision surgeries were excluded. Patient age, weight, hypospadias severity, surgery duration, month and year of surgery, caudal anesthesia use, and postoperative complications were recorded. Bivariate and multivariate statistical analyses were performed. We identified 395 single-stage primary hypospadias repairs. Mean age was 15.6 months; 326 patients had distal (83%) and 69 had proximal (17%) hypospadias. Caudal anesthetics were used in 230 (58%) cases; 165 patients (42%) underwent local penile block at the discretion of the surgeon and/or anesthesiologist. Complications of urethrocutaneous fistula or glanular deshiscence occurred in 22 patients (5.6%) and were associated with caudal anesthetic use (OR 16.5, 95% CI 2.2-123.8, P = 0.007), proximal hypospadias (OR 8.2, 95% CI 3.3-20.0, P < 0.001), increased surgical duration (OR 1.01, 95% CI 1.01-1.02, P < 0.001), and earlier year of practice (OR 3.0, 95% CI 1.2-7.9, P = 0.03 for trend). After adjusting for confounding variables via multivariable logistic regression, both caudal anesthetic use (OR 13.4, 95% CI 1.8-101.8, P = 0.01) and proximal hypospadias (OR 6.8, 95% CI 2.7-16.9, P < 0.001) remained highly associated with postoperative complications. In our experience, caudal anesthesia was associated with an over 13-fold increase in the odds of developing postoperative surgical complications in boys undergoing hypospadias repair even after adjusting for urethral meatus location. Until further investigation occurs, clinicians should carefully consider the use of caudal anesthesia for children undergoing hypospadias repair. © 2017 John Wiley & Sons Ltd.

Compressive cryotherapy versus ice-a prospective, randomized study on postoperative pain in patients undergoing arthroscopic rotator cuff repair or subacromial decompression.

PubMed

Kraeutler, Matthew J; Reynolds, Kirk A; Long, Cyndi; McCarty, Eric C

2015-06-01

The purpose of this study was to compare the effect of compressive cryotherapy (CC) vs. ice on postoperative pain in patients undergoing shoulder arthroscopy for rotator cuff repair or subacromial decompression. A commercial device was used for postoperative CC. A standard ice wrap (IW) was used for postoperative cryotherapy alone. Patients scheduled for rotator cuff repair or subacromial decompression were consented and randomized to 1 of 2 groups; patients were randomized to use either CC or a standard IW for the first postoperative week. All patients were asked to complete a "diary" each day, which included visual analog scale scores based on average daily pain and worst daily pain as well as total pain medication usage. Pain medications were then converted to a morphine equivalent dosage. Forty-six patients completed the study and were available for analysis; 25 patients were randomized to CC and 21 patients were randomized to standard IW. No significant differences were found in average pain, worst pain, or morphine equivalent dosage on any day. There does not appear to be a significant benefit to use of CC over standard IW in patients undergoing shoulder arthroscopy for rotator cuff repair or subacromial decompression. Further study is needed to determine if CC devices are a cost-effective option for postoperative pain management in this population of patients. Copyright © 2015 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.

Enhanced cartilage repair in 'healer' mice-New leads in the search for better clinical options for cartilage repair.

PubMed

Fitzgerald, Jamie

2017-02-01

Adult articular cartilage has a poor capacity to undergo intrinsic repair. Current strategies for the repair of large cartilage defects are generally unsatisfactory because the restored cartilage does not have the same resistance to biomechanical loading as authentic articular cartilage and degrades over time. Recently, an exciting new research direction, focused on intrinsic cartilage regeneration rather than fibrous repair by external means, has emerged. This review explores the new findings in this rapidly moving field as they relate to the clinical goal of restoration of structurally robust, stable and non-fibrous articular cartilage following injury. Copyright © 2016 Elsevier Ltd. All rights reserved.

Strategies for the evaluation of DNA damage and repair mechanisms in cancer.

PubMed

Figueroa-González, Gabriela; Pérez-Plasencia, Carlos

2017-06-01

DNA lesions and the repair mechanisms that maintain the integrity of genomic DNA are important in preventing carcinogenesis and its progression. Notably, mutations in DNA repair mechanisms are associated with cancer predisposition syndromes. Additionally, these mechanisms maintain the genomic integrity of cancer cells. The majority of therapies established to treat cancer are genotoxic agents that induce DNA damage, promoting cancer cells to undergo apoptotic death. Effective methods currently exist to evaluate the diverse effects of genotoxic agents and the underlying molecular mechanisms that repair DNA lesions. The current study provides an overview of a number of methods that are available for the detection, analysis and quantification of underlying DNA repair mechanisms.

[Applied anatomy study and clinical application of great saphenous veno-saphenous neurocutaneous vascular flap].

PubMed

Li, Zelong; Ding, Zihai; Wang, Peixin; Xie, Yibo; Zeng, Bo

2006-03-01

To provide the anatomic basis for defect repair of the knee, leg, foot and ankle with great saphenous veno-saphenous neurocutaneous vascular island flaps. The origin, diameter, branches, distribution and anastomoses of the saphenous artery and saphenous neurocutaneous vascular were observed on 20 sides of adult leg specimens and 4 fresh cadaver voluntary legs. Another 4 fresh cadaver voluntary legs were radiographed with a soft X-ray system after the intravenous injection of Vermilion and cross-sections under profound fascial, other hand, micro-anatomic examination was also performed in these 4 fresh cadaver legs. The soft tissue defects in lower extremity, upper extremity, heel or Hucou in hand were repaired with the proximal or distal pedicle flaps or free flaps in 18 patients (12 males and 6 females,aging from 7 to 53 years). The defect was caused by trauma, tumour, ulcer and scar. The locations were Hucou (1 case), upper leg (3 cases), lower extremity and heal (14 cases). Of then, 7 cases were complicated by bone exposure, 3 cases by tendon exposure and 1 case by steel espouse, the defect size were 4 cm x 4 cm to 7 cm x 13 cm. The flap sizes were 4 cm x 6 cm to 8 cm x 15 cm, which pedicle length was 8-11 cm with 2.5-4.0 cm fascia and 1-2 cm skin at width. Genus descending genicular artery began from 9.33 +/- 0.81 cm away from upper the condyles medialis, it branched saphenous artery accompanying saphenous nerve descendent. And saphenous artery reached the surface of the skin 7.21 +/- 0.82 cm away from lower the condyles medialis, and anastomosed with the branches of tibialis posterior artery, like "Y" or "T" pattern. The chain linking system of arteries were found accompanying along the great saphenous vein as saphenous nerve, and then a axis blood vessel was formed. The small artery of only 0.05-0.10 mm in diameter, distributed around the great saphenous vein within 5-8 mm and arranged parallelly along the vein like water wave in soft X-ray film. All proximal flaps, distal pedicle flaps and free flaps survived well. The appearance, sensation and function were satisfactory in 14 patients after a follow-up of 6-12 months. The great saphenous vein as well as saphenous neurocutaneous has a chain linking system vascular net. A flap with the vascular net can be transplanted by free, by reversed pedicle, or by direct pedicle to repair the wound of upper leg and foot. A superficial vein-superficial neurocutaneous vascular flap with abundance blood supply and without sacrificing a main artery is a favourite method in repair of soft tissue defects in foot and lower extremity.

[Clinical effect of distally-based dorsal thumb neurocutaneous vascular flap on repair of soft tissue defect in thumb].

PubMed

Huang, Yixiong; Shen, Zunli; Wang, Yongchun; Zhang, Shimin

2009-10-01

To investigate the surgical methods and clinical results of repairing soft tissue defects in the thumb with distally-based dorsal thumb neurocutaneous vascular flap. From January 2006 to October 2007, 23 patients with soft tissue defect in the thumb were treated, including 20 males and 3 females aged 19-46 years old (average 27.5 years old). The defect was caused by crush injury in 1 case, electric planer accident in 6 cases, incised injury in 8 cases, and avulsion injury in 8 cases. The defect was located on the palmar aspect of the thumb distal phalanx in 3 cases, the dorsal-radial aspect of the thumb distal phalanx in 3 cases, and ulnar or dorsal aspect in 17 cases. The defect size ranged from 3.3 cm x 1.2 cm to 4.2 cm x 1.2 cm. Among them, 18 cases were complicated with distal 1/2 nail bed defect or injury. The time between injury and hospital admission was 1-72 hours (average 22 hours). During operation, the defect was repaired with distally-based dorsal-radial neurovenocutaneous vascular flap of the thumb in 3 cases and distally-based dorsal-ulnar neurovenocutaneous vascular flap of the thumb in 20 cases. The size of those flaps was 4.0 cm x 1.6 cm-5.0 cm x 3.0 cm. The donor site underwent direct suture or split thickness skin graft repair. At 10 days after operation, 3 cases suffered from the epidermal necrosis in the distal part of the flap, 2 of them experienced the exfoliation of dark scab 14 days later and the flap survived, and the flap of the rest one survived after dressing change. The other flaps and the skin graft at the donor site all survived uneventfully. The wounds healed by first intention. All the patients were followed up for 10-16 months (average 12.6 months). The flaps were soft in texture and full in appearance. The two-point discrimination value 6 months after operation was 8-10 mm. At 12 months after operation, the growth of the residual fingernail was evident in 18 cases, including 4 cases of curved or hook fingernail. Active flexion and extension of the thumb were normal. The abduction of the first web space reached or surpassed 80 percent of the normal side in 20 cases and was below 80 percent of the normal side in 3 cases. The clinical outcomes were satisfactory in 11 cases, approximately satisfactory in 8 cases, and unsatisfactory in 4 cases according to self-designed evaluation system. The operative method of repairing the soft tissue defects in the thumb with the distally-based dorsal thumb neurocutaneous vascular flap is simple, stable in anatomy, in line with the principle of proximity, and suitable for repairing thumb tip defect 3 cm in size. It can bring a good postoperative appearance of the thumb and little influence on the hand function.

Temporal trends and geographical variation in the use of subacromial decompression and rotator cuff repair of the shoulder in England.

PubMed

Judge, A; Murphy, R J; Maxwell, R; Arden, N K; Carr, A J

2014-01-01

We explored the trends over time and the geographical variation in the use of subacromial decompression and rotator cuff repair in 152 local health areas (Primary Care Trusts) across England. The diagnostic and procedure codes of patients undergoing certain elective shoulder operations between 2000/2001 and 2009/2010 were extracted from the Hospital Episode Statistics database. They were grouped as 1) subacromial decompression only, 2) subacromial decompression with rotator cuff repair, and 3) rotator cuff repair only. The number of patients undergoing subacromial decompression alone rose by 746.4% from 2523 in 2000/2001 (5.2/100 000 (95% confidence interval (CI) 5.0 to 5.4) to 21 355 in 2009/2010 (40.2/100 000 (95% CI 39.7 to 40.8)). Operations for rotator cuff repair alone peaked in 2008/2009 (4.7/100 000 (95% CI 4.5 to 4.8)) and declined considerably in 2009/2010 (2.6/100 000 (95% CI 2.5 to 2.7)). Given the lack of evidence for the effectiveness of these operations and the significant increase in the number of procedures being performed in England and elsewhere, there is an urgent need for well-designed clinical trials to determine evidence of clinical effectiveness.

Clinical and Radiographic Outcomes of Meniscus Surgery and Future Targets for Biologic Intervention: A review of data from the MOON Group

PubMed Central

Westermann, Robert W.; Jones, Morgan; Wasserstein, David; Spindler, Kurt P.

2017-01-01

Meniscus injury and treatment occurred with the majority of anterior cruciate ligament reconstructions (ACLR) in the multicenter orthopaedic outcomes (MOON) cohort. We describe the patient reported outcomes, radiographic outcomes and predictors of pain from meniscus injuries and treatment in the setting of ACLR. Patient reported outcomes improve significantly following meniscus repair with ACLR, but differences exist based on the meniscus injury laterally (medial or lateral). Patients undergoing medial meniscus repair have worse patient-reported outcomes and more pain compared to those with uninjured menisci. However, lateral meniscal tears can be repaired with similar outcomes as uninjured menisci. Medial meniscal treatment (meniscectomy or repair) results in a significant loss of joint space at 2 years compared to uninjured menisci. Menisci treated with excision had a greater degree of joint space loss compared to those treated with repair. Clinically significant knee pain is more common following injuries to the medial meniscus and increased in patients who undergo early re-operation after initial ACLR. Future research efforts aimed at improving outcomes after combined ACLR and meniscus treatment should focus on optimizing biologic and mechanical environments that promote healing of medial meniscal tears sustained during ACL injury. PMID:28282214

Long-term outcomes after repair of symptomatic abdominal aortic aneurysms.

PubMed

Chandra, Venita; Trang, Karen; Virgin-Downey, Whitt; Dalman, Ronald L; Mell, Matthew W

2018-04-25

Previous studies have reported increased perioperative mortality of nonruptured symptomatic abdominal aortic aneurysms (Sx-AAA) compared with asymptomatic elective AAA (E-AAA) repairs, but no long-term-outcomes have been reported. We sought to compare long-term outcomes of Sx-AAA and E-AAA after repair at a single academic institution. Patients receiving AAA repair for Sx-AAA and E-AAA from 1995 through 2015 were included. Ruptured AAA and suprarenal or thoracoabdominal AAA were excluded. Demographics, comorbidities, and operative approach were collected. Long-term mortality was the primary outcome, determined by chart review or link to Social Security Death Index. Additionally, long-term mortality and reinterventions were compared after groups were matched with nearest neighbor propensity to reduce bias. AAA repair was performed for 1054 E-AAA (383 open repair [36%], 671 endovascular aneurysm repair [EVAR] [64%]), and 139 symptomatic aneurysms (60 open repair [43%], 79 EVAR [57%]). Age (73 years vs 74 years; P = .13) and aneurysm diameter were similar between Sx-AAA and E-AAA (6.0 cm vs 5.8 cm; P = .5). The proportion of women was higher for Sx-AAA (26% vs 16%; P = .003), as was the proportion of non-Caucasians (40% vs 29%; P = .009). After propensity matching, there were no differences between groups for patient characteristics, AAA diameter, treatment modality, or comorbidities, including hypertension, coronary artery disease, congestive heart failure, diabetes, hyperlipidemia, lung disease, diabetes, renal disease, and smoking history. Women were treated for Sx-AAA at significantly smaller aortic diameters; however, compared with men (5.1 cm vs 6.3 cm; P < .001). Perioperative mortality was 5.0% for Sx-AAA and 2.3% for E-AAA (P = .055). By life-table analysis, Sx-AAA had lower 5-year (62% vs 71%) and 10-year (39% vs 51%) survivals (P = .01) compared with E-AAA for the entire cohort. Similar trends were observed for 5-year and 10-year mortality after propensity matching (63% and 40% vs 71% and 52%; P = .05). When stratified by repair type 5-year and 10-year survivals trended lower after open surgery (68% and 42% Sx-AAA vs 84% and 59% E-AAA; P = .08) but not EVAR (59% and 40% Sx-AAA vs 61% and 49% E-AAA; P = .4). Aneurysm-related reinterventions were similar for Sx-AAA and E-AAA (15% vs 14%; P = .8). Reinterventions were more common after EVAR compared with open repair (22% vs 7%, Sx-AAA P = .015; 20% vs 4% E-AAA; P = .007). Patients with Sx-AAA had lower long-term survival and similar aneurysm-related reinterventions compared with patients with E-AAA undergoing repair. Women also underwent repair for Sx-AAA at a significantly smaller size when compared with men, which emphasizes the role of gender in AAA symptomatology. Differences in long-term survival may be only partially explained by measured patient, aneurysm, and operative factors, and may reflect unmeasured social factors or suggest inherent differences in pathophysiology of Sx-AAAs. Copyright © 2018 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.

Aging, Atherosclerosis, and IGF-1

PubMed Central

Higashi, Yusuke; Sukhanov, Sergiy; Anwar, Asif; Shai, Shaw-Yung

2012-01-01

Insulin-like growth factor 1 (IGF-1) is an endocrine and autocrine/paracrine growth factor that circulates at high levels in the plasma and is expressed in most cell types. IGF-1 has major effects on development, cell growth and differentiation, and tissue repair. Recent evidence indicates that IGF-1 reduces atherosclerosis burden and improves features of atherosclerotic plaque stability in animal models. Potential mechanisms for this atheroprotective effect include IGF-1–induced reduction in oxidative stress, cell apoptosis, proinflammatory signaling, and endothelial dysfunction. Aging is associated with increased vascular oxidative stress and vascular disease, suggesting that IGF-1 may exert salutary effects on vascular aging processes. In this review, we will provide a comprehensive update on IGF-1's ability to modulate vascular oxidative stress and to limit atherogenesis and the vascular complications of aging. PMID:22491965

Effect of reconstructive vascular surgery on red cell deformability--preliminary results.

PubMed Central

Irwin, S T; Rocks, M J; McGuigan, J A; Patterson, C C; Morris, T C; O'Reilly, M J

1983-01-01

Using a simple filtration method, red cell deformability was measured in healthy control subjects and in patients with peripheral vascular disease. Impaired red cell deformability was demonstrated in patients with rest pain or gangrene and in patients with intermittent claudication. An improvement in red cell deformability was demonstrated after successful reconstructive vascular surgery in both patient groups. An improvement in red cell deformability was demonstrated in patients undergoing major limb amputation. PMID:6619311

ADVANCES IN UNDERSTANDING AND MANAGEMENT OF RETINOPATHY OF PREMATURITY

PubMed Central

Hartnett, Mary Elizabeth

2016-01-01

The understanding, diagnosis and treatment of retinopathy of prematurity (ROP) have changed in the last seventy years since the original description of retrolental fibroplasia associated with high oxygenation. It is now recognized that ROP differs in appearance world-wide and as ever smaller and younger premature infants survive. New methods are being evaluated to image the retina, diagnose severe ROP, and determine windows of time for treatment to save eyes and improve visual and neural outcomes. New treatments to promote physiologic retinal vascular development, vascular repair, and inhibit vasoproliferation by regulating proteins involved in vascular endothelial growth factor, insulin-like growth factor, or erythropoietin signaling. Reducing excessive oxidative/nitrosative stress and understanding progenitor cells and neurovascular and glial vascular interactions are being studied. PMID:28012875

Vascular repair strategies in type 2 diabetes: novel insights

PubMed Central

Kuschnerus, Kira; Landmesser, Ulf

2015-01-01

Impaired functions of vascular cells are responsible for the majority of complications in patients with type 2 diabetes (T2D). Recently a better understanding of mechanisms contributing to development of vascular dysfunction and the role of systemic inflammatory activation and functional alterations of several secretory organs, of which adipose tissue has more recently been investigated, has been achieved. Notably, the progression of vascular disease within the context of T2D appears to be driven by a multitude of incremental signaling shifts. Hence, successful therapies need to target several mechanisms in parallel, and over a long time period. This review will summarize the latest molecular strategies and translational developments of cardiovascular therapy in patients with T2D. PMID:26543824

Prospective transfrontal sheep model of skull-base reconstruction using vascularized mucosa.

PubMed

Mueller, Sarina K; Scangas, George; Amiji, Mansor M; Bleier, Benjamin S

2018-05-01

No high-fidelity animal model exists to examine prospective wound healing following vascularized reconstruction of the skull base. Such a model would require the ability to study the prospective behavior of vascularized mucosal repairs of large dural and arachnoid defects within the intranasal environment. The objective of this study was to therefore develop and validate a novel, in vivo, transfrontal sheep model of cranial base repair using vascularized sinonasal mucosa. Twelve transfrontal craniotomy and 1.5-cm durotomy reconstructions were performed in 60-kg to 70-kg Dorset/Ovis Aries sheep using vascularized mucosa with or without an adjunctive Biodesign™ underlay graft (n = 6 per group). Histologic outcomes were graded (scale, 0 to 4) by a blinded veterinary histopathologist after 7, 14, and 28 days for a range of wound healing parameters. All sheep tolerated the surgery, which required 148 ± 33 minutes. By day 7, the mucosa was fully adherent with complete partitioning of the sinus and intracranial compartments. Fibroblast infiltration and flap neovascularization scores significantly increased between day 7 (0.3 ± 0.5 and 0.0 ± 0.0) and day 28 (4.0 ± 0.0, p = 0.01 and 2.0 ± 0.8, p = 0.01; respectively), while hemorrhage scores significantly decreased from 2.5 ± 0.6 to 0.0 ± 0.0 (p = 0.01). The inflammatory scores were not significantly different between the heterologous graft and control sides. The described sheep model accurately reflects prospective intranasal wound healing following vascularized mucosal reconstruction of dural defects. This model can be used in future studies to examine novel reconstructive materials, tissue glues, and transmucosal drug delivery to the central nervous system. © 2017 ARS-AAOA, LLC.

The Impact of Individual In Vivo Repair of DNA Double-Strand Breaks on Oral Mucositis in Adjuvant Radiotherapy of Head-and-Neck Cancer

DOE Office of Scientific and Technical Information (OSTI.GOV)

Fleckenstein, Jochen, E-mail: rajfle@uks.eu; Kuehne, Martin; Seegmueller, Katharina

2011-12-01

Purpose: To evaluate the impact of individual in vivo DNA double-strand break (DSB) repair capacity on the incidence of severe oral mucositis in patients with head-and-neck cancer undergoing adjuvant radiotherapy (RT) or radiochemotherapy (RCT). Patients and Methods: Thirty-one patients with resected head-and-neck cancer undergoing adjuvant RT or RCT were examined. Patients underwent RT of the primary tumor site and locoregional lymph nodes with a total dose of 60-66 Gy (single dose 2 Gy, five fractions per week). Chemotherapy consisted of two cycles of cisplatin and 5-fluorouracil. To assess DSB repair, {gamma}-H2AX foci in blood lymphocytes were quantified before and 0.5more » h, 2.5 h, 5 h, and 24 h after in vivo radiation exposure (the first fraction of RT). World Health Organization scores for oral mucositis were documented weekly and correlated with DSB repair. Results: Sixteen patients received RT alone; 15 patients received RCT. In patients who developed Grade {>=} 3 mucositis (n = 18) the amount of unrepaired DSBs 24 h after radiation exposure and DSB repair half-times did not differ significantly from patients with Grade {<=}2 mucositis (n = 13). Patients with a proportion of unrepaired DSBs after 24 h higher than the mean value + one standard deviation had an increased incidence of severe oral mucositis. Conclusions: Evaluation of in vivo DSB repair by determination of {gamma}-H2AX foci loss is feasible in clinical practice and allows identification of patients with impaired DSB repair. The incidence of oral mucositis is not closely correlated with DSB repair under the evaluated conditions.« less

Valve Repair Is Superior to Replacement in Most Patients With Coexisting Degenerative Mitral Valve and Coronary Artery Diseases.

PubMed

Javadikasgari, Hoda; Gillinov, A Marc; Idrees, Jay J; Mihaljevic, Tomislav; Suri, Rakesh M; Raza, Sajjad; Houghtaling, Penny L; Svensson, Lars G; Navia, José L; Mick, Stephanie L; Desai, Milind Y; Sabik, Joseph F; Blackstone, Eugene H

2017-06-01

For mitral regurgitation (MR) from degenerative mitral disease in patients with coexisting coronary artery disease, the appropriate surgical strategy remains controversial. From 1985 to 2011, 1,071 adults (age 70 ± 9.3 years, 77% men) underwent combined coronary artery bypass grafting and either mitral valve repair (n = 872, 81%) or replacement (n=199, 19%) for degenerative MR. Propensity matching (177 patient pairs, 89% of possible matches) was used to compare early outcomes and time-related recurrence of MR after mitral valve repair, mitral valve reoperation, and mortality. Risk factors for death were identified with multivariable, multiphase hazard-function analysis. Patients undergoing valve replacement were older, with more valve calcification and a higher prevalence of preoperative atrial fibrillation and heart failure (all p < .0001). Among matched pairs, mitral replacement versus repair was associated with higher hospital mortality (5.0% vs 1.0%, p = .0001) and more postoperative renal failure (7.0% vs 3.2%, p = .01), reexplorations for bleeding (6.0% vs 3.1%, p = .05), and respiratory failure (14% vs 4.7%, p < .0001). Of matched patients undergoing repair, 18% had MR above 3+ by 5 years. Mitral valve durability was similar between matched groups, but survival at 15 years was 18% after replacement versus 52% after repair. Nomograms from the multivariable equation revealed that in 94% of cases, 10-year survival was calculated to be higher after repair than after replacement. In patients with coexisting degenerative mitral valve and coronary artery diseases, mitral valve repair is expected to confer a long-term survival advantage over replacement despite some recurrence of MR. When feasible, it is the procedure of choice for these patients. Copyright © 2017 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.

Simple versus complex degenerative mitral valve disease.

PubMed

Javadikasgari, Hoda; Mihaljevic, Tomislav; Suri, Rakesh M; Svensson, Lars G; Navia, Jose L; Wang, Robert Z; Tappuni, Bassman; Lowry, Ashley M; McCurry, Kenneth R; Blackstone, Eugene H; Desai, Milind Y; Mick, Stephanie L; Gillinov, A Marc

2018-07-01

At a center where surgeons favor mitral valve (MV) repair for all subsets of leaflet prolapse, we compared results of patients undergoing repair for simple versus complex degenerative MV disease. From January 1985 to January 2016, 6153 patients underwent primary isolated MV repair for degenerative disease, 3101 patients underwent primary isolated MV repair for simple disease (posterior prolapse), and 3052 patients underwent primary isolated MV repair for complex disease (anterior or bileaflet prolapse), based on preoperative echocardiographic images. Logistic regression analysis was used to generate propensity scores for risk-adjusted comparisons (n = 2065 matched pairs). Durability was assessed by longitudinal recurrence of mitral regurgitation and reoperation. Compared with patients with simple disease, those undergoing repair of complex pathology were more likely to be younger and female (both P values < .0001) but with similar symptoms (P = .3). The most common repair technique was ring/band annuloplasty (3055/99% simple vs 3000/98% complex; P = .5), followed by leaflet resection (2802/90% simple vs 2249/74% complex; P < .0001). Among propensity-matched patients, recurrence of severe mitral regurgitation 10 years after repair was 6.2% for simple pathology versus 11% for complex pathology (P = .007), reoperation at 18 years was 6.3% for simple pathology versus 11% for complex pathology, and 20-year survival was 62% for simple pathology versus 61% for complex pathology (P = .6). Early surgical intervention has become more common in patients with degenerative MV disease, regardless of valve prolapse complexity or symptom status. Valve repair was associated with similarly low operative risk and time-related survival but less durability in complex disease. Lifelong annual echocardiographic surveillance after MV repair is recommended, particularly in patients with complex disease. Copyright © 2018 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

Comparison of endovascular repair with branched stent graft and open repair for aortic arch aneurysm.

PubMed

Kawatou, Masahide; Minakata, Kenji; Sakamoto, Kazuhisa; Nakatsu, Taro; Tazaki, Junichi; Higami, Hirooki; Uehara, Kyokun; Yamazaki, Kazuhiro; Inoue, Kanji; Kimura, Takeshi; Sakata, Ryuzo

2017-08-01

Although conventional open repair is our preference for patients with aortic arch aneurysms, we have often chosen thoracic endovascular aneurysm repair (TEVAR) with a handmade branched stent graft (bTEVAR) in high-risk patients. The aim of this study was to compare the midterm clinical outcomes of our bTEVAR technique to those of the open repair. Between January 2007 and December 2014, we treated 129 patients with aortic arch aneurysm by means of either conventional open repair (OPEN, n = 61) or bTEVAR (n = 68) at our institution. The mean ages were 70.5 ± 12.7 years in the OPEN group and 72.7 ± 12.5 years in the bTEVAR group (P = 0.32). The aetiologies included true aneurysm in 101 patients (78.3%) and chronic dissection in 26 (20.1%). There were 2 (3.3%) in-hospital deaths in the OPEN group and 3 (4.4%) in the bTEVAR group. The mean follow-up duration was 3.0 ± 2.1 years (2.4 ± 1.9 years in the OPEN group and 3.6 ± 2.3 years in the bTEVAR group). There was no difference in 5-year aneurysm-related mortality between groups (10.7% in OPEN vs 12.8% in bTEVAR, P = 0.50). In terms of late additional procedures, however, none were required in the OPEN group, whereas 10 (15.4%) additional endovascular repairs and 4 (6.2%) open repairs were required in the bTEVAR group. Our bTEVAR could be performed with low early mortality, and it yielded similar midterm aneurysm-related mortality to that of conventional open repair. However, these patients undergoing this technique required more late additional procedures than those undergoing conventional open repair. © The Author 2017. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.

Current Biomechanical Concepts for Rotator Cuff Repair

PubMed Central

2013-01-01

For the past few decades, the repair of rotator cuff tears has evolved significantly with advances in arthroscopy techniques, suture anchors and instrumentation. From the biomechanical perspective, the focus in arthroscopic repair has been on increasing fixation strength and restoration of the footprint contact characteristics to provide early rehabilitation and improve healing. To accomplish these objectives, various repair strategies and construct configurations have been developed for rotator cuff repair with the understanding that many factors contribute to the structural integrity of the repaired construct. These include repaired rotator cuff tendon-footprint motion, increased tendon-footprint contact area and pressure, and tissue quality of tendon and bone. In addition, the healing response may be compromised by intrinsic factors such as decreased vascularity, hypoxia, and fibrocartilaginous changes or aforementioned extrinsic compression factors. Furthermore, it is well documented that torn rotator cuff muscles have a tendency to atrophy and become subject to fatty infiltration which may affect the longevity of the repair. Despite all the aforementioned factors, initial fixation strength is an essential consideration in optimizing rotator cuff repair. Therefore, numerous biomechanical studies have focused on elucidating the strongest devices, knots, and repair configurations to improve contact characteristics for rotator cuff repair. In this review, the biomechanical concepts behind current rotator cuff repair techniques will be reviewed and discussed. PMID:23730471

Adipose-Derived Stem-Cell-Seeded Non-Cross-Linked Porcine Acellular Dermal Matrix Increases Cellular Infiltration, Vascular Infiltration, and Mechanical Strength of Ventral Hernia Repairs

PubMed Central

Iyyanki, Tejaswi S.; Dunne, Lina W.; Zhang, Qixu; Hubenak, Justin; Turza, Kristin C.

2015-01-01

Adipose-derived stem cells (ASCs) facilitate wound healing by improving cellular and vascular recruitment to the wound site. Therefore, we investigated whether ASCs would augment a clinically relevant bioprosthetic mesh—non-cross-linked porcine acellular dermal matrix (ncl-PADM)—used for ventral hernia repairs in a syngeneic animal model. ASCs were isolated from the subcutaneous adipose tissue of Brown Norway rats, expanded, and labeled with green fluorescent protein. ASCs were seeded (2.5×104 cells/cm2) onto ncl-PADM for 24 h before surgery. In vitro ASC adhesion to ncl-PADM was assessed at 0.5, 1, and 2 h after seeding, and cell morphology on ncl-PADM was visualized by scanning electron microscopy. Ventral hernia defects (2×4 cm) were created and repaired with ASC-seeded (n=31) and control (n=32) ncl-PADM. Explants were harvested at 1, 2, and 4 weeks after surgery. Explant remodeling outcomes were evaluated using gross evaluation (bowel adhesions, surface area, and grade), histological analysis (hematoxylin and eosin and Masson's trichrome staining), immunohistochemical analysis (von Willebrand factor VIII), fluorescent microscopy, and mechanical strength measurement at the tissue-bioprosthetic mesh interface. Stem cell markers CD29, CD90, CD44, and P4HB were highly expressed in cultured ASCs, whereas endothelial and hematopoietic cell markers, such as CD31, CD90, and CD45 had low expression. Approximately 85% of seeded ASCs adhered to ncl-PADM within 2 h after seeding, which was further confirmed by scanning electron microcopy examination. Gross evaluation of the hernia repairs revealed weak omental adhesion in all groups. Ultimate tensile strength was not significantly different in control and treatment groups. Conversely, elastic modulus was significantly greater at 4 weeks postsurgery in the ASC-seeded group (p<0.001). Cellular infiltration was significantly higher in the ASC-seeded group at all time points (p<0.05). Vascular infiltration was significantly greater at 4 weeks postsurgery in the ASC-seeded group (p<0.001). The presence of ASCs improved remodeling outcomes by yielding an increase in cellular infiltration and vascularization of ncl-PADM and enhanced the elastic modulus at the ncl-PADM-tissue interface. With the ease of harvesting adipose tissues that are rich in ASCs, this strategy may be clinically translatable for improving ncl-PADM ventral hernia repair outcomes. PMID:25156009

Adipose-derived stem-cell-seeded non-cross-linked porcine acellular dermal matrix increases cellular infiltration, vascular infiltration, and mechanical strength of ventral hernia repairs.

PubMed

Iyyanki, Tejaswi S; Dunne, Lina W; Zhang, Qixu; Hubenak, Justin; Turza, Kristin C; Butler, Charles E

2015-02-01

Adipose-derived stem cells (ASCs) facilitate wound healing by improving cellular and vascular recruitment to the wound site. Therefore, we investigated whether ASCs would augment a clinically relevant bioprosthetic mesh-non-cross-linked porcine acellular dermal matrix (ncl-PADM)-used for ventral hernia repairs in a syngeneic animal model. ASCs were isolated from the subcutaneous adipose tissue of Brown Norway rats, expanded, and labeled with green fluorescent protein. ASCs were seeded (2.5×10(4) cells/cm(2)) onto ncl-PADM for 24 h before surgery. In vitro ASC adhesion to ncl-PADM was assessed at 0.5, 1, and 2 h after seeding, and cell morphology on ncl-PADM was visualized by scanning electron microscopy. Ventral hernia defects (2×4 cm) were created and repaired with ASC-seeded (n=31) and control (n=32) ncl-PADM. Explants were harvested at 1, 2, and 4 weeks after surgery. Explant remodeling outcomes were evaluated using gross evaluation (bowel adhesions, surface area, and grade), histological analysis (hematoxylin and eosin and Masson's trichrome staining), immunohistochemical analysis (von Willebrand factor VIII), fluorescent microscopy, and mechanical strength measurement at the tissue-bioprosthetic mesh interface. Stem cell markers CD29, CD90, CD44, and P4HB were highly expressed in cultured ASCs, whereas endothelial and hematopoietic cell markers, such as CD31, CD90, and CD45 had low expression. Approximately 85% of seeded ASCs adhered to ncl-PADM within 2 h after seeding, which was further confirmed by scanning electron microcopy examination. Gross evaluation of the hernia repairs revealed weak omental adhesion in all groups. Ultimate tensile strength was not significantly different in control and treatment groups. Conversely, elastic modulus was significantly greater at 4 weeks postsurgery in the ASC-seeded group (p<0.001). Cellular infiltration was significantly higher in the ASC-seeded group at all time points (p<0.05). Vascular infiltration was significantly greater at 4 weeks postsurgery in the ASC-seeded group (p<0.001). The presence of ASCs improved remodeling outcomes by yielding an increase in cellular infiltration and vascularization of ncl-PADM and enhanced the elastic modulus at the ncl-PADM-tissue interface. With the ease of harvesting adipose tissues that are rich in ASCs, this strategy may be clinically translatable for improving ncl-PADM ventral hernia repair outcomes.

Enhanced Recovery After Surgery Program Implementation in 2 Surgical Populations in an Integrated Health Care Delivery System.

PubMed

Liu, Vincent X; Rosas, Efren; Hwang, Judith; Cain, Eric; Foss-Durant, Anne; Clopp, Molly; Huang, Mengfei; Lee, Derrick C; Mustille, Alex; Kipnis, Patricia; Parodi, Stephen

2017-07-19

Novel approaches to perioperative surgical care focus on optimizing nutrition, mobility, and pain management to minimize adverse events after surgical procedures. To evaluate the outcomes of an enhanced recovery after surgery (ERAS) program among 2 target populations: patients undergoing elective colorectal resection and patients undergoing emergency hip fracture repair. A pre-post difference-in-differences study before and after ERAS implementation in the target populations compared with contemporaneous surgical comparator groups (patients undergoing elective gastrointestinal surgery and emergency orthopedic surgery). Implementation began in February and March 2014 and concluded by the end of 2014 at 20 medical centers within the Kaiser Permanente Northern California integrated health care delivery system. A multifaceted ERAS program designed with a particular focus on perioperative pain management, mobility, nutrition, and patient engagement. The primary outcome was hospital length of stay. Secondary outcomes included hospital mortality, home discharge, 30-day readmission rates, and complication rates. The study included a total of 3768 patients undergoing elective colorectal resection (mean [SD] age, 62.7 [14.1] years; 1812 [48.1%] male) and 5002 patients undergoing emergency hip fracture repair (mean [SD] age, 79.5 [11.8] years; 1586 [31.7%] male). Comparator surgical patients included 5556 patients undergoing elective gastrointestinal surgery and 1523 patients undergoing emergency orthopedic surgery. Most process metrics had significantly greater changes in the ERAS target populations after implementation compared with comparator surgical populations, including those for ambulation, nutrition, and opioid use. Hospital length of stay and postoperative complication rates were also significantly lower among ERAS target populations after implementation. The rate ratios for postoperative complications were 0.68 (95% CI, 0.46-0.99; P = .04) for patients undergoing colorectal resection and 0.67 (95% CI, 0.45-0.99, P = .05) for patients with hip fracture. Among patients undergoing colorectal resection, ERAS implementation was associated with decreased rates of hospital mortality (0.17; 95% CI, 0.03-0.86; P = .03), whereas among patients with hip fracture, implementation was associated with increased rates of home discharge (1.24; 95% CI, 1.06-1.44; P = .007). Multicenter implementation of an ERAS program among patients undergoing elective colorectal resection and patients undergoing emergency hip fracture repair successfully altered processes of care and was associated with significant absolute and relative decreases in hospital length of stay and postoperative complication rates. Rapid, large-scale implementation of a multidisciplinary ERAS program is feasible and effective in improving surgical outcomes.

Effect of endoskeleton stent graft design on pulse wave velocity in patients undergoing endovascular repair of the aortic arch.

PubMed

Hori, Daijiro; Akiyoshi, Kei; Yuri, Koichi; Nishi, Satoshi; Nonaka, Takao; Yamamoto, Takahiro; Imamura, Yusuke; Matsumoto, Harunobu; Kimura, Naoyuki; Yamaguchi, Atsushi

2017-09-01

Pulse wave velocity (PWV), which measures vascular stiffness, is a powerful predictor of cardiovascular event. Treatment of aneurysms with endovascular prosthesis has been reported to increase PWV. The purpose of this study was to evaluate whether an endoskeleton stent graft design has less effect on PWV than the exoskeleton stent graft design. Between July 2008 and September 2016, 74 patients underwent endovascular treatment of aortic arch aneurysm in our institution. PWV before and after surgery were compared between those who underwent treatment with Najuta, an endoskeleton stent graft (n = 51), and those treated with other commercially available exoskeleton stent grafts (n = 23). Preoperative PWV (endoskeleton: 2004 ± 379.2 cm/s vs. exoskeleton: 2083 ± 454.5 cm/s, p = 0.47) was similar between the two groups. Factors that were associated with preoperative PWV were age (r = 0.37, 95% CI 0.15-0.56, p = 0.002) and mean arterial pressure (r = 0.53, 95% CI 0.34-0.68, p < 0.001). There was a significant increase in PWV in patients treated by exoskeleton stent grafts (before: 2083 ± 454.5 cm/s vs. after: 2305 ± 479.7 cm/s, p = 0.023) while endoskeleton stent graft showed no change in PWV (before: 2003 ± 379.2 vs. after: 2010 ± 521.1, p = 0.56). In a multivariate analysis, mean arterial pressure (coef 17.5, 95% CI 6.48-28.59, p = 0.002) and exoskeleton stent graft (coef 359.4, 95% CI 89.36-629.43, p = 0.010) were independently associated with PWV after surgery. Physiological changes after endovascular treatment should be considered including effect on vascular stiffness. Endoskeleton stent graft may provide aneurysm repair with minimum effect in PWV after surgery.

A New Technique for Volar Capsulodesis for Isolated Palmar Scapholunate Interosseous Ligament Injuries: A Cadaveric Study and Case Report.

PubMed

van Kampen, Robert J; Bayne, Christopher O; Moran, Steven L

2015-11-01

Introduction Most surgical techniques for scapholunate interosseous ligament (SLIL) repair address only the dorsal component of the ligament, potentially leading to high surgical failure rates. We introduce a new technique to reconstruct the volar SLIL using a portion of the long radiolunate ligament (LRL). A biomechanical evaluation was performed to evaluate the rupture strength of this repair, and a subsequent anatomic study was performed to verify that this repair would not compromise the blood supply to either the scaphoid or the lunate. Methods A reconstruction of the volar SLIL was developed utilizing a lunate-based strip of the LRL. Fourteen cadaver arms were injected with red-colored epoxide and latex. The blood supply of the volar wrist capsule was dissected. The vascular supply to the ligaments, scaphoid, and lunate were investigated. The biomechanical strength of this reconstruction was tested on five cadaver arms by potting the scaphoid, lunate, and radius and subjecting the repair to a tensile load using a servohydraulic vertical displacement testing machine. Results In all arms, a branch of the radial artery or radiocarpal arch supplied the radioscapholunate ligament at the medial border of the LRL. The proximal half of the scaphoid was supplied by dorsal branches of the radial artery. In all cases, a vessel entered the lunate on its ulnar volar side, away from the repair. The average strength of the intact LRL strip was 97.4 N, and the average strength of the ligament-suture interface used for the capsulodesis was 43.5 N. Conclusion This volar approach to the SLIL does not compromise the vascularity of the scaphoid or the lunate. This approach allows the possibility of repairing or augmenting the volar SLIL. The strength of this repair appears to be less than the strength of the native SLIL. Further clinical studies are warranted.

Maximal aortic diameter affects outcome after endovascular repair of abdominal aortic aneurysms.

PubMed

Huang, Ying; Gloviczki, Peter; Duncan, Audra A; Kalra, Manju; Oderich, Gustavo S; Fleming, Mark D; Harmsen, William S; Bower, Thomas C

2017-05-01

The purpose of this study was to evaluate whether maximal aortic diameter affects outcome after endovascular aneurysm repair (EVAR) of abdominal aortic aneurysm (AAA). Clinical data of patients undergoing EVAR between 1997 and 2011 for nonruptured asymptomatic AAAs in a tertiary center were reviewed. Patients were classified according to diameter of AAA: group 1, <5.0 cm; group 2, 5.0 to 5.4 cm; group 3, 5.5 to 5.9 cm; and group 4, ≥6.0 cm. The primary end point was all-cause mortality; secondary end points were complications, reinterventions, and ruptures. There were 874 patients studied (female, 108 [12%]; group 1, 119; group 2, 246; group 3, 243; group 4, 266); mean age was 76 ± 7.2 years. The 30-day mortality rate was 1.0%, not significantly different between groups (P = .22); complication and reintervention rates were 13% and 4.1%, respectively, similar between groups (P < .05). Five-year survival was 68%; freedom from complications and reinterventions was 65% and 74%, respectively; rupture rate was 0.5%. Multivariate analysis revealed that factors associated with all-cause mortality included maximal aortic diameter, age, gender, surgical risk, cancer history, and endograft type (P < .05). Group 4 had increased risks of mortality (hazard ratio [HR], 2.0; 95% confidence interval [CI], 1.38-2.85; P = .002) and complications (HR, 1.6; 95% CI, 1.2-2.7; P = .009) relative to group 1. Reinterventions were more frequent for aneurysms ≥6.0 cm (HR, 2.0; 95% CI, 1.2-3.3; P = .01). Late rupture rate after EVAR was not different between groups. Maximal aortic diameter is associated with long-term outcomes after elective EVAR. Patients with large AAAs (≥6.0 cm) have higher all-cause mortality, complication, and reintervention rates after EVAR than those with smaller aneurysms. We continue to recommend that AAAs be repaired when they reach 5.5 cm as recommended by the guidelines of the Society for Vascular Surgery. On the basis of our data, EVAR should be considered even in high-risk patients with a maximal aortic diameter between 5.5 and 6.0 cm because surgical risk with aneurysm size above 6.0 cm will increase significantly. Copyright © 2016 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.

Recurrent multifocal cutaneous Kaposiform hemangioendothelioma: A rare vascular tumor of infancy and childhood.

PubMed

Atla, Bhagyalakshmi; Sudhakar, P V; Rao, Nagarjun; Prasad, Uma

2016-01-01

Kaposiform hemangioendothelioma (KHE) is a locally aggressive vascular tumor of childhood although cases occurring in adulthood are also described. The features overlap with juvenile capillary hemangioma and Kaposi sarcoma. We report a rare case of recurrent, multifocal (nose and chin) cutaneous KHE initially occurring in a 3-year-old female child, uncomplicated by Kasabach-Merritt syndrome. Recurrences occurred over the next 6 years and resulted in complete distortion of the nose, requiring plastic repair.

Penile vascular indices in surgically treated and conservatively treated penile fracture: does conventional immediate repair matter?

PubMed

Safarinejad, Mohammad Reza; Lashkari, Mohammad Hossein; Babaei, Alireza; Dadkhah, Farid; Kolahi, Ali Asghar

2012-12-01

To investigate the impact of immediate surgical repair and conservative treatment of penile fracture (PF) on penile vascular indices. The study includes 146 surgically treated (group 1), and 56 conservatively treated patients (group 2). All of the participants underwent penile duplex Doppler ultrasonography (PDDU), and Doppler parameters including the peak systolic velocity (PSV), end diastolic velocity (EDV), and resistive index (RI) were measured in both corpora at baseline and after intracavernosal injection of 20 μg prostaglandin E1. Univariable and multivariable Cox regression analysis addressed study variables. An increased number of men in group 2 (25.0%) compared with men in group 1 (19.2%) reported ED, but the difference did not reach statistical significance (P=0.06). In patients with ED the mean PSV did not differ significantly between the group 1 (30.1±4.02 cm/s) and group 2 (30.1±4.02 cm/s) (P=0.32). Also, in patients without ED, the mean PSV for group 1 (82.4±24.1 cm/s) subjects did not differ significantly from the means for the group 2 patients (79.4±27.2 cm/s) (P=0.21). Vascular hemodynamics in fractured corpus cavernosum did not differ significantly between two groups (P=0.08). Current method of surgical treatment does not provide better outcome in terms of erectile function and penile vascular hemodynamics.

Analysis of achilles tendon vascularity with second-generation contrast-enhanced ultrasound.

PubMed

Genovese, Eugenio; Ronga, Mario; Recaldini, Chiara; Fontana, Federico; Callegari, Leonardo; Maffulli, Nicola; Fugazzola, Carlo

2011-01-01

To compare morphological, power Doppler, and contrast-enhanced ultrasound (CEUS) features of the Achilles tendon between asymptomatic athletes and athletes who had undergone surgical repair of a previous rupture. Twenty-four athletes were divided in two groups (A and B). Group A included 14 patients with a median age of 32 years (range 27 to 47 years) who had undergone surgical repair for unilateral Achilles tendon rupture. Group B (control group) included 10 subjects with a median age of 34 years (range 27 to 40 years) with no previous or present history of tendinopathy. All patients were evaluated with ultrasound, power Doppler, and CEUS with second-generation contrast agent. We studied the uninjured Achilles tendon in athletes of group A and either the left or the right Achilles tendon of the athletes in group B. CEUS showed a significantly greater ability to detect a greater number of vascular spots within the uninjured tendon of group A compared to group B (<0.05). In athletes who had suffered a tear of an Achilles tendon, CEUS detected small vessels that were not identified by power Doppler ultrasound in the uninjured contralateral Achilles tendon. CEUS is useful to evaluate vascularity not detected by other imaging techniques. Vascularity in the uninjured tendon seems to be increased in patients who had a previous rupture. Copyright © 2011 Wiley Periodicals, Inc.

Myeloperoxidase Oxidized LDL Interferes with Endothelial Cell Motility through miR-22 and Heme Oxygenase 1 Induction: Possible Involvement in Reendothelialization of Vascular Injuries

PubMed Central

Daher, Jalil; Martin, Maud; Rousseau, Alexandre; Nuyens, Vincent; Fayyad-Kazan, Hussein; Van Antwerpen, Pierre; Courbebaisse, Guy; Martiat, Philippe; Badran, Bassam; Dequiedt, Frank

2014-01-01

Cardiovascular disease linked to atherosclerosis is the leading cause of death worldwide. Atherosclerosis is mainly linked to dysfunction in vascular endothelial cells and subendothelial accumulation of oxidized forms of LDL. In the present study, we investigated the role of myeloperoxidase oxidized LDL (Mox-LDL) in endothelial cell dysfunction. We studied the effect of proinflammatory Mox-LDL treatment on endothelial cell motility, a parameter essential for normal vascular processes such as angiogenesis and blood vessel repair. This is particularly important in the context of an atheroma plaque, where vascular wall integrity is affected and interference with its repair could contribute to progression of the disease. We investigated in vitro the effect of Mox-LDL on endothelial cells angiogenic properties and we also studied the signalling pathways that could be affected by analysing Mox-LDL effect on the expression of angiogenesis-related genes. We report that Mox-LDL inhibits endothelial cell motility and tubulogenesis through an increase in miR-22 and heme oxygenase 1 expression. Our in vitro data indicate that Mox-LDL interferes with parameters associated with angiogenesis. They suggest that high LDL levels in patients would impair their endothelial cell capacity to cope with a damaged endothelium contributing negatively to the progression of the atheroma plaque. PMID:25530680

Laparoscopic paraesophageal hernia repair: current controversies.

PubMed

Soper, Nathaniel J; Teitelbaum, Ezra N

2013-10-01

The advent of laparoscopy has significantly improved postoperative outcomes in patients undergoing surgical repair of a paraesophageal hernia. Although this minimally invasive approach considerably reduces postoperative pain and recovery times, and may improve physiologic outcomes, laparoscopic paraesophageal hernia repair remains a complex operation requiring advanced laparoscopic skills and experience with the anatomy of the gastroesophageal junction and diaphragmatic hiatus. In this article, we describe our approach to patient selection, preoperative evaluation, operative technique, and postoperative management. Specific attention is paid to performing an adequate hiatal dissection and esophageal mobilization, the decision of whether to use a mesh to reinforce the crural repair, and construction of an adequate antireflux barrier (ie, fundoplication).

Vascular Welding Using The Argon Laser

NASA Astrophysics Data System (ADS)

White, Rodney A.; Donayre, Carlos; Kopchok, George; White, Geoffrey; Abergel, R. Patrick; Lyons, Richard; Klein, Stanley; Dwyer, Richard; Uitto, Jouni

1987-03-01

This study compared the histology, biochemistry, and tensile strength of laser welded and sutured canine venotomies, arteriotomies and arteriovenous fistulas. Bilateral femoral, carotid or jugular vessels were studied with one repair (control) closed with interrupted 6-0 polypropylene sutures, and the contralatral repair (experimental) welded with the argon laser. Specimens were examined at weekly intervals from 1 to 4 weeks for each type of repair and evaluated histologically by hematoxylineosin, elastin and trichrome stains, biochemically by the formation of [3H] hyaroxyproline as an index of collagen synthesis, ana mechanically by tensile strength determinations. At removal, all experimental closures were patent without hematomas, aneurysms or luminal dilatation. Histologic and biochemical examination and tensile strength determinations suggest that laser welaing may be an alternative to sutures for repair of large diameter venotomies, arteriotomies and arteriovenous fistulas, as they heal comparable to suture repairs up to 4 weeks postoperatively.

Retinal vascular injuries and intravitreal human embryonic stem cell-derived haemangioblasts.

PubMed

Wang, Jin-Da; An, Ying; Zhang, Jing-Shang; Wan, Xiu-Hua; Zhang, Wei; Lanza, Robert; Lu, Shi-Jiang; Jonas, Jost B; Xu, Liang

2017-09-01

To investigate whether intravitreally applied haemangioblasts (HB) derived from human embryonic stem cells (hESCs) are helpful for the repair of vascular damage caused in animals by an oxygen-induced retinopathy (OIR), by an induced diabetic retinopathy (DR) or by an induced retinal ischaemia with subsequent reperfusion. Human embryonic stem cell-derived HBs were transplanted intravitreally into C57BL/6J mice (OIR model), into male Wistar rats with an induced DR and into male Wistar rats undergoing induced retinal ischaemia with subsequent reperfusion. Control groups of animals received an intravitreal injection of endothelial cells (ECs) or phosphate-buffered saline (PBS). We examined the vasculature integrity in the mice with OIR, the blood-retina barrier in the rats with induced DR, and retinal thickness and retinal ganglion cell density in retina flat mounts of the rats with the retinal ischaemic-reperfusion retinopathy. In the OIR model, the study group versus control groups showed a significantly (p < 0.001) smaller retinal avascular area [5.1 ± 2.7%;n = 18 animals versus 12.2 ± 2.8% (PBS group; n = 10 animals) and versus 11.8 ± 3.7% (EC group; n = 8 animals)] and less retinal neovascularization [6.3 ± 2.5%;n = 18 versus 15.2 ± 6.3% (n = 10; PBS group) and versus 15.8 ± 3.3% (n = 8; EC group)]. On retinal flat mounts, hESC-HBs were integrated into damaged retinal vessels and stained positive for PECAM (CD31) as EC marker. In the DR model, the study group versus the EC control group showed a significantly (p = 0.001) better blood-retina barrier function as measured at 2 days after the intravitreal injections [study group: 20.2 ± 12.8 μl/(g × hr); n = 6; versus EC control group: 52.9 ± 9.9 μl/(g × hr; n = 6)]. In the retinal ischaemia-reperfusion model, the groups did not differ significantly in retinal thickness and retinal ganglion cell density at 2, 5 and 7 days after baseline. By integrating into damaged retinal vessels and differentiating into ECs, intravitreally administered hESC-HBs may have partially repaired a retinal vascular injury caused by OIR model and DR. © 2017 Acta Ophthalmologica Scandinavica Foundation. Published by John Wiley & Sons Ltd.

Traversing and labeling interconnected vascular tree structures from 3D medical images

NASA Astrophysics Data System (ADS)

O'Dell, Walter G.; Govindarajan, Sindhuja Tirumalai; Salgia, Ankit; Hegde, Satyanarayan; Prabhakaran, Sreekala; Finol, Ender A.; White, R. James

2014-03-01

Purpose: Detailed characterization of pulmonary vascular anatomy has important applications for the diagnosis and management of a variety of vascular diseases. Prior efforts have emphasized using vessel segmentation to gather information on the number or branches, number of bifurcations, and branch length and volume, but accurate traversal of the vessel tree to identify and repair erroneous interconnections between adjacent branches and neighboring tree structures has not been carefully considered. In this study, we endeavor to develop and implement a successful approach to distinguishing and characterizing individual vascular trees from among a complex intermingling of trees. Methods: We developed strategies and parameters in which the algorithm identifies and repairs false branch inter-tree and intra-tree connections to traverse complicated vessel trees. A series of two-dimensional (2D) virtual datasets with a variety of interconnections were constructed for development, testing, and validation. To demonstrate the approach, a series of real 3D computed tomography (CT) lung datasets were obtained, including that of an anthropomorphic chest phantom; an adult human chest CT; a pediatric patient chest CT; and a micro-CT of an excised rat lung preparation. Results: Our method was correct in all 2D virtual test datasets. For each real 3D CT dataset, the resulting simulated vessel tree structures faithfully depicted the vessel tree structures that were originally extracted from the corresponding lung CT scans. Conclusion: We have developed a comprehensive strategy for traversing and labeling interconnected vascular trees and successfully implemented its application to pulmonary vessels observed using 3D CT images of the chest.

Outcomes of popliteal vascular injuries at Sri Lankan war-front military hospital: case series of 44 cases.

PubMed

Ratnayake, Amila; Samarasinghe, Bandula; Bala, Miklosh

2014-05-01

Traumatic injury to the popliteal vascular zone remains a challenging problem on the modern battlefield and is frequently associated with more complications than other vascular injuries. Limb salvage and morbidity (graft infection, thrombosis and delayed haemorrhage) were studied. All popliteal vascular injuries over an 8 month period admitted to the Military Base Hospital were analyzed. Local limb evaluation included confirmation of the presence of ischaemia, extent of soft tissue damage, muscle viability after calf fasciotomy, and neurological injury. Ischaemic time was recorded from the time of injury to definitive revascularization. If there was a prior attempt at reconstruction, the amputation was considered delayed. For a series of 44 patients with popliteal vascular injury average time to presentation was 390min, 46% were completely ischaemic. Of those 39 (89%) had popliteal artery injuries. There were 24 (62%) complete popliteal artery transections and associated venous (69%) and osseous (46%) injuries. The preferred technique of repair was inter-position venous graft (IPVG) (54%). Eleven immediate amputations were performed (28%). There were 13 wound infections (33%), 5 early graft thromboses (5 of 21 IPVG, 238%), 2 anastomotic disruptions (2 of 21 IPVG, 9%), which resulted in 4 delayed amputations. Mortality was 5% (2 patients). In this case series of popliteal artery injury early identification of limbs at risk, early four compartment fasciotomy, temporary intra-luminal shunting, definitive repair of concomitant venous injuries and aggressive treatment of haemodynamic instability were shown to be beneficial in achieving reasonable outcome in an austere environment with limited recourses. Copyright © 2014 Elsevier Ltd. All rights reserved.

Epithelial-mesenchymal transition in tissue repair and fibrosis.

PubMed

Stone, Rivka C; Pastar, Irena; Ojeh, Nkemcho; Chen, Vivien; Liu, Sophia; Garzon, Karen I; Tomic-Canic, Marjana

2016-09-01

The epithelial-mesenchymal transition (EMT) describes the global process by which stationary epithelial cells undergo phenotypic changes, including the loss of cell-cell adhesion and apical-basal polarity, and acquire mesenchymal characteristics that confer migratory capacity. EMT and its converse, MET (mesenchymal-epithelial transition), are integral stages of many physiologic processes and, as such, are tightly coordinated by a host of molecular regulators. Converging lines of evidence have identified EMT as a component of cutaneous wound healing, during which otherwise stationary keratinocytes (the resident skin epithelial cells) migrate across the wound bed to restore the epidermal barrier. Moreover, EMT plays a role in the development of scarring and fibrosis, as the matrix-producing myofibroblasts arise from cells of the epithelial lineage in response to injury but are pathologically sustained instead of undergoing MET or apoptosis. In this review, we summarize the role of EMT in physiologic repair and pathologic fibrosis of tissues and organs. We conclude that further investigation into the contribution of EMT to the faulty repair of fibrotic wounds might identify components of EMT signaling as common therapeutic targets for impaired healing in many tissues. Graphical Abstract Model for injury-triggered EMT activation in physiologic wound repair (left) and fibrotic wound healing (right).

[A case of vesicovaginal fistula repair with rectus abdominus myofascial interposition flap after radical hysterectomy and radiation therapy].

PubMed

Endo, Yuki; Iigaya, Shigeki; Nishimura, Taiji; Ishii, Naohiro; Kitaoka, Yoshihisa; Kawashima, Toshifumi; Ohara, Chiharu; Hamasaki, Tsutomu; Kondo, Yukihiro

2014-10-01

Vesicovaginal fistulas (VVFs) caused after radiation are difficult to repair and require interposition of non-irradiated, well-vascularized tissue between urinary bladder and vagina. A 48-year-old female suffered cervical cancer and underwent radical hysterectomy followed by radiation therapy which caused VVF. The initial surgical repair performed 3 months after development of VVF, was unsuccessful because of the absence of peritoneum or omentum to interpose between urinary bladder and vagina probably due to history of cesarean section and radical hysterectomy. The second surgical repair was performed 15 months after the first surgery utilizing a rectus abdominus myofascial (RAM) interposition flap. Fifteen months after the second operation, she remains free from incontinence. This case suggests that RAM is useful even for postradiation VVF.

Wound repair and regeneration: mechanisms, signaling, and translation.

PubMed

Eming, Sabine A; Martin, Paul; Tomic-Canic, Marjana

2014-12-03

The cellular and molecular mechanisms underpinning tissue repair and its failure to heal are still poorly understood, and current therapies are limited. Poor wound healing after trauma, surgery, acute illness, or chronic disease conditions affects millions of people worldwide each year and is the consequence of poorly regulated elements of the healthy tissue repair response, including inflammation, angiogenesis, matrix deposition, and cell recruitment. Failure of one or several of these cellular processes is generally linked to an underlying clinical condition, such as vascular disease, diabetes, or aging, which are all frequently associated with healing pathologies. The search for clinical strategies that might improve the body's natural repair mechanisms will need to be based on a thorough understanding of the basic biology of repair and regeneration. In this review, we highlight emerging concepts in tissue regeneration and repair, and provide some perspectives on how to translate current knowledge into viable clinical approaches for treating patients with wound-healing pathologies. Copyright © 2014, American Association for the Advancement of Science.

Liver repair and hemorrhage control by using laser soldering of liquid albumin in a porcine model.

PubMed

Wadia, Y; Xie, H; Kajitani, M

2000-01-01

We evaluated laser soldering by using liquid albumin for welding liver injuries. Major liver trauma has a high mortality because of immediate exsanguination and a delayed morbidity from septicemia, peritonitis, biliary fistulae, and delayed secondary hemorrhage. Eight laceration (6 x 2 cm) and eight nonanatomic resection injuries (raw surface, 6 x 2 cm) were repaired. An 805-nm laser was used to weld 50% liquid albumin-indocyanine green solder to the liver surface, reinforcing it with a free autologous omental scaffold. The animals were heparinized and hepatic inflow occlusion was used for vascular control. All 16 soldering repairs were evaluated at 3 hours. All 16 laser mediated liver repairs had minimal blood loss as compared with the suture controls. No dehiscence, hemorrhage, or bile leakage was seen in any of the laser repairs after 3 hours. Laser fusion repair of the liver is a reliable technique to gain hemostasis on the raw surface as well as weld lacerations. Copyright 2000 Wiley-Liss, Inc.

Wound repair and regeneration: Mechanisms, signaling, and translation

PubMed Central

Eming, Sabine A.; Martin, Paul; Tomic-Canic, Marjana

2015-01-01

The cellular and molecular mechanisms underpinning tissue repair and its failure to heal are still poorly understood, and current therapies are limited. Poor wound healing after trauma, surgery, acute illness, or chronic disease conditions affects millions of people worldwide each year and is the consequence of poorly regulated elements of the healthy tissue repair response, including inflammation, angiogenesis, matrix deposition, and cell recruitment. Failure of one or several of these cellular processes is generally linked to an underlying clinical condition, such as vascular disease, diabetes, or aging, which are all frequently associated with healing pathologies. The search for clinical strategies that might improve the body’s natural repair mechanisms will need to be based on a thorough understanding of the basic biology of repair and regeneration. In this review, we highlight emerging concepts in tissue regeneration and repair, and provide some perspectives on how to translate current knowledge into viable clinical approaches for treating patients with wound-healing pathologies. PMID:25473038

Connecting the plant vasculature to friend or foe.

PubMed

Melnyk, Charles W

2017-03-01

Contents 1611 I. 1611 II. 1612 III. 1612 IV. 1614 V. 1614 VI. 1614 VII. 1615 VIII. 1616 1616 References 1616 SUMMARY: The plant vasculature transports water, sugars, hormones, RNAs and proteins. Such critical functions need to be protected from attack by pests and pathogens or from damage by wounding. Plants have developed mechanisms to repair vasculature when such protections fail and to even initiate new vascular connections to tissues supporting symbionts. The developmental phenomena underlying vascular repair and rewiring are therefore critical for horticultural grafting, for plant infection and for mutualist associations with rhizosphere microbes. Despite the biological and economic interest, we are only beginning to understand how plants connect and reconnect their vasculature to a wide variety of organisms. Here, I discuss recent work and future prospects for this emerging field. © 2016 The Author. New Phytologist © 2016 New Phytologist Trust.

Muscle fibers are injured at the time of acute and chronic rotator cuff repair.

PubMed

Davis, Max E; Stafford, Patrick L; Jergenson, Matthew J; Bedi, Asheesh; Mendias, Christopher L

2015-01-01

Rotator cuff tears are a common source of shoulder pain and disability. Even after surgical repair, some patients continue to have reduced function and progression of fatty degeneration. Because patients with chronic cuff tears often experience muscle shortening, it is possible that repairing the tendon to its anatomic footprint induces a stretch-induced muscle injury that could contribute to failures of the repair and perhaps ongoing pain. We hypothesized that, compared with acutely torn and repaired muscles, the stretch that is required to repair a chronically torn cuff would result in more muscle fiber damage. Specifically, we asked: (1) Is there muscle fiber damage that occurs from repair of an acutely torn rotator cuff and does it vary by location in the muscle; and (2) is the damage greater in the case of repair of a chronic injury? We used an open surgical approach to create a full-thickness rotator cuff tear in rats, and measured changes in muscle mass, length, and the number of fibers containing the membrane impermeable Evans Blue Dye after acute (1 day) or chronic (28 days) cuff tear or repair in rats. Differences between groups were tested using a one-way ANOVA followed by Tukey's post hoc sorting. Chronic tears resulted in 24% to 35% decreases in mass and a 20% decrease in length. The repair of acutely and chronically torn muscles resulted in damage to 90% of fibers in the distal portion of the muscle. In the proximal portion, no differences between the acutely torn and repaired groups and controls were observed, whereas repairing the chronically torn group resulted in injury to almost 70% of fibers. In a rat model, marked injury to muscle fibers is induced when the tendons of torn rotator cuffs are repaired to their anatomic footprint. In this animal model, we found that repair of chronically torn cuff muscles results in extensive injury throughout the muscle. Based on these findings, we posit that inducing a widespread injury at the time of surgical repair of chronically torn rotator cuff muscles may contribute to the problems of failed repairs or continued progression of fatty degeneration that is observed in some patients that undergo rotator cuff repair. Therapeutic interventions to protect muscle fiber membranes potentially could enhance outcomes for patients undergoing rotator cuff repair. To evaluate this, future studies that evaluate the use of membrane sealing compounds or drugs that upregulate endogenous membrane-sealing proteins are warranted.

Laser-assisted fibrinogen bonding of umbilical vein grafts.

PubMed

Oz, M C; Williams, M R; Souza, J E; Dardik, H; Treat, M R; Bass, L S; Nowygrod, R

1993-06-01

Despite success with autologous tissue welding, laser welding of synthetic vascular prostheses has not been possible. The graft material appears inert and fails to allow the collagen breakdown and electrostatic bonding that results in tissue welding. To develop a laser welding system for graft material, we repaired glutaraldehyde-tanned human umbilical cord vein graft incisions using laser-assisted fibrinogen bonding (LAFB) technology. Modified umbilical vein graft was incised transversely (1.2 cm). Incisions were repaired using sutures, laser energy alone, or LAFB. For LAFB, indocyanine green dye was mixed with human fibrinogen and the compound applied with forceps onto the weld site prior to exposure to 808 nm diode laser energy (power density 4.8 W/cm 2). Bursting pressures for sutured repairs (126.6 +/- 23.4 mm Hg) were similar to LAFB anastomoses (111.6 +/- 55.0 mm Hg). No evidence of collateral thermal injury to the graft material was noted. In vivo evaluation of umbilical graft bonding with canine arteries demonstrates that LAFB can reliably reinforce sutured anastomoses. The described system for bonding graft material with laser exposed fibrinogen may allow creation or reinforcement of vascular anastomoses in procedures where use of autologous tissue is not feasible.

Hospital costs associated with surgical site infections in general and vascular surgery patients.

PubMed

Boltz, Melissa M; Hollenbeak, Christopher S; Julian, Kathleen G; Ortenzi, Gail; Dillon, Peter W

2011-11-01

Although much has been written about excess cost and duration of stay (DOS) associated with surgical site infections (SSIs) after cardiothoracic surgery, less has been reported after vascular and general surgery. We used data from the National Surgical Quality Improvement Program (NSQIP) to estimate the total cost and DOS associated with SSIs in patients undergoing general and vascular surgery. Using standard NSQIP practices, data were collected on patients undergoing general and vascular surgery at a single academic center between 2007 and 2009 and were merged with fully loaded operating costs obtained from the hospital accounting database. Logistic regression was used to determine which patient and preoperative variables influenced the occurrence of SSIs. After adjusting for patient characteristics, costs and DOS were fit to linear regression models to determine the effect of SSIs. Of the 2,250 general and vascular surgery patients sampled, SSIs were observed in 186 inpatients. Predisposing factors of SSIs were male sex, insulin-dependent diabetes, steroid use, wound classification, and operative time (P < .05). After adjusting for those characteristics, the total excess cost and DOS attributable to SSIs were $10,497 (P < .0001) and 4.3 days (P < .0001), respectively. SSIs complicating general and vascular surgical procedures share many risk factors with SSIs after cardiothoracic surgery. Although the excess costs and DOS associated with SSIs after general and vascular surgery are somewhat less, they still represent substantial financial and opportunity costs to hospitals and suggest, along with the implications for patient care, a continuing need for cost-effective quality improvement and programs of infection prevention. Copyright © 2011 Mosby, Inc. All rights reserved.

Recapitulation of developmental mechanisms to revascularize the ischemic heart

PubMed Central

Dubé, Karina N.; Thomas, Tonia M.; Munshaw, Sonali; Rohling, Mala; Riley, Paul R.

2017-01-01

Restoring blood flow after myocardial infarction (MI) is essential for survival of existing and newly regenerated tissue. Endogenous vascular repair processes are deployed following injury but are poorly understood. We sought to determine whether developmental mechanisms of coronary vessel formation are intrinsically reactivated in the adult mouse after MI. Using pulse-chase genetic lineage tracing, we establish that de novo vessel formation constitutes a substantial component of the neovascular response, with apparent cellular contributions from the endocardium and coronary sinus. The adult heart reverts to its former hypertrabeculated state and repeats the process of compaction, which may facilitate endocardium-derived neovascularization. The capacity for angiogenic sprouting of the coronary sinus vein, the adult derivative of the sinus venosus, may also reflect its embryonic origin. The quiescent epicardium is reactivated and, while direct cellular contribution to new vessels is minimal, it supports the directional expansion of the neovessel network toward the infarcted myocardium. Thymosin β4, a peptide with roles in vascular development, was required for endocardial compaction, epicardial vessel expansion, and smooth muscle cell recruitment. Insight into pathways that regulate endogenous vascular repair, drawing on comparisons with development, may reveal novel targets for therapeutically enhancing neovascularization. PMID:29202457

The Abdominal Aortic Aneurysm Statistically Corrected Operative Risk Evaluation (AAA SCORE) for predicting mortality after open and endovascular interventions.

PubMed

Ambler, Graeme K; Gohel, Manjit S; Mitchell, David C; Loftus, Ian M; Boyle, Jonathan R

2015-01-01

Accurate adjustment of surgical outcome data for risk is vital in an era of surgeon-level reporting. Current risk prediction models for abdominal aortic aneurysm (AAA) repair are suboptimal. We aimed to develop a reliable risk model for in-hospital mortality after intervention for AAA, using rigorous contemporary statistical techniques to handle missing data. Using data collected during a 15-month period in the United Kingdom National Vascular Database, we applied multiple imputation methodology together with stepwise model selection to generate preoperative and perioperative models of in-hospital mortality after AAA repair, using two thirds of the available data. Model performance was then assessed on the remaining third of the data by receiver operating characteristic curve analysis and compared with existing risk prediction models. Model calibration was assessed by Hosmer-Lemeshow analysis. A total of 8088 AAA repair operations were recorded in the National Vascular Database during the study period, of which 5870 (72.6%) were elective procedures. Both preoperative and perioperative models showed excellent discrimination, with areas under the receiver operating characteristic curve of .89 and .92, respectively. This was significantly better than any of the existing models (area under the receiver operating characteristic curve for best comparator model, .84 and .88; P < .001 and P = .001, respectively). Discrimination remained excellent when only elective procedures were considered. There was no evidence of miscalibration by Hosmer-Lemeshow analysis. We have developed accurate models to assess risk of in-hospital mortality after AAA repair. These models were carefully developed with rigorous statistical methodology and significantly outperform existing methods for both elective cases and overall AAA mortality. These models will be invaluable for both preoperative patient counseling and accurate risk adjustment of published outcome data. Copyright © 2015 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.

Improved laser-assisted vascular tissue fusion using solder-doped polymer membranes on a canine model

NASA Astrophysics Data System (ADS)

McNally-Heintzelman, Karen M.; Sorg, Brian S.; Hammer, Daniel X.; Heintzelman, Douglas L.; Hodges, Diane E.; Welch, Ashley J.

2000-05-01

Newly developed light-activated surgical adhesives have been investigated as a substitute to traditional protein solders for vascular tissue fusion without the need for sutures. Canine femoral arteries (n equals 14), femoral veins (n equals 14) and carotid arteries (n equals 10) were exposed, and a 0.3 to 0.6 cm longitudinal incision was made in the vessel walls. The surgical adhesive, composed of a poly(L-lactic-co-glycolic acid) scaffold doped with the traditional protein solder mix of bovine serum albumin and indocyanine green dye, was used to close the incisions in conjunction with an 805 nm diode laser. Blood flow was restored to the vessels immediately after the procedure and the incision sites were checked for patency. The new adhesives were flexible enough to be wrapped around the vessels while their solid nature avoided the problems associated with 'runaway' of the less viscous liquid protein solders widely used by researchers. Assessment parameters included measurement of the ex vivo intraluminal bursting pressure one to two hours after surgery, as well as histology. The acute intraluminal bursting pressures were significantly higher in the laser-solder group (greater than 300 mmHg) compared to the suture control group (less than 150 mmHg) where four evenly spaced sutures were used to repair the vessel (n equals 4). Histological analysis showed negligible evidence of collateral thermal damage to the underlying tissue in the laser-solder repair group. These initial results indicated that laser-assisted vascular repair using the new adhesives is safe, easy to perform, and contrary to conventional suturing, provides an immediate leak-free closure. In addition, the flexible and moldable nature of the new adhesives should allow them to be tailored to a wide range of tissue geometries, thus greatly improving the clinical applicability of laser-assisted tissue repair.

Advances in understanding and management of retinopathy of prematurity.

PubMed

Hartnett, Mary Elizabeth

The understanding, diagnosis, and treatment of retinopathy of prematurity have changed in the 70 years since the original description of retrolental fibroplasia associated with high oxygenation. It is now recognized that retinopathy of prematurity differs in appearance worldwide and as ever smaller and younger premature infants survive. New methods are being evaluated to image the retina, diagnose severe retinopathy of prematurity, and determine windows of time for treatment to save eyes and improve visual and neural outcomes. New treatments to promote physiologic retinal vascular development, vascular repair, and inhibit vasoproliferation by regulating proteins involved in vascular endothelial growth factor, insulin-like growth factor, or erythropoietin signaling. Reducing excessive oxidative/nitrosative stress and understanding progenitor cells and neurovascular and glial vascular interactions are being studied. Copyright © 2016 Elsevier Inc. All rights reserved.

Management of pulmonary arterial hypertension associated with congenital heart disease.

PubMed

Togănel, Rodica; Benedek, I; Suteu, Carmen; Blesneac, Cristina

2007-01-01

Congenital heart diseases are the most common congenital malformations and account for about eight cases per 1000 births and are often associated with pulmonary arterial hypertension. Increased shear stress and the excess flow through the pulmonary vascular bed due to a systemic-to-pulmonary shunt lead to the development of pulmonary vascular disease and an increase in pulmonary vascular resistance. Without surgical repair approximately 30% of patients develop pulmonary vascular disease. Eisenmenger syndrome represents the extreme end of pulmonary arterial hypertension with congenital heart disease. We summarized the current therapeutic options for pulmonary arterial hypertension; conventional treatments including calcium channel blockers, anticoagulation, digitalis, diuretics, and new treatment: prostacyclin, bosentan, sildenafil, ambrisentan. Preliminary data of new therapies are encouraging with disease significantly improved natural history, but there is need for more evidence-based data.

Evaluation of the Trends, Concomitant Procedures, and Complications With Open and Arthroscopic Rotator Cuff Repairs in the Medicare Population.

PubMed

Jensen, Andrew R; Cha, Peter S; Devana, Sai K; Ishmael, Chad; Di Pauli von Treuheim, Theo; D'Oro, Anthony; Wang, Jeffrey C; McAllister, David R; Petrigliano, Frank A

2017-10-01

Medicare insures the largest population of patients at risk for rotator cuff tears in the United States. To evaluate the trends in incidence, concomitant procedures, and complications with open and arthroscopic rotator cuff repairs in Medicare patients. Cohort study; Level of evidence, 3. All Medicare patients who had undergone open or arthroscopic rotator cuff repair from 2005 through 2011 were identified with a claims database. Annual incidence, concomitant procedures, and postoperative complications were compared between these 2 groups. In total, 372,109 rotator cuff repairs were analyzed. The incidence of open repairs decreased (from 6.0 to 4.3 per 10,000 patients, P < .001) while the incidence of arthroscopic repairs increased (from 4.5 to 7.8 per 10,000 patients, P < .001) during the study period. Patients in the arthroscopic group were more likely to have undergone concomitant subacromial decompression than those in the open group (87% vs 35%, P < .001), and the annual incidence of concomitant biceps tenodesis increased for both groups (from 3.8% to 11% for open and 2.2% to 16% for arthroscopic, P < .001). While postoperative complications were infrequent, patients in the open group were more likely to be diagnosed with infection within 6 months (0.86% vs 0.37%, P < .001) but no more likely to undergo operative debridement (0.43% vs 0.26%, P = .08). Additionally, patients in the open group were more likely to undergo intervention for shoulder stiffness within 1 year (1.4% vs 1.1%, P = .01). In the Medicare population, arthroscopic rotator cuff repairs have increased in incidence and now represent the majority of rotator cuff repair surgery. Among concomitant procedures, subacromial decompression was most commonly performed despite evidence suggesting a lack of efficacy. Infections and stiffness were rare complications that were slightly but significantly more frequent in open rotator cuff repairs.

Evaluation of the Trends, Concomitant Procedures, and Complications With Open and Arthroscopic Rotator Cuff Repairs in the Medicare Population

PubMed Central

Jensen, Andrew R.; Cha, Peter S.; Devana, Sai K.; Ishmael, Chad; Di Pauli von Treuheim, Theo; D’Oro, Anthony; Wang, Jeffrey C.; McAllister, David R.; Petrigliano, Frank A.

2017-01-01

Background: Medicare insures the largest population of patients at risk for rotator cuff tears in the United States. Purpose: To evaluate the trends in incidence, concomitant procedures, and complications with open and arthroscopic rotator cuff repairs in Medicare patients. Study Design: Cohort study; Level of evidence, 3. Methods: All Medicare patients who had undergone open or arthroscopic rotator cuff repair from 2005 through 2011 were identified with a claims database. Annual incidence, concomitant procedures, and postoperative complications were compared between these 2 groups. Results: In total, 372,109 rotator cuff repairs were analyzed. The incidence of open repairs decreased (from 6.0 to 4.3 per 10,000 patients, P < .001) while the incidence of arthroscopic repairs increased (from 4.5 to 7.8 per 10,000 patients, P < .001) during the study period. Patients in the arthroscopic group were more likely to have undergone concomitant subacromial decompression than those in the open group (87% vs 35%, P < .001), and the annual incidence of concomitant biceps tenodesis increased for both groups (from 3.8% to 11% for open and 2.2% to 16% for arthroscopic, P < .001). While postoperative complications were infrequent, patients in the open group were more likely to be diagnosed with infection within 6 months (0.86% vs 0.37%, P < .001) but no more likely to undergo operative debridement (0.43% vs 0.26%, P = .08). Additionally, patients in the open group were more likely to undergo intervention for shoulder stiffness within 1 year (1.4% vs 1.1%, P = .01). Conclusion: In the Medicare population, arthroscopic rotator cuff repairs have increased in incidence and now represent the majority of rotator cuff repair surgery. Among concomitant procedures, subacromial decompression was most commonly performed despite evidence suggesting a lack of efficacy. Infections and stiffness were rare complications that were slightly but significantly more frequent in open rotator cuff repairs. PMID:29051905

Glans size is an independent risk factor for urethroplasty complications after hypospadias repair.

PubMed

Bush, Nicol C; Villanueva, Carlos; Snodgrass, Warren

2015-12-01

We hypothesized small glans size could increase urethroplasty complications (UC) following hypospadias repair. To test this, we measured glans width at its widest point in consecutive patients with hypospadias, and following a protocol for surgical decision-making, we then assessed post-operative UC using pre-determined definitions. We now report analysis of glans size as a potential additional independent risk factor for UC after hypospadias repair. Consecutive prepubertal patients undergoing hypospadias repair (2009-2013) had maximum glans width measured using calipers (Fig. 1). There were no differences in surgical technique for urethroplasty or glansplasty in this series based on the measured size of the glans. Multivariate logistic regression analyzed UC (fistula, glans dehiscence, diverticulum, stricture and/or meatal stenosis) based on glans size while adjusting for patient age, meatus (distal or midshaft/proximal), type of repair (TIP, inlay, 2-stage), surgeon, and primary or reoperative repair. Glans size was analyzed as both a continuous and dichotomous variable, with small glans defined as <14 mm. Mean glans size was 15 mm (10-27 mm) in 490 boys (mean 1.5 years) undergoing 432 primary repairs (380d/19mid/33prox), and 58 reoperations (28d/7mid/23prox). Increasing age between 3 months and 10 years did not correlate with increasing glans size (R = 0.01, p = 0.18). 17% had small glans <14 mm. UC occurred in 61 (13%) primary TIP, 2-stage, and reoperative repairs, including 20/81 (25%) patients with small glans <14 mm, versus 41/409 (10%) in patients with glans width ≥14 mm (p = 0.0003). On multivariate analysis, small glans size (OR 3.5, 95% CI 1.8-6.8), reoperations (OR 3.0, 95% CI 1.4-6.5) and mid/proximal meatus (OR 3.1, 95% CI 1.6-6.2) were independent risk factors for UC. Surgeon, repair type, and patient age did not impact risk for UC. Analysis with glans size as a continuous variable demonstrated each 1 mm increase in size decreased odds of UC (OR 0.8, 95% CI 0.7-0.9). Our analysis of prospectively-collected data from a standardized management protocol in 490 consecutive boys undergoing hypospadias repair adds small glans size, defined as width <14 mm, to proximal meatal location and reoperation as an independent risk factor for UC. Best means to modify this factor remain to be determined. Our data suggest that others analyzing potential risks for hypospadias UC should similarly measure and report glans width. Copyright © 2015 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.

Use of the Hardman index in predicting mortality in endovascular repair of ruptured abdominal aortic aneurysms.

PubMed

Conroy, Daniel M; Altaf, Nishath; Goode, Steve D; Braithwaite, Bruce D; MacSweeney, Shane T; Richards, Toby

2011-12-01

The Hardman index is a predictor of 30-day mortality after open ruptured abdominal aneurysm repair through the use of preoperative patient factors. The aim of this study was to assess the Hardman index in patients undergoing endovascular repair of ruptured aortic aneurysms. A retrospective analysis of 95 patients undergoing emergency endovascular repairs of computed tomography-confirmed ruptured aneurysms from 1994 to 2008 in a university hospital was performed. All relevant patient variables, calculations of the Hardman index, and the incidence of 30-day mortality were collected in these patients. Correlation of the relationship between each variable and the overall score with the incidence of 30-day mortality was undertaken. The 24-hour mortality was 16% and 30-day mortality 36%. Increasing scores on the Hardman index showed an increasing mortality rate. Thirty-day mortality in patients with a score of 0 to 2 was 30.5%, and in those with a score of ≥3 was 69.2% (P = .01, risk ratio = 2.26, 95% confidence interval = 0.98 to 5.17). This is lower than predicted in both patient groups based on Hardman index score. Loss of consciousness was the only statistically significant independent predictor of 30-day mortality with a risk ratio of 3.16 (95% confidence interval = 2.00-4.97, P < .001). These data suggest that the Hardman index can predict an increased risk of 30-day mortality from endovascular repairs of ruptured aortic aneurysms. However, mortality from endovascular repair is much lower than would be predicted in open repair and it therefore cannot be used clinically as a tool for exclusion from intervention.

Does arthroscopic rotator cuff repair improve patients' activity levels?

PubMed

Baumgarten, Keith M; Chang, Peter S; Dannenbring, Tasha M; Foley, Elaine K

2018-06-04

Rotator cuff repair decreases pain, improves range of motion, and increases strength. Whether these improvements translate to an improvement in a patient's activity level postoperatively remains unknown. The Shoulder Activity Level is a valid and reliable outcomes survey that can be used to measure a patient's shoulder-specific activity level. Currently, there are no studies that examine the effect of rotator cuff repair on shoulder activity level. Preoperative patient-determined outcomes scores collected prospectively on patients undergoing rotator cuff repair were compared with postoperative scores at a minimum of 2 years. These scores included the Shoulder Activity Level, Western Ontario Rotator Cuff Index, American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form, Single Assessment Numeric Evaluation, and simple shoulder test. Inclusion criteria were patients undergoing arthroscopic rotator cuff repair. Included were 281 shoulders from 273 patients with a mean follow-up of 3.7 years. The postoperative median Western Ontario Rotator Cuff Index (42 vs. 94), American Shoulder and Elbow Surgeons (41 vs. 95), Single Assessment Numeric Evaluation (30 vs. 95), and simple shoulder test (4 vs. 11) scores were statistically significantly improved compared with preoperative scores (P < .0001). The postoperative median Shoulder Activity Level score decreased compared with the preoperative score (12 vs. 11; P < .0001). Patients reported a statistically significant deterioration of their Shoulder Activity Level score after rotator cuff repair compared with their preoperative scores, although disease-specific and joint-specific quality of life scores all had statistically significantly improvement. This study suggests that patients generally have (1) significant improvements in their quality of life and (2) small deteriorations in activity level after arthroscopic rotator cuff repair. Copyright © 2018 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.

What happens to the rectus abdominus fascia after laparoscopic ventral hernia repair?

PubMed

Sickle, K R Van; Baghai, M; Mattar, S G; Bowers, S P; Ramaswamy, A; Swafford, V; Smith, C D; Ramshaw, B J

2005-12-01

One criticism of laparoscopic ventral hernia repair (LVH) is that the rectus muscles are not re-approximated to the midline, and the effect of LVH repair on the fascial edges is unclear. Progressive migration of the fascial edges toward the midline has been observed anecdotally, but objective evidence remains limited. The purpose of this study is to observe the effect of LVH repair on the rectus abdominus fascia. Patients undergoing LVH repair with defects > 10 cm in horizontal diameter were identified prospectively and enrolled. All were repaired laparoscopically with intraperitoneal placement of mesh (DualMesh, W.L. Gore and Associates) using a standard approach. Radio-opaque clips were placed at the fascial edges intraoperatively to mark the defect, and plain abdominal films were taken postoperatively (Time 1) to establish the initial distance between clips (measured in cm). A subsequent follow-up film was taken (Time 2), and the difference in clip distance per patient was recorded. Results were analyzed using a chi-squared test. Twelve patients qualified for analysis and their results were compared. Mean fascial defect size was 15.1 cm (range 8.3-22.0). With respect to change in clip distance from Times 1 to 2, three events were observed: (1) Diminished (i.e. medialized), (2) Enlarged, or (3) No Change. Ten patients (83%) medialized, one patient enlarged, and one patient showed no change (chi2 (d.f. = 2) 9.17, p < 0.0023). Medialization of the rectus abdominus fascia occurs in the majority of patients undergoing LVH repair. Causes for this phenomenon are unclear: however eliminating intrabdominal pressure with intraperitoneal mesh placement likely plays a role.

Role of heterotopic kidney auto-transplantation for renal artery aneurysms.

PubMed

Gwon, Jun G; Han, Duck J; Cho, Yong-Pil; Kim, Young H; Kwon, Tae-Won

2018-06-01

To assess the applicability and surgical outcomes of ex vivo repair with heterotopic kidney auto-transplantation (HKA) for the treatment of renal artery aneurysms (RAA).We retrospectively examined 36 cases presenting with RAA from September 2005 to June 2016. Patient demographics, estimated glomerular filtration rate (eGFR), and common vascular risk factors were evaluated. Patients were classified into 3 groups: those who received endovascular treatment, in situ open surgical repair, or ex vivo repair with HKA. The findings were compared among the groups.The endovascular repair, in situ open repair, and ex vivo repair with HKA groups included 14, 9, and 13 patients, respectively (mean follow-up, 30.42 ± 30.54 months). The eGFR (P = .32) and number of anti-hypertension medications (P = .33) did not significantly differ among the groups. Moreover, 3 renal infarctions were detected in the endovascular group and only 1 was detected in the in situ repair group. One patient in the endovascular repair group required dialysis due to renal failure. Patients in the ex vivo repair with HKA group did not exhibit any complications.With safety and effectiveness comparable to other RAA treatment methods, ex vivo repair with HKA for RAA treatment appears suitable particularly in cases with complicated renal artery branch aneurysm and marginal renal function.

Radiation exposure to eye lens and operator hands during endovascular procedures in hybrid operating rooms.

PubMed

Attigah, Nicolas; Oikonomou, Kyriakos; Hinz, Ulf; Knoch, Thomas; Demirel, Serdar; Verhoeven, Eric; Böckler, Dittmar

2016-01-01

The purpose of this study was to evaluate the radiation exposure of vascular surgeons' eye lens and fingers during complex endovascular procedures in modern hybrid operating rooms. Prospective, nonrandomized multicenter study design. One hundred seventy-one consecutive patients (138 male; median age, 72.5 years [interquartile range, 65-77 years]) underwent an endovascular procedure in a hybrid operating room between March 2012 and July 2013 in two vascular centers. The dose-area product (DAP), fluoroscopy time, operating time, and amount of contrast dye were registered prospectively. For radiation dose recordings, single-use dosimeters were attached at eye level and to the ring finger of the hand next to the radiation field of the operator for each endovascular procedure. Dose recordings were evaluated by an independent institution. Before the study, precursory investigations were obtained to simulate the radiation dose to eye lens and fingers with an Alderson phantome (RSD, Long Beach, Calif). Interventions were classified into six treatment categories: endovascular repair of infrarenal abdominal aneurysm (n = 65), thoracic endovascular aortic repair (n = 32), branched endovascular aortic repair for thoracoabdominal aneurysms (n = 17), fenestrated endovascular aortic repair for complex abdominal aortic aneurysm, (n = 25), iliac branched device (n = 8), and peripheral interventions (n = 24). There was a significant correlation in DAP between both lens (P < .01; r = 0.55) and finger (P < .01; r = 0.56) doses. The estimated fluoroscopy time to reach a radiation threshold of 20 mSv/y was 1404.10 minutes (90% confidence limit, 1160, 1650 minutes). According to correlation of the lens dose with the DAP an estimated cumulative DAP of 932,000 mGy/m(2) (90% confidence limit, 822,000, 1,039,000) would be critical for a threshold of 20 mSv/y for the eyes. Radiation protection is a serious issue for vascular surgeons because most complex endovascular procedures are delivering measurable radiation to the eyes. With the correlation of the DAP obtained in standard endovascular procedures a critical threshold of 20 mSv/y to the eyes can be predicted and thus an estimate of a potential harmful exposure to the eyes can be obtained. Copyright © 2016 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.

Disparities in the treatment and outcomes of vascular disease in Hispanic patients

PubMed Central

Morrissey, Nicholas J.; Giacovelli, Jeannine; Egorova, Natalia; Gelijns, Annetine; Moskowitz, Alan; McKinsey, James; Kent, Kenneth Craig; Greco, Giampaolo

2008-01-01

Background The Hispanic population represents the fastest growing minority in the United States. As the population grows and ages, the vascular surgery community will be providing increasing amounts of care to this diverse group. To appropriately administer preventive and therapeutic care, it is important to understand the incidence, risk factors, and natural history of vascular disease in Hispanic patients. Methods We analyzed hospital discharge databases from New York and Florida to determine the rate of lower extremity revascularization (LER), carotid revascularization (CR), and abdominal aortic aneurysm (AAA) repair in Hispanics relative to the general population. The rates of common comorbidities, the indications for the procedures, and outcomes during the same hospitalization as the index procedure were determined. Multivariate logistic regression analysis was used to determine the differences between Hispanics and white non-Hispanics with respect to rate of procedure, symptoms at presentation, and outcome after procedure. Demographic variables and length of stay were also analyzed. Results The rate of LER, CR, and AAA repair was significantly lower in Hispanic patients than in white non-Hispanics. Despite this lower rate of intervention, Hispanics were significantly more likely than whites to present with limb-threatening lower extremity ischemia (odds ratio [OR], 2.09; 95% confidence interval [CI], 1.91 to 2.29), symptomatic carotid artery disease (OR, 1.57; 95% CI, 1.4 to 1.75), and ruptured AAA (OR, 1.26; 95% CI, 1.04-1.52) than white non-Hispanics These differences were maintained after controlling for the presence of diabetes mellitus and other comorbidities. Hispanic patients had higher rates of amputation during the same hospitalization after LER (6.2% vs 3.4%, P < .0001) and higher mortality after elective AAA repair (5% vs 3.4%, P = .0032). Length of stay after LER, CR, and AAA repair was longer for Hispanic patients than white non-Hispanics. Conclusion Significant disparities in the rate of utilization of three common vascular surgical procedures exist between Hispanic patients and the general population. In addition, Hispanics appear to present with more advanced disease and have worse outcomes in some cases. Reasons for these disparities must be determined to improve these results in the fastest growing segment of our society. PMID:17980283

The intraosseous have it: A prospective observational study of vascular access success rates in patients in extremis using video review.

PubMed

Chreiman, Kristen M; Dumas, Ryan P; Seamon, Mark J; Kim, Patrick K; Reilly, Patrick M; Kaplan, Lewis J; Christie, Jason D; Holena, Daniel N

2018-04-01

Quick and successful vascular access in injured patients arriving in extremis is crucial to enable early resuscitation and rapid OR transport for definitive repair. We hypothesized that intraosseous (IO) access would be faster and have higher success rates than peripheral intravenous (PIV) or central venous catheters (CVCs). High-definition video recordings of resuscitations for all patients undergoing emergency department thoracotomy from April 2016 to July 2017 were reviewed as part of a quality improvement initiative. Demographics, mechanism of injury, access type, access location, start and stop time, and success of each vascular access attempt were recorded. Times to completion for access types (PIV, IO, CVC) were compared using Kruskal-Wallis test adjusted for multiple comparisons, while categorical outcomes, such as success rates by access type, were compared using χ test or Fisher's exact test. Study patients had a median age of 30 years (interquartile range [IQR], 25-38 years), 92% were male, 92% were African American, and 93% sustained penetrating trauma. A total of 145 access attempts in 38 patients occurred (median, 3.8; SD, 1.4 attempts per patient). There was no difference between duration of PIV and IO attempts (0.63; IQR, 0.35-0.96 vs. 0.39 IQR, 0.13-0.65 minutes, adjusted p = 0.03), but both PIV and IO were faster than CVC attempts (3.2; IQR, 1.72-5.23 minutes; adjusted p < 0.001 for both comparisons). Intraosseous lines had higher success rates than PIVs or CVCs (95% vs. 42% vs. 46%, p < 0.001). Access attempts using IO are as fast as PIV attempts but are more than twice as likely to be successful. Attempts at CVC access in patients in extremis have high rates of failure and take a median of over 3 minutes. While IO access may not completely supplant PIVs and CVCs, IO access should be considered as a first-line therapy for trauma patients in extremis. Therapeutic, level III.

Laparoscopic surgery for trauma: the realm of therapeutic management.

PubMed

Zafar, Syed N; Onwugbufor, Michael T; Hughes, Kakra; Greene, Wendy R; Cornwell, Edward E; Fullum, Terrence M; Tran, Daniel D

2015-04-01

The use of laparoscopy in trauma is, in general, limited for diagnostic purposes. We aim to evaluate the therapeutic role of laparoscopic surgery in trauma patients. We analyzed the National Trauma Data Bank (2007 to 2010) for all patients undergoing diagnostic laparoscopy. Patients undergoing a therapeutic laparoscopic surgical procedure were identified and tabulated. Mortality and hospital length of stay for patients with isolated abdominal injuries were compared between the open and laparoscopic groups. Of a total of 2,539,818 trauma visits in the National Trauma Data Bank, 4,755 patients underwent a diagnostic laparoscopy at 467 trauma centers. Of these, 916 (19.3%) patients underwent a therapeutic laparoscopic intervention. Common laparoscopic operations included diaphragm repair, bowel repair or resection, and splenectomy. Patients undergoing laparoscopic surgery had a significantly shorter length of stay than the open group (5 vs 6 days; P < .001). Therapeutic laparoscopic surgery for trauma is feasible and may provide better outcomes. Copyright © 2015 Elsevier Inc. All rights reserved.

Impact of hypertension on early outcomes and long-term survival of patients undergoing aortic repair with Stanford A dissection.

PubMed

Merkle, Julia; Sabashnikov, Anton; Deppe, Antje-Christin; Zeriouh, Mohamed; Eghbalzadeh, Kaveh; Weber, Carolyn; Rahmanian, Parwis; Kuhn, Elmar; Madershahian, Navid; Kroener, Axel; Choi, Yeong-Hoon; Kuhn-Régnier, Ferdinand; Liakopoulos, Oliver; Wahlers, Thorsten

2018-04-01

Stanford A acute aortic dissection (AAD) is a life-threatening emergency, typically occurring in hypertensive patients, requiring immediate surgical repair. The aim of this study was to evaluate early outcomes and long-term survival of hypertensive patients in comparison to normotensive patients suffering from Stanford A AAD. In our center, 240 patients with Stanford A AAD underwent aortic surgical repair from January 2006 to April 2015. After statistical and logistic regression analysis, Kaplan-Meier survival estimation was performed, with up to 9-year follow-up. The proportion of hypertensive patients suffering from Stanford A AAD was 75.4% (n=181). There were only few statistically significant differences in terms of basic demographics, comorbidities, preoperative baseline and clinical characteristics of hypertensive patients in comparison to normotensive patients. Hypertensive patients were significantly older (p=0.008), more frequently received hemi-arch repair (p=0.028) and selective brain perfusion (p=0.001). Our study showed similar statistical results in terms of 30-day mortality (p=0.196), long-term overall cumulative survival of patients (Log-Rank p=0.506) and survival of patients free from cerebrovascular events (Log-Rank p=0.186). Furthermore, subgroup analysis for long-term survival in terms of men (Log-Rank p=0.853), women (Log-Rank p=0.227), patients under and above 65 years of age (Log-Rank p=0.188 and Log-Rank p=0.602, respectively) and patients undergoing one of the three types of aortic repair surgery showed similar results for normotensive and hypertensive patient groups. Subgroup analysis for long-term survival of patients free from cerebrovascular events for women, patients under 65 years of age and patients undergoing aortic arch repair showed significant differences between the two groups in favor of hypertensive patients. Hypertensive patients suffering from Stanford A AAD were older, more frequently received hemi-arch replacement and were not associated with increased risk of 30-day mortality and poorer long-term survival compared to normotensive patients.

Financial impact of tertiary care in an academic medical center.

PubMed

Huber, T S; Carlton, L M; O'Hern, D G; Hardt, N S; Keith Ozaki, C; Flynn, T C; Seeger, J M

2000-06-01

To analyze the financial impact of three complex vascular surgical procedures to both an academic hospital and a department of surgery and to examine the potential impact of decreased reimbursements. The cost of providing tertiary care has been implicated as one potential cause of the financial difficulties affecting academic medical centers. Patients undergoing revascularization for chronic mesenteric ischemia, elective thoracoabdominal aortic aneurysm repair, and treatment of infected aortic grafts at the University of Florida were compared with those undergoing elective infrarenal aortic reconstruction and carotid endarterectomy. Hospital costs and profit summaries were obtained from the Clinical Resource Management Office. Departmental costs and profit summary were estimated based on the procedural relative value units (RVUs), the average clinical cost per RVU ($33.12), surgeon charges, and the collection rate for the vascular surgery division (30.2%) obtained from the Faculty Group Practice. Surgeon work effort was analyzed using the procedural work RVUs and the estimated total care time. The analyses were performed for all payors and the subset of Medicare patients, and the potential impact of a 15% reduction in hospital and physician reimbursement was analyzed. Net hospital income was positive for all but one of the tertiary care procedures, but net losses were sustained by the hospital for the mesenteric ischemia and infected aortic graft groups among the Medicare patients. In contrast, the estimated reimbursement to the department of surgery for all payors was insufficient to offset the clinical cost of providing the RVUs for all procedures, and the estimated losses were greater for the Medicare patients alone. The surgeon work effort was dramatically higher for the tertiary care procedures, whereas the reimbursement per work effort was lower. A 15% reduction in reimbursement would result in an estimated net loss to the hospital for each of the tertiary care procedures and would exacerbate the estimated losses to the department. Caring for complex surgical problems is currently profitable to an academic hospital but is associated with marginal losses for a department of surgery. Economic forces resulting from further decreases in hospital and physician reimbursement may limit access to academic medical centers and surgeons for patients with complex surgical problems and may compromise the overall academic mission.

Transaortic Alfieri Edge-to-Edge Repair for Functional Mitral Regurgitation.

PubMed

Imasaka, Ken-Ichi; Tayama, Eiki; Morita, Shigeki; Toriya, Ryohei; Tomita, Yukihiro

2018-03-01

There is controversy about handling functional mitral regurgitation in patients undergoing aortic valve or proximal aortic operations. We describe a transaortic Alfieri edge-to-edge repair for functional mitral regurgitation that reduces operative excessive invasion and prolonged cardiopulmonary bypass time. Between May 2013 and December 2016, 10 patients underwent transaortic Alfieri edge-to-edge mitral repair. There were no operative deaths. The severity of mitral regurgitation immediately after the operation by transesophageal echocardiography was none or trivial in all patients. A transaortic Alfieri edge-to-edge repair for functional mitral regurgitation is a simple and safe approach. Copyright © 2018 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.

Risk factors associated with surgical site infection and the development of short-term complications in macaques undergoing indwelling vascular access port placement.

PubMed

Graham, M L; Rieke, E F; Wijkstrom, M; Dunning, M; Aasheim, T C; Graczyk, M J; Pilon, K J; Hering, B J

2008-08-01

Risk factors associated with surgical site infection (SSI) and the development of short-term complications in macaques undergoing vascular access port (VAP) placement are evaluated in this study. Records from 80 macaques with VAPs were retrospectively reviewed. Logistic regression was used to identify factors associated with short-term post-operative complications. The primary outcome was SSI, which occurred in 21.6% (52.6% in the first 12 months vs. 13% thereafter) of procedures. SSI was associated with major secondary complications including VAP removal (11.4%), wound dehiscence (5.7%), and mechanical catheter occlusion (5.7%). In multivariate modeling, only surgical program progress was a statistically significant predictor of SSI, while animal compliance had a slightly protective effect. Vascular access ports have a moderate risk of complications, provided the surgical program optimizes best practices. Under complex experimental conditions, VAPs represent an important refinement, both improving animals' overall well-being and environment and reducing stress.

Usefulness of the Hardman index in predicting outcome after endovascular repair of ruptured abdominal aortic aneurysms.

PubMed

Karkos, Christos D; Karamanos, Dimitrios; Papazoglou, Konstantinos O; Kantas, Alexandros S; Theochari, Evangelia G; Kamparoudis, Apostolos G; Gerassimidis, Thomas S

2008-10-01

The Hardman index, which has five variables, has been recommended as a predictor of outcome after open repair of ruptured abdominal aortic aneurysms (RAAAs). It has been reported that the presence of three or more variables is uniformly fatal. The aim of this study was to test the same model in an independent series of RAAA patients undergoing endovascular repair. A consecutive series of 41 patients undergoing endovascular repair for RAAA during an 8-year period was analyzed retrospectively. Thirty-day mortality and patient variables, including the five Hardman risk factors of age >76 years, serum creatinine >190 micromol/L, hemoglobin <9 g/dL, loss of consciousness, and electrocardiographic (ECG) evidence of ischemia, were recorded. The Hardman index and a revised version of the index with four variables (without ECG ischemia) were calculated and related to clinical outcome. Operative mortality was 41% (17 of 41). On univariate analysis, only age >76 years (P = .01) and the use of local anesthesia (P < .0001) were statistically significant. Loss of consciousness (P = .05) showed a trend toward a higher mortality, albeit not statistically significant. On multivariate analysis, the use of local anesthesia was the only significant predictor of survival (odds ratio [OR], 0.03; 95% confidence interval [CI], 0.003-0.25, P = .001). Again, loss of consciousness showed an association with a higher chance of dying but did not achieve statistical significance (OR, 6.30; 95% CI, 0.93-42.51, P = .059). The original and revised versions of the Hardman index were both significantly associated with death (P = .02 and P = .001, chi(2) test for trend). The cumulative effect of 0, 1, 2, and >/=3 risk factors on mortality was 0%, 27%, 36%, and 71% for the original index, and 12.5%, 21%, 60%, and 78% for the revised version, respectively. Four and two patients with a score of >/=3 in each version of the index survived endovascular repair. The Hardman index, with or without incorporating ECG ischemia, seems to be a simple and useful predictive tool in patients undergoing endovascular repair of RAAA, with the mortality rate increasing along with the Hardman score. However, the index cannot be used to accurately identify patients with no chance of survival after endovascular repair.

Adipose Tissue-Derived Pericytes for Cartilage Tissue Engineering.

PubMed

Zhang, Jinxin; Du, Chunyan; Guo, Weimin; Li, Pan; Liu, Shuyun; Yuan, Zhiguo; Yang, Jianhua; Sun, Xun; Yin, Heyong; Guo, Quanyi; Zhou, Chenfu

2017-01-01

Mesenchymal stem cells (MSCs) represent a promising alternative source for cartilage tissue engineering. However, MSC culture is labor-intensive, so these cells cannot be applied immediately to regenerate cartilage for clinical purposes. Risks during the ex vivo expansion of MSCs, such as infection and immunogenicity, can be a bottleneck in their use in clinical tissue engineering. As a novel stem cell source, pericytes are generally considered to be the origin of MSCs. Pericytes do not have to undergo time-consuming ex vivo expansion because they are uncultured cells. Adipose tissue is another optimal stem cell reservoir. Because adipose tissue is well vascularized, a considerable number of pericytes are located around blood vessels in this accessible and dispensable tissue, and autologous pericytes can be applied immediately for cartilage regeneration. Thus, we suggest that adipose tissue-derived pericytes are promising seed cells for cartilage regeneration. Many studies have been performed to develop isolation methods for the adipose tissuederived stromal vascular fraction (AT-SVF) using lipoaspiration and sorting pericytes from AT-SVF. These methods are useful for sorting a large number of viable pericytes for clinical therapy after being combined with automatic isolation using an SVF device and automatic magnetic-activated cell sorting. These tools should help to develop one-step surgery for repairing cartilage damage. However, the use of adipose tissue-derived pericytes as a cell source for cartilage tissue engineering has not drawn sufficient attention and preclinical studies are needed to improve cell purity, to increase sorting efficiency, and to assess safety issues of clinical applications. Copyright© Bentham Science Publishers; For any queries, please email at epub@benthamscience.org.

Canines as sentinel species for assessing chronic exposures to air pollutants: part 1. Respiratory pathology.

PubMed

Calderón-Garcidueñas, L; Mora-Tiscareño, A; Fordham, L A; Chung, C J; García, R; Osnaya, N; Hernández, J; Acuña, H; Gambling, T M; Villarreal-Calderón, A; Carson, J; Koren, H S; Devlin, R B

2001-06-01

A complex mixture of air pollutants is present in the ambient air in urban areas. People, animals, and vegetation are chronically and sequentially exposed to outdoor pollutants. The objective of this first of 2 studies is to evaluate by light and electron microscopy the lungs of Mexico City dogs and compare the results to those of 3 less polluted cities in MEXICO: One hundred fifty-two clinically healthy stray mongrel dogs (91 males/61 females), including 43 dogs from 3 less polluted cities, and 109 from southwest and northeast metropolitian Mexico City (SWMMC, NEMMC) were studied. Lungs of dogs living in Mexico City and Cuernavaca exhibited patchy chronic mononuclear cell infiltrates along with macrophages loaded with particulate matter (PM) surrounding the bronchiolar walls and extending into adjacent vascular structures; bronchiolar epithelial and smooth muscle hyperplasia, peribronchiolar fibrosis, microthrombi, and capillary and venule polymorphonuclear leukocytes (PMN) margination. Ultrafine PM was seen in alveolar type I and II cells, endothelial cells, interstitial macrophages (Mtheta), and intravascular Mtheta-like cells. Bronchoalveolar lavage showed significant numbers of alveolar macrophages undergoing proliferation. Exposure to complex mixtures of pollutants-predominantly particulate matter and ozone-is causing lung structural changes induced by the sustained inflammatory process and resulting in airway and vascular remodeling and altered repair. Cytokines released from both, circulating inflammatory and resident lung cells in response to endothelial and epithelial injury may be playing a role in the pathology described here. Deep concern exists for the potential of an increasing rise in lung diseases in child populations exposed to Mexico City's environment.

Urological results after fetal myelomeningocele repair in pre-MOMS trial patients at the Children's Hospital of Philadelphia.

PubMed

Carr, Michael C

2015-01-01

Myelomeningocele patients deal with multiple medical issues, including lower extremity neurological deficits, bowel and bladder incontinence and the sequelae of hydrocephalus secondary to a Chiari II malformation. In utero intervention holds the promise of reversing some of the sequelae and improving outcome. Between 1998 and 2003 (preceding the formal Management of Myelomeningocele Study, MOMS), an initial group of 58 patients underwent in utero repair of their myelomeningocele between 21 and 25 weeks' gestation. Long-term (5-year) follow-up has occurred in this cohort of patients. Previous reports have documented decreased incidence of ventriculoperitoneal shunting and neuromotor functioning, showing improved outcomes compared with historical controls. Overall, 4 fetal deaths occurred, while the majority of patients returned for follow-up for up to 5 years after closure. Phone follow-up has also been conducted for those who could not return. To date, 10 patients (18.5%) have successfully toilet-trained, while 2 patients have bowel continence and 1 has bladder continence but requires enemas; 2 patients who successfully toilet-trained developed spinal dermoid cysts requiring surgical resection. Historically, in utero repair of myelomeningocele patients yields a greater percentage of patients who have achieved continence compared with those undergoing postnatal repair. The MOMS trial will compare contemporary urological outcomes of those patients undergoing either prenatal or postnatal repair in a randomized fashion. The results of this trial showed a decreased need for ventriculoperitoneal shunting in those patients who underwent in utero repair as well as an improvement in lower extremity function. © 2014 S. Karger AG, Basel.

Vascular Wall-Resident Multipotent Stem Cells of Mesenchymal Nature within the Process of Vascular Remodeling: Cellular Basis, Clinical Relevance, and Implications for Stem Cell Therapy.

PubMed

Klein, Diana

2016-01-01

Until some years ago, the bone marrow and the endothelial cell compartment lining the vessel lumen (subendothelial space) were thought to be the only sources providing vascular progenitor cells. Now, the vessel wall, in particular, the vascular adventitia, has been established as a niche for different types of stem and progenitor cells with the capacity to differentiate into both vascular and nonvascular cells. Herein, vascular wall-resident multipotent stem cells of mesenchymal nature (VW-MPSCs) have gained importance because of their large range of differentiation in combination with their distribution throughout the postnatal organism which is related to their existence in the adventitial niche, respectively. In general, mesenchymal stem cells, also designated as mesenchymal stromal cells (MSCs), contribute to the maintenance of organ integrity by their ability to replace defunct cells or secrete cytokines locally and thus support repair and healing processes of the affected tissues. This review will focus on the central role of VW-MPSCs within vascular reconstructing processes (vascular remodeling) which are absolute prerequisite to preserve the sensitive relationship between resilience and stability of the vessel wall. Further, a particular advantage for the therapeutic application of VW-MPSCs for improving vascular function or preventing vascular damage will be discussed.

Vascular Endothelial Growth Factor and Angiogenesis in the Regulation of Cutaneous Wound Repair

PubMed Central

Johnson, Kelly E.; Wilgus, Traci A.

2014-01-01

Significance: Angiogenesis, the growth of new blood vessels from existing vessels, is an important aspect of the repair process. Restoration of blood flow to damaged tissues provides oxygen and nutrients required to support the growth and function of reparative cells. Vascular endothelial growth factor (VEGF) is one of the most potent proangiogenic growth factors in the skin, and the amount of VEGF present in a wound can significantly impact healing. Recent Advances: The activity of VEGF was once considered to be specific for endothelial cells lining the inside of blood vessels, partly because VEGF receptor (VEGFR) expression was believed to be restricted to endothelial cells. It is now known, however, that VEGFRs can be expressed by a variety of other cell types involved in wound repair. For example, keratinocytes and macrophages, which both carry out important functions during wound healing, express VEGFRs and are capable of responding directly to VEGF. Critical Issues: The mechanisms by which VEGF promotes angiogenesis are well established. Recent studies, however, indicate that VEGF can directly affect the activity of several nonendothelial cell types present in the skin. The implications of these extra-angiogenic effects of VEGF on wound repair are not yet known, but they suggest that this growth factor may play a more complex role during wound healing than previously believed. Future Directions: Despite the large number of studies focusing on VEGF and wound healing, it is clear that the current knowledge of how VEGF contributes to the repair of skin wounds is incomplete. Further research is needed to obtain a more comprehensive understanding of VEGF activities during the wound healing process. PMID:25302139

Transplantation of in vitro cultured endothelial progenitor cells repairs the blood-brain barrier and improves cognitive function of APP/PS1 transgenic AD mice.

PubMed

Zhang, Shishuang; Zhi, Yongle; Li, Fei; Huang, Shan; Gao, Huabin; Han, Zhaoli; Ge, Xintong; Li, Dai; Chen, Fanglian; Kong, Xiaodong; Lei, Ping

2018-04-15

To date, the pathogenesis of Alzheimer's disease (AD) remains unclear. It is well-known that excessive deposition of Aβ in the brain is a crucial part of the pathogenesis of AD. In recent years, the AD neurovascular unit hypothesis has attracted much attention. Impairment of the blood-brain barrier (BBB) leads to abnormal amyloid-β (Aβ) transport, and chronic cerebral hypoperfusion causes Aβ deposition throughout the onset and progression of AD. Endothelial progenitor cells (EPCs) are the universal cells for repairing blood vessels. Our previous studies have shown that a reduced number of EPCs in the peripheral blood results in cerebral vascular repair disorder, cerebral hypoperfusion and neurodegeneration, which might be related to the cognitive dysfunction of AD patients. This study was designed to confirm whether EPCs transplantation could repair the blood-brain barrier, stimulate angiogenesis and reduce Aβ deposition in AD. The expression of ZO-1, Occludin and Claudin-5 was up-regulated in APP/PS1 transgenic mice after hippocampal transplantation of EPCs. Consistent with previous studies, EPC transplants also increased the microvessel density. We observed that Aβ senile plaque deposition was decreased and hippocampal cell apoptosis was reduced after EPCs transplantation. The Morris water maze test showed that spatial learning and memory functions were significantly improved in mice transplanted with EPCs. Consequently, EPCs could up-regulate the expression of tight junction proteins, repair BBB tight junction function, stimulate angiogenesis, promote Aβ clearance, and decrease neuronal loss, ultimately improve cognitive function. Taken together, these data demonstrate EPCs may play an important role in the therapeutic implications for vascular dysfunction in AD. Copyright © 2018 Elsevier B.V. All rights reserved.

The axonal guidance cue semaphorin 3C contributes to alveolar growth and repair.

PubMed

Vadivel, Arul; Alphonse, Rajesh S; Collins, Jennifer J P; van Haaften, Tim; O'Reilly, Megan; Eaton, Farah; Thébaud, Bernard

2013-01-01

Lung diseases characterized by alveolar damage such as bronchopulmonary dysplasia (BPD) in premature infants and emphysema lack efficient treatments. Understanding the mechanisms contributing to normal and impaired alveolar growth and repair may identify new therapeutic targets for these lung diseases. Axonal guidance cues are molecules that guide the outgrowth of axons. Amongst these axonal guidance cues, members of the Semaphorin family, in particular Semaphorin 3C (Sema3C), contribute to early lung branching morphogenesis. The role of Sema3C during alveolar growth and repair is unknown. We hypothesized that Sema3C promotes alveolar development and repair. In vivo Sema3C knock down using intranasal siRNA during the postnatal stage of alveolar development in rats caused significant air space enlargement reminiscent of BPD. Sema3C knock down was associated with increased TLR3 expression and lung inflammatory cells influx. In a model of O2-induced arrested alveolar growth in newborn rats mimicking BPD, air space enlargement was associated with decreased lung Sema3C mRNA expression. In vitro, Sema3C treatment preserved alveolar epithelial cell viability in hyperoxia and accelerated alveolar epithelial cell wound healing. Sema3C preserved lung microvascular endothelial cell vascular network formation in vitro under hyperoxic conditions. In vivo, Sema3C treatment of hyperoxic rats decreased lung neutrophil influx and preserved alveolar and lung vascular growth. Sema3C also preserved lung plexinA2 and Sema3C expression, alveolar epithelial cell proliferation and decreased lung apoptosis. In conclusion, the axonal guidance cue Sema3C promotes normal alveolar growth and may be worthwhile further investigating as a potential therapeutic target for lung repair.

Surgical Outcomes of Porcine Acellular Dermis Graft in Anophthalmic Socket: Comparison with Oral Mucosa Graft.

PubMed

Teo, Livia; Woo, Young Jun; Kim, Dong Kyu; Kim, Chang Yeom; Yoon, Jin Sook

2017-02-01

We describe our experience with the Permacol graft in anophthalmic socket reconstruction, and compare it to the autologous buccal mucosal graft, emphasizing the postoperative vascularization and contraction of each graft. This was a retrospective comparative study. We measured the time necessary for the graft surface to be completely vascularized, as well as the fornix depth of the conjunctival sac in anophthalmic patients. Ten patients underwent Permacol graft reconstruction, with 44 undergoing buccal mucosal graft reconstruction. Seven eyelids (70%) in the Permacol group had a good outcome, with improvement in lower eyelid position and prosthesis retention. Nine out of 10 eyelids (90%) in this group showed complete vascularization of the graft at 2.6 ± 1.9 months postoperatively, while the grafted buccal mucosa was fully vascularized at 1.1 ± 0.3 months postoperatively ( p < 0.01). Postoperative fornix depth in the Permacol group was 9.1 ± 2.2 mm, compared to 14.9 ± 4.5 mm in the buccal mucosal graft group ( p < 0.01). Mean increases in fornix depth were 33.1% and 67.9% of the mean vertical length of the implanted graft. The Permacol graft can be useful as spacer graft material in anophthalmic socket patients. It takes longer to vascularize, and undergoes greater graft shrinkage with time, compared to the buccal mucosal graft.

Vascular endothelial growth factor/bone morphogenetic protein-2 bone marrow combined modification of the mesenchymal stem cells to repair the avascular necrosis of the femoral head

PubMed Central

Ma, Xiao-Wei; Cui, Da-Ping; Zhao, De-Wei

2015-01-01

Vascular endothelial cell growth factor (VEGF) combined with bone morphogenetic protein (BMP) was used to repair avascular necrosis of the femoral head, which can maintain the osteogenic phenotype of seed cells, and effectively secrete VEGF and BMP-2, and effectively promote blood vessel regeneration and contribute to formation and revascularization of tissue engineered bone tissues. To observe the therapeutic effect on the treatment of avascular necrosis of the femoral head by using bone marrow mesenchymal stem cells (BMSCs) modified by VEGF-165 and BMP-2 in vitro. The models were avascular necrosis of femoral head of rabbits on right leg. There groups were single core decompression group, core decompression + BMSCs group, core decompression + VEGF-165/BMP-2 transfect BMSCs group. Necrotic bone was cleared out under arthroscope. Arthroscopic observation demonstrated that necrotic bone was cleared out in each group, and fresh blood flowed out. Histomorphology determination showed that blood vessel number and new bone area in the repair region were significantly greater at various time points following transplantation in the core decompression + VEGF-165/BMP-2 transfect BMSCs group compared with single core decompression group and core decompression + BMSCs group (P < 0.05). These suggested that VEGF-165/BMP-2 gene transfection strengthened osteogenic effects of BMSCs, elevated number and quality of new bones and accelerated the repair of osteonecrosis of the femoral head. PMID:26629044

Assessment of vascularization and myelination following peripheral nerve repair using angiographic and polarization sensitive optical coherence tomography (Conference Presentation)

NASA Astrophysics Data System (ADS)

Nam, Ahhyun S.; Chico-Calero, Isabel; Easow, Jeena M.; Villiger, Martin; Welt, Jonathan; Winograd, Jonathan M.; Randolph, Mark A.; Redmond, Robert W.; Vakoc, Benjamin J.

2017-02-01

A severe traumatic injury to a peripheral nerve often requires surgical graft repair. However, functional recovery after these surgical repairs is often unsatisfactory. To improve interventional procedures, it is important to understand the regeneration of the nerve grafts. The rodent sciatic nerve is commonly used to investigate these parameters. However, the ability to longitudinally assess the reinnervation of injured nerves are limited, and to our knowledge, no methods currently exist to investigate the timing of the revascularization in functional recovery. In this work, we describe the development and use of angiographic and polarization-sensitive (PS) optical coherence tomography (OCT) to visualize the vascularization, demyelination and remyelination of peripheral nerve healing after crush and transection injuries, and across a variety of graft repair methods. A microscope was customized to provide 3.6 cm fields of view along the nerve axis with a capability to track the nerve height to maintain the nerve within the focal plane. Motion artifact rejection was implemented in the angiography algorithm to reduce degradation by bulk respiratory motion in the hindlimb site. Vectorial birefringence imaging methods were developed to significantly enhance the accuracy of myelination measurements and to discriminate birefringent contributions from the myelin and epineurium. These results demonstrate that the OCT platform has the potential to reveal new insights in preclinical studies and may ultimately provide a means for clinical intra-surgical assessment of peripheral nerve function.

Towards organ printing: engineering an intra-organ branched vascular tree.

PubMed

Visconti, Richard P; Kasyanov, Vladimir; Gentile, Carmine; Zhang, Jing; Markwald, Roger R; Mironov, Vladimir

2010-03-01

Effective vascularization of thick three-dimensional engineered tissue constructs is a problem in tissue engineering. As in native organs, a tissue-engineered intra-organ vascular tree must be comprised of a network of hierarchically branched vascular segments. Despite this requirement, current tissue-engineering efforts are still focused predominantly on engineering either large-diameter macrovessels or microvascular networks. We present the emerging concept of organ printing or robotic additive biofabrication of an intra-organ branched vascular tree, based on the ability of vascular tissue spheroids to undergo self-assembly. The feasibility and challenges of this robotic biofabrication approach to intra-organ vascularization for tissue engineering based on organ-printing technology using self-assembling vascular tissue spheroids including clinically relevantly vascular cell sources are analyzed. It is not possible to engineer 3D thick tissue or organ constructs without effective vascularization. An effective intra-organ vascular system cannot be built by the simple connection of large-diameter vessels and microvessels. Successful engineering of functional human organs suitable for surgical implantation will require concomitant engineering of a 'built in' intra-organ branched vascular system. Organ printing enables biofabrication of human organ constructs with a 'built in' intra-organ branched vascular tree.

Transforming growth factor β-activated kinase 1 negatively regulates interleukin-1α-induced stromal-derived factor-1 expression in vascular smooth muscle cells

DOE Office of Scientific and Technical Information (OSTI.GOV)

Yang, Bin; Li, Wei; Zheng, Qichang

Stromal-derived Factor-1 (SDF-1) derived from vascular smooth muscle cells (VSMCs) contributes to vascular repair and remodeling in various vascular diseases. In this study, the mechanism underlying regulation of SDF-1 expression by interleukin-1α (IL-1α) was investigated in primary rat VSMCs. We found IL-1α promotes SDF-1 expression by up-regulating CCAAT-enhancer-binding protein β (C/EBPβ) in an IκB kinase β (IKKβ) signaling-dependent manner. Moreover, IL-1α-induced expression of C/EBPβ and SDF-1 was significantly potentiated by knockdown of transforming growth factor β-activated kinase 1 (TAK1), an upstream activator of IKKβ signaling. In addition, we also demonstrated that TAK1/p38 mitogen-activated protein kinase (p38 MAPK) signaling exerted negativemore » effect on IL-1α-induced expression of C/EBPβ and SDF-1 through counteracting ROS-dependent up-regulation of nuclear factor erythroid 2-related factor 2 (NRF2). In conclusion, TAK1 acts as an important regulator of IL-1α-induced SDF-1 expression in VSMCs, and modulating activity of TAK1 may serve as a potential strategy for modulating vascular repair and remodeling. - Highlights: • IL-1α induces IKKβ signaling-dependent SDF-1 expression by up-regulating C/EBPβ. • Activation of TAK1 by IL-1α negatively regulates C/EBPβ-dependent SDF-1 expression. • IL-1α-induced TAK1/p38 MAPK signaling counteracts ROS-dependent SDF-1 expression. • TAK1 counteracts IL-1α-induced SDF-1 expression by attenuating NRF2 up-regulation.« less

Outcomes of ring versus suture annuloplasty for tricuspid valve repair in patients undergoing mitral valve surgery.

PubMed

Shinn, Sung Ho; Dayan, Victor; Schaff, Hartzell V; Dearani, Joseph A; Joyce, Lyle D; Lahr, Brian; Greason, Kevin L; Stulak, John M; Daly, Richard C

2016-08-01

There is controversy regarding the comparative effectiveness of methods of tricuspid valve (TV) repair-prosthetic ring versus suture annuloplasty-in patients undergoing operation for primary mitral valve (MV) disease. In this study, we analyzed factors associated with patient survival and recurrent tricuspid regurgitation (TR) following TV repair and focused on results stratified by method of tricuspid valve repair. We reviewed patients who underwent TV repair with suture (De Vega) or flexible ring annuloplasties at the time of MV surgery from 1995 to 2010. Patients with prior cardiac or concomitant aortic valve operations were excluded. Propensity matching was performed to account for potential differences in baseline characteristics between the groups. Primary outcomes were long-term mortality and postoperative TR grade. In the overall study, there were 415 patients with median age 72 years (range, 63-78 years), from which 148 matched pairs were identified by propensity score analysis. In the overall cohort, patients in the ring annuloplasty group more often had preoperative transvenous pacemakers (P = .05), lower ejection fractions (P = .028), and more recent years of operation (P < .001). For patients who had De Vega suture annuloplasty, long-term mortality was not different from that of patients who had ring annuloplasty (hazard ratio, 0.93; 95% confidence interval, 0.67-1.30). Older age, preoperative diabetes, and preoperative right ventricular dysfunction were predictors for long-term mortality. Durability of the annuloplasty methods was similar with no significant difference in trend of recurrent TR grades over follow-up (P = .807). Etiology of mitral regurgitation was not associated with recurrent TR during follow-up (P = .857). Late survival and TV durability following concomitant TV repair during MV surgery did not differ with respect to TV repair technique. In this series of patients with repaired tricuspid valves, etiology of MV disease did not influence postoperative changes in TR. Copyright © 2016 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

Repair of symptomatic paraesophageal hernias in elderly (>70 years) patients results in sustained quality of life at 5 years and beyond.

PubMed

Merzlikin, Oleg V; Louie, Brian E; Farivar, Alexander S; Shultz, Dale; Aye, Ralph W

2017-10-01

Paraesophageal hernias (PEHs) involve herniation of stomach and/or other viscera into the mediastinum. These commonly occur in the elderly and can severely limit quality of life. Short term outcomes of repaired PEH demonstrated low morbidity and significant improvement in quality of life, but long-term data for all patients, especially the elderly, are lacking. Retrospective chart review of a prospectively collected database of patients aged 70 or greater with a symptomatic PEH repaired 5+ years ago. Quality of life data were assessed preoperatively, at 12-24 months, and at 5+ years using QOLRAD, GERD-HRQL, and DSS. We identified 137 patients who met the age criteria, with 69 patients undergoing surgery 5+ years ago. With ten patients were lost to follow-up, 59 patients were analyzed, including 24 males and 35 females. Median age at repair was 77 years. There were two 90-day mortalities, with one occurring within 30 days of surgery. Patients alive at evaluation had a median age of 74 years and were followed a median 7.4 years. From baseline, QOLRAD improved from 4 to 6.5, GERD-HRQL improved from 11 to 5, and swallowing improved from 11 to 38. During follow-up, 21 patients died. Deceased patients lived a median of 4 years after repair, with a median age at repair of 80 years. At a median time follow-up of 2 years, this group's QOLRAD improved from 5.1 to 7, GERD-HRQL improved from 16 to 4, and swallowing improved from 14.5 to 35. In elderly patients with symptomatic PEH undergoing surgical repair more than 5 years ago, there was sustained improvement in quality of life. This justifies surgical repair of symptomatic PEH in elderly patients.

The effect of smoking on surgical outcomes in ventral hernia repair: a propensity score matched analysis of the National Surgical Quality Improvement Program data.

PubMed

Borad, N P; Merchant, A M

2017-12-01

Although studies have implicated smoking as a positive predictor of post-operative outcomes in inguinal hernia repair, its impact on ventral hernia repair (VHR) is not as clear. This study aims to fill this gap by investigating the impact of smoking on developing adverse 30-day post-operative outcomes in VHR. Patients undergoing VHR between 2005 and 2014 were extracted from the American College of Surgeons National Surgical Quality Improvement Program database. Patients were stratified by smoking status and compared for significant differences in baseline characteristics. Logistic regression modeled the impact of smoking on the primary outcome variable of 30-day mortality and the secondary outcome variables of 30-day overall, cardiac, respiratory, or wound morbidity. To evaluate the influence of smoking in comparable groups undergoing VHR, a propensity score matched analysis was performed. Out of 169,458 patients identified, 32,973 (19.5%) were classified as current smokers. Smokers and non/ex-smokers differed significantly in multiple pre-operative baseline characteristics. Unmatched univariate analyses revealed smoking status as a positive predictor of every post-operative outcome. These findings were validated with propensity score matching analyses, which found current smokers have an increased likelihood of 30-day mortality (OR 1.42), overall morbidity (OR 1.39), wound (OR 1.40), respiratory (OR 1.14), or cardiac morbidity (OR 1.88) compared to non/ex-smokers (p < 0.05 for all). Smoking is a modifiable risk factor with a detrimental impact on outcomes in patients undergoing ventral hernia repair. Delaying VHR and promoting smoking cessation prior to surgery may help reduce the odds of adverse 30-day post-operative outcomes.

Vascularized nerve graft: a clinical contribution.

PubMed

Luchetti, R; De Santis, G; Soragni, O; Deluca, S; Pederzini, L; Alfarano, M; Landi, A

1990-01-01

The authors present 4 cases of vascularized nerve graft. The results were better than those obtained with traditional grafting. The indication is a rare one, and the experimental results are contradictory. Indications are limited to Volkmann ischemic syndromes, post-actinic lesions of the brachial plexus, infections and finally, post-burning scarring. Nevertheless, traditional nerve grafts remain the treatment of choice for peripheral nerve lesions which cannot undergo direct suturing.

Combined use of infraorbital and external nasal nerve blocks for effective perioperative pain control during and after cleft lip repair.

PubMed

Salloum, Mariah L; Eberlin, Kyle R; Sethna, Navil; Hamdan, Usama S

2009-11-01

Perioperative analgesia in patients undergoing cleft lip and palate repair is complicated by the risk of postoperative airway obstruction. We describe a technique of combined infraorbital and external nasal nerve blocks to reduce the need for opioid analgesia. Using this technique, we have successfully performed cleft lip repair under local anesthesia alone, without general anesthesia or intravenous sedation, in adolescents and adults. In children, this technique can reduce the need for postoperative opioids. We describe this novel analgesic approach to decrease opioid requirements and minimize perioperative risk.

Assessment of open operative vascular surgical experience among general surgery residents.

PubMed

Krafcik, Brianna M; Sachs, Teviah E; Farber, Alik; Eslami, Mohammad H; Kalish, Jeffrey A; Shah, Nishant K; Peacock, Matthew R; Siracuse, Jeffrey J

2016-04-01

General surgeons have traditionally performed open vascular operations. However, endovascular interventions, vascular residencies, and work-hour limitations may have had an impact on open vascular surgery training among general surgery residents. We evaluated the temporal trend of open vascular operations performed by general surgery residents to assess any changes that have occurred. The Accreditation Council for Graduate Medical Education's database was used to evaluate graduating general surgery residents' cases from 1999 to 2013. Mean and median case volumes were analyzed for carotid endarterectomy, open aortoiliac aneurysm repair, and lower extremity bypass. Significance of temporal trends were identified using the R(2) test. The average number of carotid endarterectomies performed by general surgery residents decreased from 23.1 ± 14 (11.6 ± 9 chief, 11.4 + 10 junior) cases per resident in 1999 to 10.7 ± 9 (3.4 ± 5 chief, 7.3 ± 6 junior) in 2012 (R(2) = 0.98). Similarly, elective open aortoiliac aneurysm repairs decreased from 7.4 ± 5 (4 ± 4 chief, 3.4 ± 4 junior) in 1999 to 1.3 ± 2 (0.4 ± 1 chief, 0.8 ± 1 junior) in 2012 (R(2) = 0.98). The number of lower extremity bypasses decreased from 21 ± 12 (9.5 ± 7 chief, 11.8 ± 9 junior) in 1999 to 7.6 ± 2.6 (2.4 ± 1.3 chief, 5.2 + 1.8 junior) in 2012 (R(2) = 0.94). Infrapopliteal bypasses decreased from 8.1 ± 3.8 (3.5 ± 2.2 chief, 4.5 ± 2.9 junior) in 2001 to 3 ± 2.2 (1 ± 1.6 chief, 2 ± 1.6 junior) in 2012 (R(2) = 0.94). General surgery resident exposure to open vascular surgery has significantly decreased. Current and future graduates may not have adequate exposure to open vascular operations to be safely credentialed to perform these procedures in future practice without advanced vascular surgical training. Copyright © 2016 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.

[Resection of alae nasi malignant and nasolabial flaps pedicled facial prosthetics I period of repair].

PubMed

Tuo, Honglian; Yang, Guangdong; Ling, Dan; Ma, Gang

2010-04-01

To Discuss nasolabial pedicle flap in the repair of facial malignant asal nasi resection defect after clinical practicality and feasibility. Eleven cases of patients with asal nasi surgery in patients with malignant tumor resection. And in accordance with the characteristics of the blood supply of the nasolabial fold area and the size of design defects to be repaired region length. angle and size, design nasolabial flaps pedicled flap face. Go through the nasal alar defect repair defects. All patients were I wound healing, skins all survived, good blood circulation, good color and no obvious scar area. One year postoperative follow-up to 5 years without recurrence of the tumor, the effect of external nose satisfied with the cosmetic restoration. The nasolabial flap pedicled facial blood rich and easy to survive, organizations can provide sufficient volume to the repair of larger nasal defects, vascular pedicle length, the transfer of a flexible, easy to operate and no obvious scar area. Nasolabial pedicle flap to repair the face of larger asal nasi defects after resection of malignant tumors can choose the best skin.

Sutureless liver repair and hemorrhage control using laser-mediated fusion of human albumin as a solder.

PubMed

Wadia, Y; Xie, H; Kajitani, M

2001-07-01

Major liver trauma has a high mortality because of immediate exsanguination and a delayed morbidity from septicemia, peritonitis, biliary fistulae, and delayed secondary hemorrhage. We evaluated laser soldering using liquid albumin for welding liver injuries. Fourteen lacerations (6 x 2 cm) and 13 nonanatomic resection injuries (raw surface, 8 x 2 cm) were repaired. An 805-nm laser was used to weld 53% liquid albumin-indocyanine green solder to the liver surface, reinforcing it by welding a free autologous omental scaffold. The animals were heparinized and hepatic inflow occlusion was used for vascular control. For both laceration and resection injuries, 16 soldering repairs were evaluated acutely at 3 hours. Eleven animals were evaluated chronically, two at 2 weeks and nine at 4 weeks. All 27 laser mediated-liver repairs had minimal blood loss compared with the suture controls. No dehiscence, hemorrhage, or bile leakage was seen in any of the laser repairs after 3 hours. All 11 chronic repairs healed without complication. This modality effectively seals the liver surface, joins lacerations with minimal thermal injury, and works independently of the patient's coagulation status.

VCAM-1 expression is upregulated by CD34+/CD133+-stem cells derived from septic patients

PubMed Central

Remmé, Christoph; Betzen, Christian; Tönshoff, Burkhard; Yard, Benito A.; Beck, Grietje; Rafat, Neysan

2018-01-01

CD34+/CD133+- cells are a bone marrow derived stem cell population, which presumably contain vascular progenitor cells and are associated with improved vascular repair. In this study, we investigated whether the adhesion molecules ICAM-1 (intercellular adhesion molecule-1), VCAM-1 (vascular adhesion molecule-1), E-selectin und L-selectin, which are involved in homing of vascular stem cells, are upregulated by CD34+/CD133+-stem cells from septic patients and would be associated with improved clinical outcome. Peripheral blood mononuclear cells from intensive care unit (ICU) patients with (n = 30) and without sepsis (n = 10), and healthy volunteers (n = 15) were isolated using Ficoll density gradient centrifugation. The expression of VCAM-1, ICAM-1, E-selectin and L-selectin was detected on CD34+/CD133+-stem cells by flow cytometry. The severity of disease was assessed by the Simplified Acute Physiology Score (SAPS) II. Serum concentrations of vascular endothelial growth factor (VEGF) and angiopoietin (Ang)-2 were determined by Enzyme-linked immunosorbent assay. The expression of VCAM-1, ICAM-1, E-selectin and L-selectin by CD34+/CD133+-stem cells was significantly upregulated in septic patients, and correlated with sepsis severity. Furthermore, high expression of VCAM-1 by CD34+/CD133+-stem cells revealed a positive association with mortalitiy (p<0.05). Furthermore, significantly higher serum concentrations of VEGF and Ang-2 were found in septic patients, however none showed a strong association with survival. Our data suggest, that VCAM-1 upregulation on CD34+/CD133+-stem cells could play a crucial role in their homing in the course of sepsis. An increase in sepsis severity resulted in both and increase in CD34+/CD133+-stem cells and VCAM-1-expression by those cells, which might reflect an increase in need for vascular repair. PMID:29601599

The epidemiology of vascular injury in the wars in Iraq and Afghanistan.

PubMed

White, Joseph M; Stannard, Adam; Burkhardt, Gabriel E; Eastridge, Brian J; Blackbourne, Lorne H; Rasmussen, Todd E

2011-06-01

Blood vessel trauma leading to hemorrhage or ischemia presents a significant cause of morbidity and mortality after battlefield injury. The objective of this study is to characterize the epidemiology of vascular injury in the wars of Iraq and Afghanistan, including categorization of anatomic patterns, mechanism, and management of casualties. The Joint Theater Trauma Registry was interrogated (2002-2009) for vascular injury in US troops to identify specific injury (group 1) and operative intervention (group 2) groups. Battle-related injuries (nonreturn to duty) were used as the denominator to establish injury rates. Mechanism of injury was compared between theaters of war and the management strategies of ligation versus revascularization (repair and interposition grafting) reported. Group 1 included 1570 Troops injured in Iraq (OIF) (n = 1390) and Afghanistan (OEF) (n = 180). Mechanism included explosive (73%), gunshot (27%), and other (<1%) with explosive more common in OIF than OEF (P < 0.05). During this period, 13,076 battle-related injuries occurred resulting in a specific rate of 12% (1570 of 13,076), which was higher in OIF than OEF (12.5% vs 9% respectively; P < 0.05). Of group 1, 60% (n = 940) sustained injury to major or proximal vessels and 40% (n = 630) to minor or distal vessels (unknown vessel, n = 27). Group 2 (operative) comprised 1212 troops defining an operative rate of 9% (1212 of 13,076) and included ligation (n = 660; 54%) or repair (n = 552; 46%). Peak rates in OIF and OEF occurred in November 2004 (15%) and August 2009 (11%), respectively and correlated with combat operational tempo. The rate of vascular injury in modern combat is 5 times that reported in previous wars and varies according to theater of war, mechanism of injury and operational tempo. Methods of reconstruction are now applied to nearly half of the vascular injuries and should be a focus of training for combat surgery. Selective ligation of vascular injury remains an important management strategy, especially for minor or distal vessel injuries.

Knockdown of Nrf2 Inhibits the Angiogenesis of Rat Cardiac Micro-vascular Endothelial Cells under Hypoxic Conditions

PubMed Central

Kuang, Lihong; Feng, Jian; He, Guoxiang; Jing, Tao

2013-01-01

Angiogenesis plays an important role in myocardial repair after myocardial infarction (MI). Cardiac micro-vascular endothelial cells (CMECs) are important participants in myocardial angiogenesis processes. Recent studies have revealed that Nuclear factor-erythroid 2-related factor 2 (Nrf2), a master transcription factor of endogenous anti-oxidative defense systems, exerts cardio-protection in the cardiovascular system. However, the role of Nrf2 in the process of myocardial angiogenesis and corresponding mechanisms are not fully understood. Thus, the present study investigated the role of Nrf2 in the angiogenesis of rat CMECs to hypoxia. Trans-well assay, three-dimensional Matrigel assay were used to determine cell migration and vascular tube formation. Real-time RT-PCR, ELISA and Western blot were measured mRNA and protein expression. Here, we report that the mRNA and protein expression of Nrf2 and heme oxygenase-1(HO-1) were temporarily upregulated under hypoxic condition. Furthermore, knock down of Nrf2 significantly suppressed the migration and vascular tube formation of rat CMECs to hypoxia, Nrf2 knockdown also significantly decreased HO-1 and vascular endothelial growth factor (VEGF) expression at 48 h after transfection under hypoxic condition. Finally, transfection of CMECs with the Nrf2 over-expressing lentiviral vector upregulated HO-1 expression with a concomitant increase in cell migration and vascular tube formation induced by hypoxia, and this effect was greatly attenuated in the presence of ZnPP (a HO-1 inhibitor). Taken together, these results suggest that Nrf2 may mediate the angiogenesis of CMECs under hypoxic condition, and HO-1 is involved in regulating the angiogenesis of CMECs through Nrf2. Therefore, Nrf2 is a potent regulator of hypoxia-condition mediated angiogenesis in CMECs, which may provide a therapeutic strategy for myocardial repair after MI. PMID:23904790

Angiogenic T cell expansion correlates with severity of peripheral vascular damage in systemic sclerosis.

PubMed

Manetti, Mirko; Pratesi, Sara; Romano, Eloisa; Bellando-Randone, Silvia; Rosa, Irene; Guiducci, Serena; Fioretto, Bianca Saveria; Ibba-Manneschi, Lidia; Maggi, Enrico; Matucci-Cerinic, Marco

2017-01-01

The mechanisms underlying endothelial cell injury and defective vascular repair in systemic sclerosis (SSc) remain unclear. Since the recently discovered angiogenic T cells (Tang) may have an important role in the repair of damaged endothelium, this study aimed to analyze the Tang population in relation to disease-related peripheral vascular features in SSc patients. Tang (CD3+CD31+CXCR4+) were quantified by flow cytometry in peripheral blood samples from 39 SSc patients and 18 healthy controls (HC). Circulating levels of the CXCR4 ligand stromal cell-derived factor (SDF)-1α and proangiogenic factors were assessed in paired serum samples by immunoassay. Serial skin sections from SSc patients and HC were subjected to CD3/CD31 and CD3/CXCR4 double immunofluorescence. Circulating Tang were significantly increased in SSc patients with digital ulcers (DU) compared either with SSc patients without DU or with HC. Tang levels were significantly higher in SSc patients with late nailfold videocapillaroscopy (NVC) pattern than in those with early/active NVC patterns and in HC. No difference in circulating Tang was found when comparing either SSc patients without DU or patients with early/active NVC patterns and HC. In SSc peripheral blood, Tang percentage was inversely correlated to levels of SDF-1α and CD34+CD133+VEGFR-2+ endothelial progenitor cells (EPC), and positively correlated to levels of vascular endothelial growth factor and matrix metalloproteinase-9. Tang were frequently detected in SSc dermal perivascular inflammatory infiltrates. In summary, our findings demonstrate for the first time that Tang cells are selectively expanded in the circulation of SSc patients displaying severe peripheral vascular complications like DU. In SSc, Tang may represent a potentially useful biomarker reflecting peripheral vascular damage severity. Tang expansion may be an ineffective attempt to compensate the need for increased angiogenesis and EPC function. Further studies are required to clarify the function of Tang cells and investigate the mechanisms responsible for their change in SSc.

Hypothermia is associated with increased mortality in patients undergoing repair of ruptured abdominal aortic aneurysm.

PubMed

Quiroga, Elina; Tran, Nam T; Hatsukami, Thomas; Starnes, Benjamin W

2010-06-01

To evaluate the impact of hypothermia on mortality in patients presenting with ruptured abdominal aortic aneurysms (rAAA). Between July 2007 and September 2009, 73 patients with ruptured AAAs presented to our Emergency Department (ED). Thirteen patients did not receive surgical treatment; of the 60 patients (46 men; mean age 76 years, range 63-90) who did, 35 had endovascular aneurysm repair (EVAR) and 25 open repair. Body temperatures, which were recorded upon arrival to the ED and operating room, during the procedure, and just prior to leaving the operating room, were analyzed for any association with mortality or hypotension. The primary outcome measure was the 30-day mortality rate. Six (17%) patients in the EVAR group and 10 (40%) patients in the open group died during the 30-day period. Temperature upon arrival to OR, lowest temperature recorded during the procedure, and temperature at the end of the procedure were higher among survivors (p<0.005), independent of the repair technique implemented. Patients in the EVAR group left the OR with a mean temperature of 35.5 degrees C versus 35.0 degrees C for patients in the open group (p = 0.12). Hypothermia is associated with increased mortality after repair of rAAA. Efforts to correct hypothermia are more frequently successful in patients undergoing EVAR. Increased communication with anesthesia providers, as well as aggressive measures to correct hypothermia, including active intravascular rewarming methods, should be considered to improve mortality in this gravely ill patient population.

Risk of Osteosarcoma in Dogs After Open Fracture Fixation.

PubMed

Arthur, Elizabeth G; Arthur, Gerald L; Keeler, Matthew R; Bryan, Jeffrey N

2016-01-01

To critically evaluate whether open fracture fixation is a significant risk factor for latent osteosarcoma development. Case-control study. Dogs undergoing open fracture repair and dogs diagnosed with osteosarcoma. Records were retrieved from the Veterinary Medical Database VMDB (1970-2000) for dogs undergoing surgical repair of a fracture and dogs diagnosed with osteosarcoma. Dogs with open reduction of joint luxation, dogs diagnosed with bacterial cystitis, and dogs diagnosed with urinary bladder transitional cell carcinoma (UBTCC) were queried as comparison populations. Relative risk for osteosarcoma development was determined. From a population of 19,041 fractures treated surgically, 15 of those dogs subsequently appeared in the VMDB with osteosarcoma affecting the same bone. The relative risk of a fracture repair and associated orthopedic implants and osteosarcoma occurrence was equivalent to the relative risk of open joint reduction and osteosarcoma occurrence (95% confidence interval; 0.998-1.00). The relative risk of having bacterial cystitis and appearing again in the VMDB with UBTCC was higher than the risk of open fracture repair and a subsequent diagnosis of osteosarcoma (P < .02). The incidence of fracture-related osteosarcoma may be significantly less than previously estimated based on cases queried from the VMDB. Although possible cases of implant-associated osteosarcoma were identified, their occurrence was rare. Elective implant removal for the purpose of reducing the risk of osteosarcoma after fracture repair may not be warranted and merits further investigation. © Copyright 2015 by The American College of Veterinary Surgeons.

Design of Nanostructured Biological Materials Through Self-Assembly of Peptides and Proteins

DTIC Science & Technology

2002-01-01

of applications, including scaffolding for tissue repair in regenerative medicine, drug delivery and biological surface engineering. Tirrell and...colleagues [2] designed artificial proteins that undergo self-assembly to form hydrogels responsive to pH and other environmental changes. Ghadiri and...showed that other β-sheet peptide systems can also undergo self-assembly into regular nanofiber structures. Although they share no sequence

Repair of giant postlaminectomy pseudomeningocele with fast-resorbing polymer mesh: technical report of 2 cases.

PubMed

Alvarez, Carlos M; Urakov, Timur M; Vanni, Steven

2018-03-01

Pseudomeningocele is a rare but well-known complication of lumbar spine surgery, which arises in 0.068%-0.1% of individuals in large series of patients undergoing laminectomy and in up to 2% of patients with postlaminectomy symptoms. In symptomatic pseudomeningoceles, surgical reexploration and repair of the dural defect are typically necessary. Whereas the goals of pseudomeningocele repair, which are extirpation of the pseudomeningocele cavity and elimination of extradural dead space, can typically be achieved by primary closure performed using nonabsorbable sutures, giant pseudomeningoceles (> 8 cm) can require more elaborate repair in which fibrin glues, dural substitute, myofascial flaps, or all of the above are used. The authors present 2 cases of postsurgical symptomatic giant pseudomeningoceles that were repaired using a fast-resorbing polymer mesh-supported reconstruction technique, which is described here for the first time.

Comparison of acellular dermal matrix and synthetic mesh for lateral chest wall reconstruction in a rabbit model.

PubMed

Holton, Luther H; Chung, Thomas; Silverman, Ronald P; Haerian, Hafez; Goldberg, Nelson H; Burrows, Whitney M; Gobin, Andrea; Butler, Charles E

2007-04-01

Synthetic mesh is used for chest wall reconstruction, but infection or exposure can occur and necessitate removal. Human acellular dermal matrix (AlloDerm) has been used to reconstruct musculofascial defects in the trunk with low infection and herniation rates. AlloDerm may have advantages over synthetic mesh for chest wall reconstruction. This study compared outcomes and repair strengths of AlloDerm to expanded polytetrafluoroethylene mesh used for repair of rib cage defects. A 3 x 3-cm, full-thickness, lateral rib cage defect was created in each rabbit and repaired with expanded polytetrafluoroethylene (n = 8) or acellular dermal matrix (n = 9). At 4 weeks, the animals were euthanized and evaluated for lung herniation/dehiscence, strength of adhesions between the implant and intrapleural structures, and breaking strength of the implant materials and the implant-fascia interface. Tissue sections were analyzed with histologic and immunohistochemical staining to evaluate cellular infiltration and vascularization. No herniation or dehiscence occurred with either material. The incidence and strength of adhesions was similar between materials. The mean breaking strength of the AlloDerm-fascia interface (14.5 +/- 8.9 N) was greater than the expanded polytetrafluoroethylene-fascia interface (8.7 +/- 4.4 N; p = 0.027) and similar to the rib-intercostal-rib interface of the contralateral native chest wall (14.0 +/- 5.6 N). The AlloDerm grafts became infiltrated with cells and vascularized after implantation. AlloDerm used for chest wall reconstruction results in greater implant-defect interface strength than expanded polytetrafluoroethylene. The ability of AlloDerm to become vascularized and remodeled by autologous cells and to resist infection may be advantageous for chest wall reconstruction.

Increase in acid sphingomyelinase level in human retinal endothelial cells and CD34+ circulating angiogenic cells isolated from diabetic individuals is associated with dysfunctional retinal vasculature and vascular repair process in diabetes

PubMed Central

Kady, Nermin; Yan, Yuanqing; Salazar, Tatiana; Wang, Qi; Chakravarthy, Harshini; Huang, Chao; Beli, Eleni; Navitskaya, Svetlana; Grant, Maria; Busik, Julia

2017-01-01

Background Diabetic retinopathy (DR) is a microvascular disease that results from retinal vascular degeneration and defective repair due to diabetes induced endothelial progenitor dysfunction. Objective Understanding key molecular factors involved in vascular degeneration and repair is paramount for developing effective DR treatment strategies. We propose that diabetes-induced activation of acid sphingomyelinase (ASM) plays essential role in retinal endothelial and CD34+ circulating angiogenic cell (CAC) dysfunction in diabetes. Methods Human retinal endothelial cells (HRECs) isolated from control and diabetic donor tissue and human CD34+ CACs from control and diabetic patients were used in this study. ASM mRNA and protein expression was assessed by quantitative PCR and ELISA, respectively. To evaluate the effect of diabetes-induced ASM on HRECs and CD34+ CACs function, tube formation, CAC incorporation into endothelial tubes, and diurnal release of CD34+ CACs in diabetic individuals was determined. Results ASM expression level was significantly increased in HRECs isolated from diabetic compared to control donor tissue, as well as CD34+CACs and plasma of diabetic patients. A significant decrease in tube area was observed in HRECs from diabetic donors as compared to control HRECs. The tube formation deficiency was associated with increased expression of ASM in diabetic HRECs. Moreover, diabetic CD34+ CACs with high ASM showed defective incorporation into endothelial tubes. Diurnal release of CD34+ CACs was disrupted with the rhythmicity lost in diabetic patients. Conclusion Collectively, these findings support that diabetes-induced ASM upregulation has a marked detrimental effect on both retinal endothelial cells and CACs. PMID:28457994

Vascularization of repaired limb bone defects using chitosan-β-tricalcium phosphate composite as a tissue engineering bone scaffold.

PubMed

Yang, Le; Wang, Qinghua; Peng, Lihua; Yue, Hong; Zhang, Zhendong

2015-08-01

Ensuring histocompatibility in the tissue engineering of bones is a complex issue. The aim of this study was to observe the feasibility of chitosan-β-tricalcium phosphate composite in repairing limb bone defects, and to evaluate the therapeutic effects on osteogenesis. Beagle mesenchymal stem cells (MSCs) were divided into an experimental group that was cultured with an injectable form of chitosan-β-tricalcium phosphate composite and a control group. The effect of the composite on bone tissue growth was evaluated by MTT assay. In addition, 12-month-old beagles were subjected to 15-mm femur defects and subsequently implanted with scaffolds to observe the effects on osteogenesis and vascularization. The dogs were subdivided into two groups of five animals: Group A, which was implanted with scaffold-MSC compounds, and Group B, which was implanted with scaffolds alone. The dogs were observed on the 2nd, 4th, 8th and 12th weeks post-implantation. Scanning electron microscopy analysis revealed that the composite was compatible with MSCs, with similar outcomes in the control and experimental groups. MTT analysis additionally showed that the MSCs in the experimental group grew in a similar manner to those in the control group. The composite did not significantly affect the MSC growth or proliferation. In combination with MSCs, the scaffold materials were effective in the promotion of osteogenesis and vascularization. In conclusion, the chitosan-β-tricalcium phosphate composite was compatible with the MSCs and did not affect cellular growth or proliferation, therefore proving to be an effective injectable composite for tissue engineered bone. Simultaneous implantation of stem cells with a carrier composite proved to function effectively in the repair of bone defects.

Novel Function for Vascular Endothelial Growth Factor Receptor-1 on Epidermal Keratinocytes

PubMed Central

Wilgus, Traci A.; Matthies, Annette M.; Radek, Katherine A.; Dovi, Julia V.; Burns, Aime L.; Shankar, Ravi; DiPietro, Luisa A.

2005-01-01

Vascular endothelial growth factor (VEGF-A), a potent stimulus for angiogenesis, is up-regulated in the skin after wounding. Although studies have shown that VEGF is important for wound repair, it is unclear whether this is based solely on its ability to promote angiogenesis or if VEGF can also promote healing by acting directly on non-endothelial cell types. By immunohistochemistry and reverse transcriptase-polymerase chain reaction, expression of VEGF receptor-1 (VEGFR-1), but not VEGFR-2, was detected in murine keratinocytes during wound repair and in normal human epidermal keratinocytes (NHEKs). The presence of VEGF receptors on NHEKs was verified by binding studies with 125I-VEGF. In vitro, VEGF stimulated the proliferation of NHEKs, an effect that could be blocked by treatment with neutralizing VEGFR-1 antibodies. A role for VEGFR-1 in keratinocytes was also shown in vivo because treatment of excisional wounds with neutralizing VEGFR-1 antibodies delayed re-epithelialization. Treatment with anti-VEGFR-1 antibodies also reduced the number of proliferating keratinocytes at the leading edge of the wound, suggesting that VEGF sends a proliferative signal to these cells. Together, these data describe a novel role for VEGFR-1 in keratinocytes and suggest that VEGF may play several roles in cutaneous wound repair. PMID:16251410

Two-Stage Thoracoscopic Repair of Long-Gap Esophageal Atresia Using Internal Traction Is Safe and Feasible.

PubMed

Tainaka, Takahisa; Uchida, Hiroo; Tanano, Akihide; Shirota, Chiyoe; Hinoki, Akinari; Murase, Naruhiko; Yokota, Kazuki; Oshima, Kazuo; Shirotsuki, Ryo; Chiba, Kosuke; Amano, Hizuru; Kawashima, Hiroshi; Tanaka, Yujiro

2017-01-01

The treatment of long-gap esophageal atresia remains an issue for pediatric surgeons. Many techniques for treating long-gap esophageal atresia have been proposed, but the optimal method has not been established. The thoracoscopic esophageal elongation technique has recently been developed. We previously reported a case in which two-stage thoracoscopic repair was performed using internal esophageal traction without esophageal tearing, and we retrospectively reviewed the outcomes of this procedure in this study. Five patients underwent thoracoscopic treatment involving internal esophageal traction for esophageal atresia involving a long gap or vascular ring over a 5-year period. Between November 2010 and November 2015, 5 patients were treated with thoracoscopic traction. All of these patients successfully underwent thoracoscopic-delayed primary anastomosis. Conversion to open thoracotomy was not required in any case. The postoperative complications experienced by the patients included minor anastomotic leakage in 2 cases, anastomotic stenosis in 1 case, gastroesophageal reflux (GER) in 4 cases, and a hiatal hernia in 1 case. None of the patients died. Two-stage thoracoscopic repair for esophageal atresia involving a long gap or vascular ring is a safe and feasible procedure; however, we must develop methods for treating minor anastomotic complications and GER due to esophageal traction in future.

A PEGylated platelet free plasma hydrogel based composite scaffold enables stable vascularization and targeted cell delivery for volumetric muscle loss.

PubMed

Aurora, Amit; Wrice, Nicole; Walters, Thomas J; Christy, Robert J; Natesan, Shanmugasundaram

2018-01-01

Extracellular matrix (ECM) scaffolds are being used for the clinical repair of soft tissue injuries. Although improved functional outcomes have been reported, ECM scaffolds show limited tissue specific remodeling response with concomitant deposition of fibrotic tissue. One plausible explanation is the regression of blood vessels which may be limiting the diffusion of oxygen and nutrients across the scaffold. Herein we develop a composite scaffold as a vasculo-inductive platform by integrating PEGylated platelet free plasma (PFP) hydrogel with a muscle derived ECM scaffold (m-ECM). In vitro, adipose derived stem cells (ASCs) seeded onto the composite scaffold differentiated into two distinct morphologies, a tubular network in the hydrogel, and elongated structures along the m-ECM scaffold. The composite scaffold showed a high expression of ITGA5, ITGB1, and FN and a synergistic up-regulation of ang1 and tie-2 transcripts. The in vitro ability of the composite scaffold to provide extracellular milieu for cell adhesion and molecular cues to support vessel formation was investigated in a rodent volumetric muscle loss (VML) model. The composite scaffold delivered with ASCs supported robust and stable vascularization. Additionally, the composite scaffold supported increased localization of ASCs in the defect demonstrating its ability for localized cell delivery. Interestingly, ASCs were observed homing in the injured muscle and around the perivascular space possibly to stabilize the host vasculature. In conclusion, the composite scaffold delivered with ASCs presents a promising approach for scaffold vascularization. The versatile nature of the composite scaffold also makes it easily adaptable for the repair of soft tissue injuries. Decellularized extracellular matrix (ECM) scaffolds when used for soft tissue repair is often accompanied by deposition of fibrotic tissue possibly due to limited scaffold vascularization, which limits the diffusion of oxygen and nutrients across the scaffold. Although a variety of scaffold vascularization strategies has been investigated, their limitations preclude rapid clinical translation. In this study we have developed a composite scaffold by integrating bi-functional polyethylene glycol modified platelet free plasma (PEGylated PFP) with adipose derived stem cells (ASCs) along with a muscle derived ECM scaffold (m-ECM). The composite scaffold provides a vasculo-inductive and an effective cell delivery platform for volumetric muscle loss. Copyright © 2017 Acta Materialia Inc. All rights reserved.

Economic Analysis of Cleft Palate Repair in International Adoptees.

PubMed

Tomlinson-Hansen, Sandra; Paliga, J Thomas; Tahiri, Youssef; Paine, Kaitlyn M; Bartlett, Scott P; Taylor, Jesse A

2016-09-01

Retrospective cohort study. Major international tertiary care referral center for cleft palate repair. One hundred thirty-eight patients at the Children's Hospital of Philadelphia who had palate repair performed between 2010 and 2013, excluding syndromic patients, patients undergoing palate revision, and patients with incomplete payment information. None. Fees and charges for procedures. Surgeon payment was significantly higher for international adoptees (Δ = $2047.51 [$128.35 to $3966.66], P = .038). Medicaid-adjusted surgeon payments averaged $1006 more for adoptees ([-$394.19 to $2406.98], P = .158). Hospital and anesthesiology costs for adoptee palate repair were highly variable but did not differ significantly from those for nonadoptees. Partly due to payer mix, surgeon reimbursement was somewhat higher for international adoptees. No difference in total payment was found.

An Endochondral Ossification-Based Approach to Bone Repair: Chondrogenically Primed Mesenchymal Stem Cell-Laden Scaffolds Support Greater Repair of Critical-Sized Cranial Defects Than Osteogenically Stimulated Constructs In Vivo.

PubMed

Thompson, Emmet M; Matsiko, Amos; Kelly, Daniel J; Gleeson, John P; O'Brien, Fergal J

2016-03-01

The lack of success associated with the use of bone grafts has motivated the development of tissue engineering approaches for bone defect repair. However, the traditional tissue engineering approach of direct osteogenesis, mimicking the process of intramembranous ossification (IMO), leads to poor vascularization. In this study, we speculate that mimicking an endochondral ossification (ECO) approach may offer a solution by harnessing the potential of hypertrophic chondrocytes to secrete angiogenic signals that support vasculogenesis and enhance bone repair. We hypothesized that stimulation of mesenchymal stem cell (MSC) chondrogenesis and subsequent hypertrophy within collagen-based scaffolds would lead to improved vascularization and bone formation when implanted within a critical-sized bone defect in vivo. To produce ECO-based constructs, two distinct scaffolds, collagen-hyaluronic acid (CHyA) and collagen-hydroxyapatite (CHA), with proven potential for cartilage and bone repair, respectively, were cultured with MSCs initially in the presence of chondrogenic factors and subsequently supplemented with hypertrophic factors. To produce IMO-based constructs, CHA scaffolds were cultured with MSCs in the presence of osteogenic factors. These constructs were subsequently implanted into 7 mm calvarial defects on Fischer male rats for up to 8 weeks in vivo. The results demonstrated that IMO- and ECO-based constructs were capable of supporting enhanced bone repair compared to empty defects. However, it was clear that the scaffolds, which were previously shown to support the greatest cartilage formation in vitro (CHyA), led to the highest new bone formation (p < 0.05) within critical-sized bone defects 8 weeks postimplantation. We speculate this to be associated with the secretion of angiogenic signals as demonstrated by the higher VEGF protein production in the ECO-based constructs before implantation leading to the greater blood vessel ingrowth. This study thus demonstrates the ability of recapitulating a developmental process of bone formation to develop tissue-engineered constructs that manifest appreciable promise for bone defect repair.

Editor's Choice - Prolonged ICU Length of Stay after AAA Repair: Analysis of Time Trends and Long-term Outcome.

PubMed

Gavali, H; Mani, K; Tegler, G; Kawati, R; Covaciu, L; Wanhainen, A

2017-08-01

The aim of the study was to investigate the frequency and outcome of prolonged intensive care unit (ICU) length of stay (LOS) after abdominal aortic aneurysm (AAA) repair in the endovascular era. All patients operated on for AAA between 1999 and 2013 at Uppsala University hospital were identified. Data were retrieved from the Swedish Vascular registry, the Swedish Intensive Care registry, the National Population registry, and case records. Prolonged ICU LOS was defined as ≥ 48 h during the primary hospital stay. Patients surviving ≥ 48 h after AAA surgery were included in the analysis. A total of 725 patients were identified, of whom 707 (97.5%) survived ≥ 48 h; 563 (79.6%) underwent intact AAA repair and 144 (20.4%) ruptured AAA repair. A total of 548 patients (77.5%) required < 48 h of intensive care, 115 (16.3%) 2-6 days and 44 (6.2%) ≥ 7 days. The rate of prolonged ICU LOS declined considerably over time, from 41.4% of all AAA repairs in 1999 to 7.3% in 2013 (p < .001) whereas the use of endovascular aortic repair (EVAR) increased from 6.9% in 1999 to 78.0% in 2013 (p < .001). The 30 day survival rate was 98.2% for those with < 48 h ICU stay versus 93.0% for 2-6 days versus 81.8% for ≥ 7 days (p < .001); the corresponding 90 day survival was 97.1% versus 86.1% versus 63.6% (p < .001) respectively. For patients surviving 90 days after repair, there was no difference in long-term survival between the groups. During the period of progressively increasing use of EVAR, a simultaneous significant reduction in frequency of prolonged ICU LOS occurred. Although prolonged ICU LOS was associated with a high short-term mortality, long-term outcome among those surviving the initial 90 days was less affected. Copyright © 2017 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.

Epithelial-Mesenchymal Transition in Tissue Repair and Fibrosis

PubMed Central

Stone, Rivka C.; Pastar, Irena; Ojeh, Nkemcho; Chen, Vivien; Liu, Sophia; Garzon, Karen I.; Tomic-Canic, Marjana

2016-01-01

Epithelial-mesenchymal transition (EMT) describes the global process by which stationary epithelial cells undergo phenotypic changes, including loss of cell-cell adhesion and apical-basal polarity, and acquire mesenchymal characteristics which confer migratory capacity. EMT and its converse, MET (mesenchymal-to-epithelial transition), are integral stages of many physiologic processes, and as such are tightly coordinated by a host of molecular regulators. Converging lines of evidence have identified EMT as a component of cutaneous wound healing, during which otherwise stationary keratinocytes - the resident skin epithelial cells - migrate across the wound bed to restore the epidermal barrier. Moreover, EMT also plays a role in the development of scarring and fibrosis, as the matrix-producing myofibroblast arises from cells of epithelial lineage in response to injury but is pathologically sustained instead of undergoing MET or apoptosis. In this review, we summarize the role of EMT in physiologic repair and pathologic fibrosis of tissues and organs. We conclude that further investigation into the contribution of EMT to the impaired repair of fibrotic wounds may identify components of EMT signaling as common therapeutic targets for impaired healing in many tissues. PMID:27461257

Influences on Early and Medium-Term Survival Following Surgical Repair of the Aortic Arch

PubMed Central

Bashir, Mohamad; Field, Mark; Shaw, Matthew; Fok, Matthew; Harrington, Deborah; Kuduvalli, Manoj; Oo, Aung

2014-01-01

Objectives: It is now well established by many groups that surgery on the aortic arch may be achieved with consistently low morbidity and mortality along with relatively good survival compared to estimated natural history for a number of aortic arch pathologies. The objectives of this study were to: 1) report, compare, and analyze our morbidity and mortality outcomes for hemiarch and total aortic arch surgery; 2) examine the survival benefit of hemiarch and total aortic arch surgery compared to age- and sex-matched controls; and 3) define factors which influence survival in these two groups and, in particular, identify those that are modifiable and potentially actionable. Methods: Outcomes from patients undergoing surgical resection of both hemiarch and total aortic arch at the Liverpool Heart and Chest Hospital between June 1999 and December 2012 were examined in a retrospective analysis of data collected for The Society for Cardiothoracic Surgeons (UK). Results: Over the period studied, a total of 1240 patients underwent aortic surgery, from which 287 were identified as having undergone hemi to total aortic arch surgery under deep or moderate hypothermic circulatory arrest. Twenty three percent of patients' surgeries were nonelective. The median age at the time of patients undergoing elective hemiarch was 64.3 years and total arch was 65.3 years (P = 0.25), with 40.1% being female in the entire group. A total of 140 patients underwent elective hemiarch replacement, while 81 underwent elective total arch replacement. Etiology of the aortic pathology was degenerative in 51.2% of the two groups, with 87.1% requiring aortic valve repair in the elective hemiarch group and 64.2% in the elective total arch group (P < 0.001). Elective in-hospital mortality was 2.1% in the hemiarch group and 6.2% (P = 0.15) in the total arch group with corresponding rates of stroke (2.9% versus 4.9%, P = 0.47), renal failure (4.3% versus 6.2%, P = 0.54), reexploration for bleeding (4.3% versus 4.9%, P > 0.99), and prolonged ventilation (8.6% versus 16.1%, P = 0.09). Overall mortality was 20.9% at 5 years, while it was 15.7% in the elective hemiarch and 25.9% in the total arch group (P = 0.065). Process control charts demonstrated stability of annualized mortality outcomes over the study period. Survival curve was flat and parallel compared to age- and sex-matched controls beyond 2 years. Multivariate analysis demonstrated the following independent factors associated with survival: renal dysfunction [hazard ratio (HR) = 3.11; 95% confidence interval (CI) = 1.44-6.73], New York Heart Association (NYHA) class ≥ III (HR = 2.25; 95% CI = 1.38-3.67), circulatory arrest time > 100 minutes (HR = 2.92; 95% CI = 1.57-5.43), peripheral vascular disease (HR = 2.44; 95% CI = 1.25-4.74), and concomitant coronary artery bypass graft operation (HR = 2.14; 95% CI = 1.20-3.80). Conclusions: Morbidity, mortality, and medium-term survival were not statistically different for patients undergoing elective hemi-aortic arch and total aortic arch surgery. The survival curve in this group of patients is flat and parallel to sex- and age-matched controls beyond 2 years. Multivariate analysis identified independent influences on survival as renal dysfunction, NYHA class ≥ III, circulatory arrest time (> 100 min), peripheral vascular disease, and concomitant coronary artery bypass grafting. Focus on preoperative optimization of some of these variables may positively influence long-term survival. PMID:26798716

Role of Resident Stem Cells in Vessel Formation and Arteriosclerosis.

PubMed

Zhang, Li; Issa Bhaloo, Shirin; Chen, Ting; Zhou, Bin; Xu, Qingbo

2018-05-25

Vascular, resident stem cells are present in all 3 layers of the vessel wall; they play a role in vascular formation under physiological conditions and in remodeling in pathological situations. Throughout development and adult early life, resident stem cells participate in vessel formation through vasculogenesis and angiogenesis. In adults, the vascular stem cells are mostly quiescent in their niches but can be activated in response to injury and participate in endothelial repair and smooth muscle cell accumulation to form neointima. However, delineation of the characteristics and of the migration and differentiation behaviors of these stem cells is an area of ongoing investigation. A set of genetic mouse models for cell lineage tracing has been developed to specifically address the nature of these cells and both migration and differentiation processes during physiological angiogenesis and in vascular diseases. This review summarizes the current knowledge on resident stem cells, which has become more defined and refined in vascular biology research, thus contributing to the development of new potential therapeutic strategies to promote endothelial regeneration and ameliorate vascular disease development. © 2018 The Authors.

[Management of Acute Type A Dissection Complicated with Acute Mesenteric Ischemia].

PubMed

Abe, Tomonobu; Usui, Akihiko

2017-07-01

Acute mesenteric ischemia as malperfusion syndrome associated with acute aortic dissection is a difficult situation. The incidence is approximately 3~4% in acute type A dissection. Traditionally, most of these patients underwent immediate simple central aortic repair expecting that mesenteric artery obstruction and intestinal ischemia would be resolved by simple central aortic repair. However, short term mortality has been reported very high in this strategy. With the aid of rapidly progressing imaging techniques and newer endovascular repair techniques, results seem to be improving in recent years. Newer management strategy include aggressive and patient specific revascularization to the mesenteric arteries, delayed central aortic repair, and meticulous intensive care. Diagnosis and management of this condition require high level of expertise. Cardiac surgeons, vascular surgeons, interventional radiologists, gastroenterologists, general surgeons, anesthesiologists, intensivists must corporate to save these patients' lives. Since this is a relatively rare condition, scientific evidence is insufficient to make robust recommendations. Further studies are warranted.

Early-Dynamic Positron Emission Tomography (PET)/Computed Tomography and PET Angiography for Endoleak Detection After Endovascular Aneurysm Repair.

PubMed

Drescher, Robert; Gühne, Falk; Freesmeyer, Martin

2017-06-01

To propose a positron emission tomography (PET)/computed tomography (CT) protocol including early-dynamic and late-phase acquisitions to evaluate graft patency and aneurysm diameter, detect endoleaks, and rule out graft or vessel wall inflammation after endovascular aneurysm repair (EVAR) in one examination without intravenous contrast medium. Early-dynamic PET/CT of the endovascular prosthesis is performed for 180 seconds immediately after intravenous injection of F-18-fluorodeoxyglucose. Data are reconstructed in variable time frames (time periods after tracer injection) to visualize the arterial anatomy and are displayed as PET angiography or fused with CT images. Images are evaluated in view of vascular abnormalities, graft configuration, and tracer accumulation in the aneurysm sac. Whole-body PET/CT is performed 90 to 120 minutes after tracer injection. This protocol for early-dynamic PET/CT and PET angiography has the potential to evaluate vascular diseases, including the diagnosis of complications after endovascular procedures.

Local Wound Care for Primary Cleft Lip Repair: Treatment and Outcomes With use of Topical Hydrogen Peroxide.

PubMed

Strong, Amy L; Nauta, Allison C; Kuang, Anna A

2015-12-01

This study highlights and validates a peroxide-based wound healing strategy for treatment of surgically closed facial wounds in a pediatric population. The authors identified pediatric patients undergoing primary cleft lip repair as a specific population to evaluate the outcomes of such a protocol. Through analysis of defined outcome measures, a reliable and reproducible protocol for postoperative wound care following primary cleft lip repair with favorable results is described. This retrospective study analyzes wound healing outcomes in pediatric patients undergoing primary cleft lip repair from 2006 to 2011 at a tertiary academic center. The wound healing protocol was used in both primary unilateral and bilateral repairs. One hundred fortysix patients between the ages of 0 and 4 years underwent primary cleft lip repair and cleft rhinoplasty by a single, fellowship-trained craniofacial surgeon. Postoperatively, wounds were treated with half-strength hydrogen peroxide and bacitracin, as well as scar massage. Incisional dehiscence, hypertrophic scar formation, discoloration, infection, and reoperation were studied. Outcomes were evaluated in light of parent compliance, demographics, preoperative nasoalveolar molding (PNAM), and diagnosis. The authors identified 146 patients for inclusion in this study. There was no wound or incisional dehiscence. One hundred twenty-four patients demonstrated favorable cosmetic outcome. Only 3 (2%) of patients who developed suboptimal outcomes underwent secondary surgical revision (> 1 year after surgery). Demographic differences were not statistically significant, and PNAM treatment did not influence outcomes. These data validate the use of halfstrength hydrogen peroxide and bacitracin as part of a wound healing strategy in pediatric incisional wounds. The use of hydrogen peroxide produced comparable outcomes to previously published studies utilizing other wound healing strategies and, therefore, these study findings support the further use of this regimen for this particular population.

Measure Guideline: Air Conditioner Diagnostics, Maintenance, and Replacement

DOE Office of Scientific and Technical Information (OSTI.GOV)

Springer, D.; Dakin, B.

2013-03-01

This guideline responds to the need for an efficient means of identifying, diagnosing, and repairing faults in air conditioning systems in existing homes that are undergoing energy upgrades. Inadequate airflow due to constricted ducts or undersized filters, improper refrigerant charge, and other system defects can be corrected at a fraction of the cost of equipment replacement and can yield significant savings. The guideline presents a two-step approach to diagnostics and repair.

Measure Guideline. Air Conditioner Diagnostics, Maintenance, and Replacement

DOE Office of Scientific and Technical Information (OSTI.GOV)

Springer, David; Dakin, Bill

2013-03-01

This guideline responds to the need for an efficient means of identifying, diagnosing, and repairing faults in air conditioning systems in existing homes that are undergoing energy upgrades. Inadequate airflow due to constricted ducts or undersized filters, improper refrigerant charge, and other system defects can be corrected at a fraction of the cost of equipment replacement and can yield significant savings. The guideline presents a two-step approach to diagnostics and repair.

Congenital extrahepatic portosystemic shunt (Abernethy malformation) treated endovascularly with vascular plug shunt closure.

PubMed

Passalacqua, Matthew; Lie, Kevin T; Yarmohammadi, Hooman

2012-01-01

A 3-year-old boy, who presented with progressive cyanosis and hypoxia, was diagnosed with a large congenital extrahepatic portosystemic shunt, interrupted IVC with azygos continuation, and multiple congenital anomalies. Traditionally open and laparoscopic surgical techniques have been used to treat this malformation. Endovascular repair using a 16-mm Amplatzer vascular plug (AGA Medical Corporation, Golden Valley, Minnesota, USA) was used to occlude the shunt. Immediate post-placement venography demonstrated cessation of flow within the shunt and increased portal venous flow. The patient's hypoxia and cyanosis decreased significantly, and he was discharged on the 5th post-procedure day in stable clinical condition. Three months follow-up evaluation demonstrated the vascular plug in place, unchanged in position.

Surgical management of tumors invading the aorta and major arterial structures.

PubMed

Carpenter, Susanne G; Stone, William M; Bower, Thomas C; Fowl, Richard J; Money, Samuel R

2011-11-01

This study investigates surgical management of tumors arising from or involving the aorta and major arterial structures. A retrospective single institutional review was conducted of patients undergoing arterial resection for tumors involving the aorta or major arterial structures between January 1992 and May 2009 at a tertiary care center. Patients with tumors abutting arteries without necessitating resection and those involving only venous structures were excluded. Patients were analyzed in groups by vessel involvement: aorta, carotid, external/common iliac, internal iliac, superficial femoral, and miscellaneous. Sixty patients were identified and included for review. The iliac arteries were most often resected, and sarcomatous pathology was most common (37 patients, 62%). Twelve patients underwent aortic resection, with eight (67%) of these undergoing graft reconstruction, one (8%) graft patch, and two (17%) primary repair. None of the 17 patients undergoing internal iliac resection underwent reconstruction, whereas the majority of patients in all other groups underwent reconstruction. Thirty-day mortality (TDM) was 0% in all groups, except the aortic (2/12, 17% TDM), and internal iliac arteries (1/17, 6% TDM). Estimated blood loss varied widely and was not significantly different between vessel groups (p = 0.280). Overall, 44 of 60 (73%) patients had negative margins. Fourteen patients (23%) returned to the operating room, most for wound infection or dehiscence. Mean follow-up was 20.25 months (range: 0.5-122.0 months, SD: 23 months). Forty patients were followed up for more than 1 year. Thus, with an overall median follow-up of 12.25 months, overall survival was 60% with disease-free survival of 40%. Resection of tumors involving the aorta and major arterial structures provides a reasonable option for treatment, but with significant perioperative morbidity. In selected patients, this aggressive intervention should be considered. Copyright © 2011 Annals of Vascular Surgery Inc. Published by Elsevier Inc. All rights reserved.

Towards organ printing: engineering an intra-organ branched vascular tree

PubMed Central

Visconti, Richard P; Kasyanov, Vladimir; Gentile, Carmine; Zhang, Jing; Markwald, Roger R; Mironov, Vladimir

2013-01-01

Importance of the field Effective vascularization of thick three-dimensional engineered tissue constructs is a problem in tissue engineering. As in native organs, a tissue-engineered intra-organ vascular tree must be comprised of a network of hierarchically branched vascular segments. Despite this requirement, current tissue-engineering efforts are still focused predominantly on engineering either large-diameter macrovessels or microvascular networks. Areas covered in this review We present the emerging concept of organ printing or robotic additive biofabrication of an intra-organ branched vascular tree, based on the ability of vascular tissue spheroids to undergo self-assembly. What the reader will gain The feasibility and challenges of this robotic biofabrication approach to intra-organ vascularization for tissue engineering based on organ-printing technology using self-assembling vascular tissue spheroids including clinically relevantly vascular cell sources are analyzed. Take home message It is not possible to engineer 3D thick tissue or organ constructs without effective vascularization. An effective intra-organ vascular system cannot be built by the simple connection of large-diameter vessels and microvessels. Successful engineering of functional human organs suitable for surgical implantation will require concomitant engineering of a ‘built in’ intra-organ branched vascular system. Organ printing enables biofabrication of human organ constructs with a ‘built in’ intra-organ branched vascular tree. PMID:20132061

Gamma Knife® radiosurgery for trigeminal neuralgia.

PubMed

Yen, Chun-Po; Schlesinger, David; Sheehan, Jason P

2011-11-01

Trigeminal neuralgia is characterized by a temporary paroxysmal lancinating facial pain in the trigeminal nerve distribution. The prevalence is four to five per 100,000. Local pressure on nerve fibers from vascular loops results in painful afferent discharge from an injured segment of the fifth cranial nerve. Microvascular decompression addresses the underlying pathophysiology of the disease, making this treatment the gold standard for medically refractory trigeminal neuralgia. In patients who cannot tolerate a surgical procedure, those in whom a vascular etiology cannot be identified, or those unwilling to undergo an open surgery, stereotactic radiosurgery is an appropriate alternative. The majority of patients with typical facial pain will achieve relief following radiosurgical treatment. Long-term follow-up for recurrence as well as for radiation-induced complications is required in all patients undergoing stereotactic radiosurgery for trigeminal neuralgia.

Right heart chamber geometry and tricuspid annulus morphology in patients undergoing mitral valve repair with and without tricuspid valve annuloplasty.

PubMed

Tamborini, Gloria; Fusini, Laura; Muratori, Manuela; Gripari, Paola; Ghulam Ali, Sarah; Fiorentini, Cesare; Pepi, Mauro

2016-06-01

According to current recommendations, patients could benefit from tricuspid valve (TV) annuloplasty at the time mitral valve (MV) surgery if tricuspid regurgitation is severe or if tricuspid annulus (TA) dilatation is present. Therefore, an accurate pre-operative echocardiographic study is mandatory for left but also for right cardiac structures. Aims of this study are to assess right atrial (RA), right ventricular (RV) and TA geometry and function in patients undergoing MV repair without or with TV annuloplasty. We studied 103 patients undergoing MV surgery without (G1: 54 cases) or with (G2: 49 cases) concomitant TV annuloplasty and 40 healthy subjects (NL) as controls. RA, RV and TA were evaluated by three-dimensional (3D) transthoracic echocardiography. Comparing the pathological to the NL group, TA parameters and 3D right chamber volumes were significantly larger. RA and RV ejection fraction and TA% reduction were lower in pathological versus NL, and in G2 versus G1. In pathological patients, TA area positively correlated to systolic pulmonary pressure and negatively with RV and RA ejection fraction. Patients undergoing MV surgery and TV annuloplasty had an increased TA dimensions and a more advanced remodeling of right heart chambers probably reflecting an advanced stage of the disease.

A Markov chain model for reliability growth and decay

NASA Technical Reports Server (NTRS)

Siegrist, K.

1982-01-01

A mathematical model is developed to describe a complex system undergoing a sequence of trials in which there is interaction between the internal states of the system and the outcomes of the trials. For example, the model might describe a system undergoing testing that is redesigned after each failure. The basic assumptions for the model are that the state of the system after a trial depends probabilistically only on the state before the trial and on the outcome of the trial and that the outcome of a trial depends probabilistically only on the state of the system before the trial. It is shown that under these basic assumptions, the successive states form a Markov chain and the successive states and outcomes jointly form a Markov chain. General results are obtained for the transition probabilities, steady-state distributions, etc. A special case studied in detail describes a system that has two possible state ('repaired' and 'unrepaired') undergoing trials that have three possible outcomes ('inherent failure', 'assignable-cause' 'failure' and 'success'). For this model, the reliability function is computed explicitly and an optimal repair policy is obtained.

In vivo experimental study on laser welded ICG-loaded chitosan patches for vessel repair

NASA Astrophysics Data System (ADS)

Rossi, Francesca; Matteini, Paolo; Esposito, Giuseppe; Albanese, Alessio; Puca, Alfredo; Maira, Giulio; Rossi, Giacomo; Pini, Roberto

2011-03-01

Laser welding of microvessels provides several advantages over conventional suturing techniques: surgical times reduction, vascular healing process improvement, tissue damage reduction. We present the first application of biopolymeric patches in an in vivo laser assisted procedure for vessel repair. The study was performed in 20 New Zealand rabbits. After anesthesia, a 3-cm segment of the right common carotid artery was exposed and clamped proximally and distally. A linear lesion 3 mm in length was carried out. We used a diode laser emitting at 810 nm and equipped with a 300 μm diameter optical fiber. To close the cut, ICG-loaded chitosan films were prepared: chitosan is characterized by biodegradability, biocompatibility, antimicrobial, haemostatic and wound healing-promoting activity. ICG is an organic chromophore commonly used in the laser welding procedures to mediate the photothermal conversion at the basis of the welding effect. The membranes were used to wrap the whole length of the cut, and then they were welded in the correct position by delivering single laser spots to induce local patch/tissue adhesion. The result is an immediate closure of the wound, with no bleeding at clamps release. The animals were observed during follow-up and sacrificed after 2, 7, 30 and 90 days. All the repaired vessels were patent, no bleeding signs were documented. The carotid samples underwent histological examinations. The advantages of the proposed technique are: simplification of the surgical procedure and shortening of the operative time; good strength of the vessel repair; decreased foreign-body reaction, reduced inflammatory response and improved vascular healing process.

Effect of platelet-rich plasma on tendon-to-bone healing after rotator cuff repair in rats: an in vivo experimental study.

PubMed

Hapa, Onur; Cakıcı, Hüsamettin; Kükner, Aysel; Aygün, Hayati; Sarkalan, Nazlı; Baysal, Gökhan

2012-01-01

The purpose of this experimental study was to analyze the effects of local autologous platelet-rich plasma (PRP) injection on tendon-to-bone healing in a rotator cuff repair model in rats. Rotator cuff injury was created in 68 left shoulders of rats. PRP was obtained from the blood of an additional 15 rats. The 68 rats were divided into 4 groups with 17 rats in each group; PRP group (Week 2), control group (Week 2), PRP group (Week 4), and control group (Week 4). Platelet-rich plasma or saline was injected to the repair area intraoperatively. Rats were sacrificed 2 and 4 weeks after the surgery. Histological analysis using a semiquantitative scoring was performed on 7 rats per group. Tendon integrity and increases in vascularity and inflammatory cells and the degree of new bone formation were evaluated and compared between the groups. The remaining tendons (n=10) were mechanically tested. Degree of inflammation and vascularity were less in the study group at both time intervals (p<0.05). Tendon continuity was better in the study group at 2 weeks (p<0.05). Obvious new bone formation was detected in the control group at 4 weeks (p<0.05). Biomechanically, platelet-rich plasma-treated specimens were stronger at 2 weeks (p<0.05). Local autologous PRP injection may have beneficial effects on initial rotator cuff tendon-to-bone healing and enhance initial tendon-to-bone healing remodeling. This may represent a clinically important improvement in rotator cuff repair.

Risk models for mortality following elective open and endovascular abdominal aortic aneurysm repair: a single institution experience.

PubMed

Choke, E; Lee, K; McCarthy, M; Nasim, A; Naylor, A R; Bown, M; Sayers, R

2012-12-01

To develop and validate an "in house" risk model for predicting perioperative mortality following elective AAA repair and to compare this with other models. Multivariate logistics regression analysis was used to identify risk factors for perioperative-day mortality from one tertiary institution's prospectively maintained database. Consecutive elective open (564) and endovascular (589) AAA repairs (2000-2010) were split randomly into development (810) and validation (343) data sets. The resultant model was compared to Glasgow Aneurysm Score (GAS), Modified Customised Probability Index (m-CPI), CPI, the Vascular Governance North West (VGNW) model and the Medicare model. Variables associated with perioperative mortality included: increasing age (P = 0.034), myocardial infarct within last 10 years (P = 0.0008), raised serum creatinine (P = 0.005) and open surgery (P = 0.0001). The areas under the receiver operating characteristic curve (AUC) for predicted probability of 30-day mortality in development and validation data sets were 0.79 and 0.82 respectively. AUCs for GAS, m-CPI and CPI were poor (0.63, 0.58 and 0.58 respectively), whilst VGNW and Medicare model were fair (0.73 and 0.79 respectively). In this study, an "in-house" developed and validated risk model has the most accurate discriminative value in predicting perioperative mortality after elective AAA repair. For purposes of comparative audit with case mix adjustments, national models such as the VGNW or Medicare models should be used. Copyright © 2012 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.

Outpatient repair for inguinal hernia in elderly patients: still a challenge?

PubMed

Palumbo, Piergaspare; Amatucci, Chiara; Perotti, Bruno; Zullino, Antonio; Dezzi, Claudia; Illuminati, Giulio; Vietri, Francesco

2014-01-01

Elective inguinal hernia repair as a day case is a safe and suitable procedure, with well-recognized feasibility. The increasing number of elderly patients requiring inguinal hernia repair leads clinicians to admit a growing number of outpatients. The aim of the current study was to analyze the outcomes (feasibility and safety) of day case treatment in elderly patients. Eighty patients >80 years of age and 80 patients ≤55 years of age underwent elective inguinal hernia repairs under local anesthesia. There were no mortalities or major complications in the elderly undergoing inguinal herniorraphies as outpatients, and only one unanticipated admission occurred in the younger age group. Elective inguinal hernia repair in the elderly has a good outcome, and age alone should not be a drawback to day case treatment. Copyright © 2014 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.

DNA repair mechanisms in cancer development and therapy.

PubMed

Torgovnick, Alessandro; Schumacher, Björn

2015-01-01

DNA damage has been long recognized as causal factor for cancer development. When erroneous DNA repair leads to mutations or chromosomal aberrations affecting oncogenes and tumor suppressor genes, cells undergo malignant transformation resulting in cancerous growth. Genetic defects can predispose to cancer: mutations in distinct DNA repair systems elevate the susceptibility to various cancer types. However, DNA damage not only comprises a root cause for cancer development but also continues to provide an important avenue for chemo- and radiotherapy. Since the beginning of cancer therapy, genotoxic agents that trigger DNA damage checkpoints have been applied to halt the growth and trigger the apoptotic demise of cancer cells. We provide an overview about the involvement of DNA repair systems in cancer prevention and the classes of genotoxins that are commonly used for the treatment of cancer. A better understanding of the roles and interactions of the highly complex DNA repair machineries will lead to important improvements in cancer therapy.

Innovative postmarket device evaluation using a quality registry to monitor thoracic endovascular aortic repair in the treatment of aortic dissection.

PubMed

Beck, Adam W; Lombardi, Joseph V; Abel, Dorothy B; Morales, J Pablo; Marinac-Dabic, Danica; Wang, Grace; Azizzadeh, Ali; Kern, John; Fillinger, Mark; White, Rodney; Cronenwett, Jack L; Cambria, Richard P

2017-05-01

United States Food and Drug Administration (FDA)-mandated postapproval studies have long been a mainstay of the continued evaluation of high-risk medical devices after initial marketing approval; however, these studies often present challenges related to patient/physician recruitment and retention. Retrospective single-center studies also do not fully represent the spectrum of real-world performance nor are they likely to have a sufficiently large enough sample size to detect important signals. In recent years, The FDA Center for Devices and Radiological Health has been promoting the development and use of patient registries to advance infrastructure and methodologies for medical device investigation. The FDA 2012 document, "Strengthening the National System for Medical Device Post-market Surveillance," highlighted registries as a core foundational infrastructure when linked to other complementary data sources, including embedded unique device identification. The Vascular Quality Initiative (VQI) thoracic endovascular aortic repair for type B aortic dissection project is an innovative method of using quality improvement registries to meet the needs of device evaluation after market approval. Here we report the organization and background of this project and highlight the innovation facilitated by collaboration of physicians, the FDA, and device manufacturers. This effort used an existing national network of VQI participants to capture patients undergoing thoracic endovascular aortic repair for acute type B aortic dissection within a registry that aligns with standard practice and existing quality efforts. The VQI captures detailed patient, device, and procedural data for consecutive eligible cases under the auspices of a Patient Safety Organization (PSO). Patients were divided into a 5-year follow-up group (200 acute; 200 chronic dissections) and a 1-year follow-up group (100 acute; 100 chronic). The 5-year cohort required additional imaging details, and the 1-year group required standard VQI registry data entry. The sample size of patients in each of the 5-year acute and chronic dissection arms was achieved ≤24 months of project initiation, and data capture for the 1-year follow-up group is also nearly complete. Data completeness and follow-up has been excellent, and the two FDA-approved devices for dissection are equally represented. Although the completeness of long-term follow-up is yet to be determined, the rapidity of data collection supports the use of this construct for device assessment after market approval. The alignment of this effort with routine clinical practice and ongoing quality improvement initiatives is critical and has required minimal additional effort by practitioners, thus facilitating patient inclusion. Importantly, the success and development of this unique project has helped inform FDA strategy for future device evaluation after market approval. Copyright © 2017 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.

Review of vascularised bone tissue-engineering strategies with a focus on co-culture systems.

PubMed

Liu, Yuchun; Chan, Jerry K Y; Teoh, Swee-Hin

2015-02-01

Poor angiogenesis within tissue-engineered grafts has been identified as a main challenge limiting the clinical introduction of bone tissue-engineering (BTE) approaches for the repair of large bone defects. Thick BTE grafts often exhibit poor cellular viability particularly at the core, leading to graft failure and lack of integration with host tissues. Various BTE approaches have been explored for improving vascularisation in tissue-engineered constructs and are briefly discussed in this review. Recent investigations relating to co-culture systems of endothelial and osteoblast-like cells have shown evidence of BTE efficacy in increasing vascularization in thick constructs. This review provides an overview of key concepts related to bone formation and then focuses on the current state of engineered vascularized co-culture systems using bone repair as a model. It will also address key questions regarding the generation of clinically relevant vascularized bone constructs as well as potential directions and considerations for research with the objective of pursuing engineered co-culture systems in other disciplines of vascularized regenerative medicine. The final objective is to generate serious and functional long-lasting vessels for sustainable angiogenesis that will enable enhanced cellular survival within thick voluminous bone grafts, thereby aiding in bone formation and remodelling in the long term. However, more evidence about the quality of blood vessels formed and its associated functional improvement in bone formation as well as a mechanistic understanding of their interactions are necessary for designing better therapeutic strategies for translation to clinical settings. Copyright © 2012 John Wiley & Sons, Ltd.

Growth and regression of vasculature in healthy and diabetic mice after hindlimb ischemia.

PubMed

Landázuri, Natalia; Joseph, Giji; Guldberg, Robert E; Taylor, W Robert

2012-07-01

The formation of vascular networks during embryogenesis and early stages of development encompasses complex and tightly regulated growth of blood vessels, followed by maturation of some vessels, and spatially controlled disconnection and pruning of others. The adult vasculature, while more quiescent, is also capable of adapting to changing physiological conditions by remodeling blood vessels. Numerous studies have focused on understanding key factors that drive vessel growth in the adult in response to ischemic injury. However, little is known about the extent of vessel rarefaction and its potential contribution to the final outcome of vascular recovery. We addressed this topic by characterizing the endogenous phases of vascular repair in a mouse model of hindlimb ischemia. We showed that this process is biphasic. It encompasses an initial rapid phase of vessel growth, followed by a later phase of vessel rarefaction. In healthy mice, this process resulted in partial recovery of perfusion and completely restored the ability of mice to run voluntarily. Given that the ability to revascularize can be compromised by a cardiovascular risk factor such as diabetes, we also examined vascular repair in diabetic mice. We found that paradoxically both the initial growth and subsequent regression of collateral vessels were more pronounced in the setting of diabetes and resulted in impaired recovery of perfusion and impaired functional status. In conclusion, our findings demonstrate that the formation of functional collateral vessels in the hindlimb requires vessel growth and subsequent vessel rarefaction. In the setting of diabetes, the physiological defect was not in the initial formation of vessels but rather in the inability to sustain newly formed vessels.

Retinoic acid-loaded polymeric nanoparticles enhance vascular regulation of neural stem cell survival and differentiation after ischaemia

NASA Astrophysics Data System (ADS)

Ferreira, R.; Fonseca, M. C.; Santos, T.; Sargento-Freitas, J.; Tjeng, R.; Paiva, F.; Castelo-Branco, M.; Ferreira, L. S.; Bernardino, L.

2016-04-01

Stroke is one of the leading causes of death and disability worldwide. However, current therapies only reach a small percentage of patients and may cause serious side effects. We propose the therapeutic use of retinoic acid-loaded nanoparticles (RA-NP) to safely and efficiently repair the ischaemic brain by creating a favourable pro-angiogenic environment that enhances neurogenesis and neuronal restitution. Our data showed that RA-NP enhanced endothelial cell proliferation and tubule network formation and protected against ischaemia-induced death. To evaluate the effect of RA-NP on vascular regulation of neural stem cell (NSC) survival and differentiation, endothelial cell-conditioned media (EC-CM) were collected. EC-CM from healthy RA-NP-treated cells reduced NSC death and promoted proliferation while EC-CM from ischaemic RA-NP-treated cells decreased cell death, increased proliferation and neuronal differentiation. In parallel, human endothelial progenitor cells (hEPC), which are part of the endogenous repair response to vascular injury, were collected from ischaemic stroke patients. hEPC treated with RA-NP had significantly higher proliferation, which further highlights the therapeutic potential of this formulation. To conclude, RA-NP protected endothelial cells from ischaemic death and stimulated the release of pro-survival, proliferation-stimulating factors and differentiation cues for NSC. RA-NP were shown to be up to 83-fold more efficient than free RA and to enhance hEPC proliferation. These data serve as a stepping stone to use RA-NP as vasculotrophic and neurogenic agents for vascular disorders and neurodegenerative diseases with compromised vasculature.

Endothelial FoxM1 Mediates Bone Marrow Progenitor Cell-Induced Vascular Repair and Resolution of Inflammation following Inflammatory Lung Injury

PubMed Central

Zhao, Yidan D.; Huang, Xiaojia; Yi, Fan; Dai, Zhiyu; Qian, Zhijian; Tiruppathi, Chinnaswamy; Tran, Khiem; Zhao, You-Yang

2015-01-01

Adult stem cell treatment is a potential novel therapeutic approach for acute respiratory distress syndrome. Given the extremely low rate of cell engraftment, it is believed that these cells exert their beneficial effects via paracrine mechanisms. However, the endogenous mediator(s) in the pulmonary vasculature remains unclear. Employing the mouse model with endothelial cell (EC)-restricted disruption of FoxM1 (FoxM1 CKO), here we show that endothelial expression of the reparative transcriptional factor FoxM1 is required for the protective effects of bone marrow progenitor cells (BMPC) against LPS-induced inflammatory lung injury and mortality. BMPC treatment resulted in rapid induction of FoxM1 expression in WT but not FoxM1 CKO lungs. BMPC-induced inhibition of lung vascular injury, resolution of lung inflammation, and survival, as seen in WT mice, were abrogated in FoxM1 CKO mice following LPS challenge. Mechanistically, BMPC treatment failed to induce lung EC proliferation in FoxM1 CKO mice, which was associated with impaired expression of FoxM1 target genes essential for cell cycle progression. We also observed that BMPC treatment enhanced endothelial barrier function in WT, but not in FoxM1-deficient EC monolayers. Restoration of β-catenin expression in FoxM1-deficient ECs normalized endothelial barrier enhancement in response to BMPC treatment. These data demonstrate the requisite role of endothelial FoxM1 in the mechanism of BMPC-induced vascular repair to restore vascular integrity and accelerate resolution of inflammation, thereby promoting survival following inflammatory lung injury. PMID:24578354

Indications, Contraindications, and Complications of Mesh in Surgical Treatment of Pelvic Organ Prolapse

PubMed Central

Ellington, David R.; Richter, Holly E.

2013-01-01

Women are seeking care for pelvic organ prolapse (POP) in increasing numbers and a significant proportion of them will undergo a second repair for recurrence. This has initiated interest by both surgeons and industry to utilize and design prosthetic mesh materials to help augment longevity of prolapse repairs. Unfortunately, the introduction of transvaginal synthetic mesh kits for use in women was done without the benefit of Level 1 data to determine its utility compared to native tissue repair. This report summarizes the potential benefit/risks of transvaginal synthetic mesh use for POP and recommendations regarding its continued use. PMID:23563869

46 CFR 298.37 - Examination and audit.

Code of Federal Regulations, 2013 CFR

2013-10-01

... force. (3) When a Vessel is in port or undergoing repairs, we may make photostatic or other copies of... office space and other facilities that we reasonably require in performing the examination, audit or...

Influence of Health Insurance Status on the Timing of Surgery and Treatment of Bucket-Handle Meniscus Tears

PubMed Central

Sood, Amit; Gonzalez-Lomas, Guillem; Gehrmann, Robin

2015-01-01

Background Lack of insurance has been shown to lead to delays in seeking care as well as fewer preventive medicine visits and poorer overall health status. Purpose To investigate the effects of insurance status on the timing and treatment of patients with bucket-handle meniscus tears. Study Design Cohort study; Level of evidence, 3. Methods Charts from 2004 to 2013 were retrospectively reviewed for patients diagnosed with bucket-handle meniscus tears. Patients were divided into 2 groups: insured or underinsured. The insured group included patients with commercial insurance or Medicare. The underinsured group included patients with Medicaid or Charity Care. Time intervals were categorized as <6 weeks or ≥6 weeks. Results A total of 52 patients were included in this study: 15 (29%) insured and 37 (71%) underinsured. Underinsured patients experienced delays in initial presentation to an orthopaedic surgeon (P = .004), time from magnetic resonance imaging to surgery (P = .01), and time from injury to surgery (P = .007). Repair rates were 40% and 38% (P > .999) for the insured and underinsured, respectively. Repair rates for <6 weeks from injury to surgery were 75% for insured (P = .007) and 100% for underinsured patients (P = .001). Repair rates for ≥6 weeks from injury to surgery were 0% for insured and 30% for underinsured patients. Overall, patients with an injury-to-surgery time of <6 weeks had a significantly higher repair rate (87%) than those managed >6 weeks (19%) (P < .001). Conclusion Underinsured patients experience significant delays in time to presentation and overall time to surgery. However, the overall repair rate between the insured and underinsured is similar. Regardless of insurance status, patients undergoing arthroscopy within 6 weeks of injury have a significantly higher repair rate than those after 6 weeks. Clinical Relevance Patients undergoing arthroscopy within 6 weeks of injury have a significantly higher repair rate than those after 6 weeks. PMID:26676153

Arthroscopic Repair of Full-Thickness Rotator Cuff Tears With and Without Acromioplasty: Randomized Prospective Trial With 2-Year Follow-up.

PubMed

Abrams, Geoffrey D; Gupta, Anil K; Hussey, Kristen E; Tetteh, Elizabeth S; Karas, Vasili; Bach, Bernard R; Cole, Brian J; Romeo, Anthony A; Verma, Nikhil N

2014-06-01

Acromioplasty is commonly performed during arthroscopic rotator cuff repair, but its effect on short-term outcomes is debated. To report the short-term clinical outcomes of patients undergoing arthroscopic repair of full-thickness rotator cuff tears with and without acromioplasty. Randomized controlled trial; Level of evidence, 2. Patients undergoing arthroscopic repair of full-thickness rotator cuff tears were randomized into acromioplasty or nonacromioplasty groups. The Simple Shoulder Test (SST), American Shoulder and Elbow Surgeons (ASES) score, Constant score, University of California-Los Angeles (UCLA) score, and Short Form-12 (SF-12) health assessment were collected along with physical examination including range of motion and dynamometer strength testing. Intraoperative data including tear size, repair configuration, and concomitant procedures were recorded. Follow-up examination was performed at regular intervals up to 2 years. Preoperative imaging was reviewed to classify the acromial morphologic type, acromial angle, and lateral acromial angulation. A total of 114 patients were initially enrolled in the study, and 95 (83%; 43 nonacromioplasty, 52 acromioplasty) were available for a minimum 2-year follow-up. There were no significant differences in baseline characteristics, including number of tendons torn, repair configuration, concomitant procedures, and acromion type and angles. Within groups, there was a significant (P < .001) improvement in all functional outcome scores from preoperatively to all follow-up time points, including 2 years, for the nonacromioplasty and acromioplasty groups (ASES score: 55.1-91.5, 48.8-89.0; Constant score: 48.3-75.0, 51.9-78.7, respectively). There were no significant differences in functional outcomes between nonacromioplasty and acromioplasty groups or between subjects with different acromial features at any time point. The results of this study demonstrate no difference in clinical outcomes after rotator cuff repair with or without acromioplasty at 2 years postoperatively. © 2014 The Author(s).

Early and mid-term outcomes of endovascular and open surgical repair of non-dissected aortic arch aneurysm†.

PubMed

Hori, Daijiro; Okamura, Homare; Yamamoto, Takahiro; Nishi, Satoshi; Yuri, Koichi; Kimura, Naoyuki; Yamaguchi, Atsushi; Adachi, Hideo

2017-06-01

With the introduction of endovascular stent graft technology, a variety of surgical options are available for patients with aortic aneurysms. We sought to evaluate early-term and mid-term outcomes of patients undergoing endovascular and open surgical repair for non-dissected aortic arch aneurysm. Overall, 200 patients underwent treatment for isolated non-dissected aortic arch aneurysm between January 2008 and February 2016: 133 patients had open surgery and 67, endovascular repair. Early-term and mid-term outcomes were compared. Seventy percent ( n  = 47) needing endovascular repair underwent fenestrated stent graft and 30% ( n  = 20) underwent the debranched technique. Patients in the open surgery group were younger (71 vs 75 years, P  < 0.001) and had a lower prevalence of ischaemic heart disease (11% vs 35%, P  < 0.001). Intensive care unit stay (1 vs 3 days, P  < 0.001), hospital stay (11 vs 17 days, P  < 0.001) and surgical time (208 vs 390 min, P  < 0.001) were lower in the endovascular repair group than in the open surgery group. There were 3 in-hospital deaths each in the open surgery and endovascular groups (2% vs 5%, respectively, P  = 0.40). Mid-term survival ( P  < 0.001) and freedom from reintervention ( P  = 0.009) were better in the open surgery than in the endovascular repair group. No aneurysm-related deaths were observed. The propensity-matched comparison ( n  = 58) demonstrated that survival was better in the open surgery group ( P  = 0.011); no significant difference was seen in the reintervention rate ( P  = 0.28). Close follow-up for re-intervention may reduce the risk for aneurysm-related deaths and provide acceptable outcomes in patients undergoing endovascular repair. © The Author 2017. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.

Editor's Choice - Renal complications after EVAR with suprarenal versus infrarenal fixation among all users and routine users.

PubMed

Zettervall, S L; Deery, S E; Soden, P A; Shean, K; Siracuse, J J; Alef, M; Patel, V I; Schermerhorn, M L

2017-09-01

Previous studies comparing endografts with suprarenal and infrarenal fixation for endovascular abdominal aortic aneurysm repair (EVAR) have found conflicting results and did not account for differences in patient selection. This study aims to evaluate the differences in outcomes among surgeons who routinely use either suprarenal or infrarenal fixation, as well as all surgeons in the Vascular Study Group of New England (VSGNE). All patients undergoing EVAR in the VSGNE from 2003 to 2014 were identified. All ruptured aneurysms, repairs with concomitant procedures, and infrequently used stent grafts (<50) were excluded. Suprarenal endografts included Talent, Zenith, and Endurant; infrarenal endografts included AneuRx and Excluder. Grafts were compared among surgeons who used only one type of endograft (suprarenal or infrarenal) for >80% of cases, as well as all surgeons. Multivariate regression and Cox hazard models were utilised to account for patient demographics, comorbidities, operative differences, and procedure year. This study identified 2574 patients (suprarenal, 1264; infrarenal, 1310) with 888 endografts placed by routine users (suprarenal, 409; infrarenal, 479). There were no differences in baseline comorbidities, including the estimated glomerular filtration rate, between suprarenal and infrarenal fixation, or between patients with endografts placed by routine and non-routine users. Patients treated with suprarenal endografts received more contrast than all users (102 mL vs. 100 mL, p = .01) and routine users (110 mL vs. 88 mL, p < .01), but other vascular and operative details were similar. Among all users, patients treated with suprarenal grafts had higher rates of creatinine increase >.5 mg/dL (3.7% vs. 2.0%, p = .01), length of stay >2 days (27% vs. 19%, p < .01), and discharge to a skilled nursing facility (9.2% vs. 6.7%, p = .02). There were no differences in 30 day or 1 year mortality. Following adjustment, suprarenal stent grafts remained associated with an increased risk of renal deterioration (OR 2.0; 95% CI 1.2-3.4) and prolonged length of stay (OR 1.8; 95% CI 1.4-2.2). Among routine users, suprarenal fixation was also associated with higher rates of renal dysfunction (3.7% vs. 1.3%, p = .02; OR 2.9; 95% CI 1.1-7.8). Despite potential differences in patient selection, endografts with suprarenal fixation among all users and routine users were associated with higher rates of renal deterioration and longer length of hospital stay. Longer-term data are needed to determine the duration and severity of renal function decline and to identify potential benefits of decreased migration or endoleak. Copyright © 2017 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.

Tissue expander-stimulated lengthening of arteries for the treatment of midaortic syndrome in children.

PubMed

Kim, Heung Bae; Vakili, Khashayar; Ramos-Gonzalez, Gabriel J; Stein, Deborah R; Ferguson, Michael A; Porras, Diego; Lock, James E; Chaudry, Gulraiz; Alomari, Ahmad; Fishman, Steven J

2018-01-17

Midaortic syndrome (MAS) is a rare condition characterized by stenosis of the abdominal aorta. Patients with disease refractory to medical management will usually require either endovascular therapy or surgery with use of prosthetic graft material for bypass or patch angioplasty. We report our early experience with a novel approach using a tissue expander (TE) to lengthen the normal native arteries in children with MAS, allowing primary aortic repair without the need for prosthetic graft material. We conducted a retrospective review of patients with MAS undergoing the TE-stimulated lengthening of arteries (TESLA) procedure at our institution from 2010 to 2014. Data are presented as mean (range). Five patients aged 4.8 years (3-8 years) underwent the TESLA procedure. Stages of this procedure include the following: stage I, insertion of retroaortic TE; stage II, serial TE injections; and stage III, final repair with excision of aortic stenosis and primary end-to-end aortic anastomosis. Stage II was completed in 4 months (1-9 months) with 12 (7-20) TE injections. Goal lengthening was achieved in all patients. Stage III could not be completed in one patient because of extreme aortic inflammation, which precluded safe excision of the aortic stenosis and required use of a prosthetic bypass graft. The other four patients completed stage III with two (one to three) additional vessels also requiring reconstruction (renal or mesenteric arteries). At 3.2 years (1-6 years) of follow-up, all patients are doing well. The TESLA procedure allows surgical correction of MAS without the need for prosthetic grafts in young children who are still growing. Copyright © 2017 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.

The financial implications of endovascular aneurysm repair in the cost containment era.

PubMed

Stone, David H; Horvath, Alexander J; Goodney, Philip P; Rzucidlo, Eva M; Nolan, Brian W; Walsh, Daniel B; Zwolak, Robert M; Powell, Richard J

2014-02-01

Endovascular aneurysm repair (EVAR) is associated with significant direct device costs. Such costs place EVAR at odds with efforts to constrain healthcare expenditures. This study examines the procedure-associated costs and operating margins associated with EVAR at a tertiary care academic medical center. All infrarenal EVARs performed from April 2011 to March 2012 were identified (n = 127). Among this cohort, 49 patients met standard commercial instruction for use guidelines, were treated using a single manufacturer device, and billed to Medicare diagnosis-related group (DRG) 238. Of these 49 patients, net technical operating margins (technical revenue minus technical cost) were calculated in conjunction with the hospital finance department. EVAR implant costs were determined for each procedure. DRG 238-associated costs and length of stay were benchmarked against other academic medical centers using University Health System Consortium 2012 data. Among the studied EVAR cohort (age 75, 82% male, mean length of stay, 1.7 days), mean technical costs totaled $31,672. Graft implants accounted for 52% of the allocated technical costs. Institutional overhead was 17% ($5495) of total technical costs. Net mean total technical EVAR-associated operating margins were -$4015 per procedure. Our institutional costs and length of stay, when benchmarked against comparable centers, remained in the lowest quartile nationally using University Health System Consortium costs for DRG 238. Stent graft price did not correlate with total EVAR market share. EVAR is currently associated with significant negative operating margins among Medicare beneficiaries. Currently, device costs account for over 50% of EVAR-associated technical costs and did not impact EVAR market share, reflecting an unawareness of cost differential among surgeons. These data indicate that EVAR must undergo dramatic care delivery redesign for this practice to remain sustainable. Copyright © 2014 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.

Long-term outcome in dogs undergoing mitral valve repair with suture annuloplasty and chordae tendinae replacement.

PubMed

Mizuno, T; Mizukoshi, T; Uechi, M

2013-02-01

Mitral valve repair under cardiopulmonary bypass was performed in three dogs with clinical signs associated with mitral regurgitation that were not controlled by medication. Mitral valve repair comprised circumferential annuloplasty and chordal replacement with expanded polytetrafluoroethylene. One dog died 2 years after surgery because of severe mitral regurgitation resulting from partial circumferential suture detachment. The others survived for over 5 years, but mild mitral valve stenosis persisted in one. The replaced chordae did not rupture in any dog. Mitral valve repair appears to be an effective treatment for mitral regurgitation in dogs. Chordal replacement with expanded polytetrafluoroethylene is a feasible technique, demonstrating long-term durability in dogs. However, mitral annuloplasty techniques need improvement. © 2012 British Small Animal Veterinary Association.

Innovative Chimney-Graft Technique for Endovascular Repair of a Pararenal Abdominal Aortic Aneurysm

PubMed Central

Galiñanes, Edgar Luis; Hernandez-Vila, Eduardo A.

2015-01-01

After abdominal aortic aneurysm repair, progressive degeneration of the aneurysm can be challenging to treat. Multiple comorbidities and previous operations place such patients at high risk for repeat surgery. Endovascular repair is a possible alternative; however, challenging anatomy can push the limits of available technology. We describe the case of a 71-year-old man who presented with a 5.3-cm pararenal aneurysm 4 years after undergoing open abdominal aortic aneurysm repair. To avoid reoperation, we excluded the aneurysm by endovascular means, using visceral-artery stenting, a chimney-graft technique. Low-profile balloons on a monorail system enabled the rapid exchange of coronary wires via a buddy-wire technique. This novel approach facilitated stenting and simultaneous angioplasty of multiple visceral vessels and the abdominal aorta. PMID:25873796

Innovative chimney-graft technique for endovascular repair of a pararenal abdominal aortic aneurysm.

PubMed

Galiñanes, Edgar Luis; Hernandez-Vila, Eduardo A; Krajcer, Zvonimir

2015-02-01

After abdominal aortic aneurysm repair, progressive degeneration of the aneurysm can be challenging to treat. Multiple comorbidities and previous operations place such patients at high risk for repeat surgery. Endovascular repair is a possible alternative; however, challenging anatomy can push the limits of available technology. We describe the case of a 71-year-old man who presented with a 5.3-cm pararenal aneurysm 4 years after undergoing open abdominal aortic aneurysm repair. To avoid reoperation, we excluded the aneurysm by endovascular means, using visceral-artery stenting, a chimney-graft technique. Low-profile balloons on a monorail system enabled the rapid exchange of coronary wires via a buddy-wire technique. This novel approach facilitated stenting and simultaneous angioplasty of multiple visceral vessels and the abdominal aorta.

[Effectiveness of Sacral Intervertebral Epidural Block for Umbilical Hernia Repair in Children].

PubMed

Nagamine, Norimitsu; Furuya, Atsushi; Suzuki, Sho; Kondo, Satoko; Kiuchi, Riko; Suzuki, Satomi; Nonaka, Akihiko

2015-02-01

Effectiveness of sacral intervertebral epidural block (S 2-3 block) for umbilical hernia repair has not been clarified. We investigate 24 children, undergoing umbilical hernia repair; mean age of 3 years (age range: 20-65 months). Under general anesthesia, epidural block was performed at S 2-3 interspace with 1 ml x kg(-1) ropivacaine (0.2%) at injecting rate of 1 ml x sec(-1) followed by 0.25 ml x kg(-1) normal saline. In all cases, neither systolic blood pressure nor heart rate increased > 15% from those just before the block. Postoperative analgesics were given in 6 patients (25%) rectally. Mean time between the block and the administration of analgesic was 10.5 hours. S 2-3 block can be effective for postoperative pain in umbilical hernia repair.

Comparative effectiveness of peripheral vascular intervention versus surgical bypass for critical limb ischemia in the Vascular Study Group of Greater New York.

PubMed

Meltzer, Andrew J; Sedrakyan, Art; Isaacs, Abby; Connolly, Peter H; Schneider, Darren B

2016-11-01

In this study, the effectiveness of peripheral vascular intervention (PVI) was compared with surgical bypass grafting (BPG) for critical limb ischemia (CLI) in the Vascular Study Group of Greater New York (VSGGNY). Patients undergoing BPG or PVI for CLI at VSGGNY centers (2011-2013) were included. The Society for Vascular Surgery objective performance goals for CLI were used to directly compare the safety and effectiveness of PVI and BPG. Propensity score matching was used for risk-adjusted comparisons of PVI with BPG. A total of 414 patients (268 PVI, 146 BPG) were treated for tissue loss (69%) or rest pain (31%). Patients undergoing PVI were more likely to have tissue loss (74.6% vs 57.5%; P < .001) and comorbidities such as diabetes (69.3% vs 57.5%; P = .02), heart failure (22% vs 13.7%; P = .04), and severe renal disease (13.1% vs 4.1%; P = .004). No significant differences were found between the groups across a panel of safety objective performance goals. In unadjusted analyses at 1 year, BPG was associated with higher rates of freedom from reintervention, amputation, or restenosis (90.4% vs 81.7%; P = .02) and freedom from reintervention or amputation (92.5% vs 85.8%, P = .045). After propensity score matching, PVI was associated with improved freedom from major adverse limb events and postoperative death at 1 year (95.6% vs 88.5%; P < .05). By unadjusted comparison, early reintervention and restenosis are more prevalent with PVI. However, risk-adjusted comparison underscores the safety and effectiveness of PVI in the treatment of CLI. Copyright © 2016 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.

Randomized controlled trial of laparoscopic transabdominal preperitoneal hernioplasty vs Shouldice repair.

PubMed

Tschudi, J F; Wagner, M; Klaiber, C; Brugger, J J; Frei, E; Krähenbühl, L; Inderbitzi, R; Boinski, J; Hsu Schmitz, S F; Hüsler, J

2001-11-01

There is a scarcity of data on long-term results after laparoscopic hernia repair. Herein we report on the outcome of a group of patients who were followed up for 5 years in a multicenter study on hernia repair. A total of 100 patients with 127 hernias were randomized to undergo either transabdominal preperitoneal (TAPP) or Shouldice hernia repair. Follow-up was by clinical examination and standardized questionnaire. Of the 100 patients who underwent surgery, 84 were available for follow-up at 5 years. The TAPP procedure was less painful than the Shouldice repair, with fewer patients receiving narcotic analgesics. The median time to return to 100% activity was shorter in the laparoscopic group (21 days) than in the Shouldice group (40 days). Up to 60 months after the operation, the complication rate was lower in laparoscopically repaired hernias (19/66) than in the open group (25/61). There were two recurrences (3.9%) in the TAPP group and five in the Shouldice group (10.2%). The TAPP hernia repair yields comparable or better results than Shouldice herniorrhaphy in terms of postoperative pain, recovery, and recurrence rate.

Evaluation of Anesthesia Profile in Pediatric Patients after Inguinal Hernia Repair with Caudal Block or Local Wound Infiltration.

PubMed

Gavrilovska-Brzanov, Aleksandra; Kuzmanovska, Biljana; Kartalov, Andrijan; Donev, Ljupco; Lleshi, Albert; Jovanovski-Srceva, Marija; Spirovska, Tatjana; Brzanov, Nikola; Simeonov, Risto

2016-03-15

The aim of this study is to evaluate anesthesia and recovery profile in pediatric patients after inguinal hernia repair with caudal block or local wound infiltration. In this prospective interventional clinical study, the anesthesia and recovery profile was assessed in sixty pediatric patients undergoing inguinal hernia repair. Enrolled children were randomly assigned to either Group Caudal or Group Local infiltration. For caudal blocks, Caudal Group received 1 ml/kg of 0.25% bupivacaine; Local Infiltration Group received 0.2 ml/kg 0.25% bupivacaine. Investigator who was blinded to group allocation provided postoperative care and assessments. Postoperative pain was assessed. Motor functions and sedation were assessed as well. The two groups did not differ in terms of patient characteristic data and surgical profiles and there weren't any hemodynamic changes between groups. Regarding the difference between groups for analgesic requirement there were two major points - on one hand it was statistically significant p < 0.05 whereas on the other hand time to first analgesic administration was not statistically significant p = 0.40. There were significant differences in the incidence of adverse effects in caudal and local group including: vomiting, delirium and urinary retention. Between children undergoing inguinal hernia repair, local wound infiltration insures safety and satisfactory analgesia for surgery. Compared to caudal block it is not overwhelming. Caudal block provides longer analgesia, however complications are rather common.

Impact of concomitant laparoscopic sleeve gastrectomy and hiatal hernia repair on gastro-oesophageal reflux disease in morbidly obese patients.

PubMed

Garg, Harshit; Vigneshwaran, Balasubiramaniyan; Aggarwal, Sandeep; Ahuja, Vineet

2017-01-01

The aim of this study was to analyse the impact of hiatal hernia repair (HHR) on gastro-oesophageal reflux disease (GERD) in morbidly obese patients with hiatus hernia undergoing laparoscopic sleeve gastrectomy (LSG). It is a retrospective study involving ten morbidly obese patients with large hiatus hernia diagnosed on pre-operative endoscopy who underwent LSG and simultaneous HHR. The patients were assessed for symptoms of GERD using a Severity symptom score (SS) questionnaire and anti-reflux medications. Of the ten patients, five patients had GERD preoperatively. At the mean follow-up of 11.70 ± 6.07 months after surgery, four patients (80%) showed complete resolution while one patient complained of persistence of symptoms. Endoscopy in this patient revealed resolution of esophagitis indicating that the persistent symptoms were not attributable to reflux. The other five patients without GERD remained free of any symptom attributable to GERD. Thus, in all ten patients, repair of hiatal hernia (HH) during LSG led to either resolution of GERD or prevented any new onset symptom related to GER. In morbidly obese patients with HH with or without GERD undergoing LSG, repair of the hiatus hernia helps in amelioration of GERD and prevents any new onset GER. Thus, the presence of HH should not be considered as a contraindication for LSG.

Outcome after open surgery repair in endovascular-suitable patients with ruptured abdominal aortic aneurysms.

PubMed

Krenzien, Felix; Matia, Ivan; Wiltberger, Georg; Hau, Hans-Michael; Freitas, Bruno; Moche, Michael; Schmelzle, Moritz; Jonas, Sven; Fellmer, Peter T

2013-11-01

Endovascular aneurysm repair (EVAR) has been suggested in several studies to be superior to open surgery repair (OSR) for the treatment of ruptured abdominal aortic aneurysms (rAAAs), but this finding might be affected by selection bias based on aneurysm morphology and patient characteristics. We tested rAAA anatomy according to EVAR suitability in patients undergoing OSR to assess the impact on mortality. This retrospective analysis reports on 83 patients with rAAAs treated between November 2002 and July 2013. Pre-operative computed tomography (CT) scans were evaluated based on EVAR suitability and were determined by blinded independent reviewers. CT scans were lacking due to acquisition in an external institution with no availability (n = 9) or solely ultrasound evaluations (n = 8). In addition patient characteristics and outcomes were assessed. All patients who underwent OSR and who had available preoperative CT scans were included in the study (n = 66). In summary, 42 % of the patients (28/66; 95 % confidence interval [CI], 30.5 - 54.4) were considered eligible for EVAR according to pre-operative CT scans and 58 % of the patients (38/66; 95 % CI, 45.6 - 69.5) were categorized as unsuitable for endovascular repair. Patients suitable for EVAR had a significantly lower prevalence of in-hospital deaths (25 % [7/28]; 95 % CI, 9 - 41) in contrast to patients unsuitable for EVAR (53 % [20/38]; 95 % CI, 36.8 - 68.5; p = 0.02). EVAR-suitable patients had a highly significant mortality reduction undergoing OSR. Thus, the present study proposes that EVAR suitability is a positive predictor for survival after open repair of rAAA.

[Ultrasound-guided Rectus Sheath Block vs Transversus Abdominis Plane Block in Children Undergoing Umbilical Hernia Repair].

PubMed

Torii, Naoko; Tachibana, Kazuya; Iwasaki, Mitsuo; Takeuchi, Muneyuki; Kinouchi, Keiko

2016-06-01

Although many reports describe the usefulness of the rectus sheath block (RSB) in the umbilical hernia repair, the efficacy of the transversus abdominis plane block (TAPB) is rarely reported. The purpose of this study was to compare the efficacy and technique of ultrasound-guided RSB and TAPB in children undergoing umbilical hernia repair. Thirty-four children younger than 12 years of age scheduled for umbilical hernia repair were enrolled in this prospective observer-blinded randomized clinical trial. They were randomly assigned either to RSB group (median age, 3.7 years) or TAPB group (median age, 3.8 years). After the induction of general anesthesia with sevoflurane, nitrous oxide, and oxygen children in both groups received regional anesthesia with 0.3 ml x kg(-1) of 0.25% ropivacaine on each side under ultrasound guidance. Hemodynamic changes at the skin incision, postoperative pain scores and parental satisfaction were recorded. Anesthesiologists rated the quality of ultrasound images and easiness of the block performance. The patients' demographics of the two groups were similar. There were no significant differences in the time needed for the block procedure, quality of ultrasound images and the change of the heart rate and blood pressure at the skin incision between the two groups. Postoperative pain score (immediately, 2 and 4 hours after the operation), need for rescue analgesia and satisfaction of the parents also did not differ. There were no major complications in the patients. TAPB provided comparable perioperative analgesia and easiness of block performance to RSB in the pediatric umbilical hernia repair.

78 FR 77477 - National Heart, Lung, and Blood Institute; Notice of Closed Meeting

Federal Register 2010, 2011, 2012, 2013, 2014

2013-12-23

... Emphasis Panel; Small Business Development of New Methods for Mitral Valve Repair. Date: January 10, 2014... Center for Sleep Disorders Research; 93.837, Heart and Vascular Diseases Research; 93.838, Lung Diseases Research; 93.839, Blood Diseases and Resources Research, National Institutes of Health, HHS). Dated...

METACASPASE9 modulates autophagy to confine cell death to the target cells during Arabidopsis vascular xylem differentiation

PubMed Central

Escamez, Sacha; André, Domenique; Zhang, Bo; Bollhöner, Benjamin; Pesquet, Edouard; Tuominen, Hannele

2016-01-01

ABSTRACT We uncovered that the level of autophagy in plant cells undergoing programmed cell death determines the fate of the surrounding cells. Our approach consisted of using Arabidopsis thaliana cell cultures capable of differentiating into two different cell types: vascular tracheary elements (TEs) that undergo programmed cell death (PCD) and protoplast autolysis, and parenchymatic non-TEs that remain alive. The TE cell type displayed higher levels of autophagy when expression of the TE-specific METACASPASE9 (MC9) was reduced using RNAi (MC9-RNAi). Misregulation of autophagy in the MC9-RNAi TEs coincided with ectopic death of the non-TEs, implying the existence of an autophagy-dependent intercellular signalling from within the TEs towards the non-TEs. Viability of the non-TEs was restored when AUTOPHAGY2 (ATG2) was downregulated specifically in MC9-RNAi TEs, demonstrating the importance of autophagy in the spatial confinement of cell death. Our results suggest that other eukaryotic cells undergoing PCD might also need to tightly regulate their level of autophagy to avoid detrimental consequences for the surrounding cells. PMID:26740571

Higher surgeon annual volume, but not years of experience, is associated with reduced rates of postoperative complications and reoperations after open abdominal aortic aneurysm repair.

PubMed

Dubois, Luc; Allen, Britney; Bray-Jenkyn, Krista; Power, Adam H; DeRose, Guy; Forbes, Thomas L; Duncan, Audra; Shariff, Salimah Z

2018-06-01

Volume-outcome relationships for open abdominal aortic aneurysm (AAA) repair have received less attention in publicly funded health systems. Furthermore, the roles of surgeon seniority (years of experience) and composite volume (encompassing all major arterial cases) on outcomes after open AAA repair are less well known. We sought to determine the effects of surgeon volume, surgeon years of experience, and composite volume on outcomes after elective open AAA repairs performed in Ontario, Canada. Using a population-based, prospectively collected health administrative database, all elective open AAA repairs occurring in the province of Ontario from 2005 to 2014 were identified. Surgeon annual volume was classified by quintiles, with the highest volume quintile acting as the reference category. Multivariable logistic regression modeling was used, adjusting for patient factors (age, sex, comorbidities, year of procedure, income) to investigate the relationship between surgeon annual volume and 30-day mortality, 30-day major complications, 30-day reoperations, 1-year mortality, and 1-year reoperations (related to index procedure). The potential effects of annual surgeon composite volume and surgeon years of experience on postoperative outcomes were also explored. A total of 7211 elective open AAA repairs performed by 101 surgeons were identified between 2005 and 2014. Most of the operations were performed by vascular surgeons (81.5%), followed by cardiac (12.1%) and general surgeons (6.1%). Median number of procedures in the lowest quintile group was 3 repairs/y, whereas the highest quintile group performed 54 repairs/y. Overall 30-day mortality was 3%. No difference in mortality was detected in comparing the lowest with the highest volume groups (1.89% vs 3.01%; adjusted odds ratio [OR], 0.60; 95% confidence interval [CI], 0.27-1.33). The lowest volume group exhibited a higher 30-day complication rate (28.0% vs 20.4%; OR, 1.54; 95% CI, 1.15-2.06) and 30-day reoperation rate (10.53% vs 6.73%; OR, 1.64; 95% CI, 1.13-2.38) compared with the highest volume group. No effect of surgeon volume on 1-year mortality or 1-year reoperation was observed. Similarly, composite volume and surgeon years of experience were not associated with postoperative outcomes. In a single-payer system with a relatively high number of open AAA repairs/surgeon per year, surgeon annual volume had no effect on postoperative mortality but was associated with lower postoperative complication and reoperation rates. Copyright © 2017 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.

Meta-analysis of posterior versus medial approach for popliteal artery aneurysm repair.

PubMed

Phair, Alison; Hajibandeh, Shahin; Hajibandeh, Shahab; Kelleher, Damian; Ibrahim, Riza; Antoniou, George A

2016-10-01

Popliteal artery aneurysm is an uncommon vascular disease but one that can cause significant morbidity, the most severe being limb loss reported in 20% to 59% of cases. Two approaches to repair are described in the literature, the posterior and the medial; however, the "gold standard" method of repair remains controversial. A systematic review of electronic information sources was undertaken to identify papers comparing outcomes of posterior repair vs medial repair. The methodologic quality of the papers was assessed using the Newcastle-Ottawa Scale. Fixed-effect or random-effects models were applied to synthesize data. The search yielded seven articles eligible for inclusion. The total population comprised 1427 patients; 338 had posterior repair and 1089 had medial repair. There was no difference in the two groups in terms of postoperative nerve damage (odds ratio [OR], 1.01; 95% confidence interval [CI], 0.24-4.2) and 30-day postoperative complications (OR, 0.87; 95% CI, 0.43-1.77). Limb loss at 30 days occurred more frequently in the medial approach group, but the difference was not statistically significant (risk difference [RD], 0.02; 95% CI, -0.04 to 0.00). Thirty-day primary patency was not statistically different between groups (RD, -0.01; 95% CI, -0.04 to 0.02), but the 30-day secondary patency suggested superiority of the posterior approach (RD, 0.05; 95% CI, 0.02-0.07). Long-term primary and secondary patency both favored the posterior approach (OR, 1.61 [95% CI, 1.06-2.43] and OR, 1.73 [95% CI, 0.91-3.30], respectively). Aneurysm exclusion was also superior with the posterior approach (OR, 4.20; 95% CI, 1.40-12.60). The rate of reoperation favored the posterior approach (OR, 0.26; 95% CI, 0.09-0.72). Long-term risk of limb loss favored posterior repair, but no statistically significant difference was found (OR, 0.32; 95% CI, 0.43-1.77). High-level comparative data comparing posterior and medial repair for popliteal artery aneurysms are not available. Within the parameters of this review, however, superiority of the posterior approach for primary and secondary patency, aneurysm exclusion, and need for reoperation was noted. High-level evidence from randomized clinical trials is required to define the relative benefits of the posterior approach over the medial approach in selected patients. Copyright © 2016 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.

Quantified Aortic Luminal Irregularity as a Predictor of Complications and Prognosis After Endovascular Aneurysm Repair

PubMed Central

Hosaka, Akihiro; Kato, Masaaki; Motoki, Manabu; Sugai, Hiroko; Okubo, Nobukazu

2016-01-01

Abstract Atheromatous degeneration of the aorta is considered to be a risk factor for postoperative embolic complications after endovascular treatment, and is associated with a high incidence of vascular events in the long term. We devised a method to quantify the shagginess of the aorta using contrast-enhanced computed tomography (CT) images. This study examined the method's validity and prognostic usefulness in patients undergoing elective endovascular abdominal aortic aneurysm repair (EVAR). We retrospectively investigated 427 patients who underwent elective EVAR between 2007 and 2013. Preoperative contrast-enhanced CT images with a slice thickness of 1 mm were analyzed using a workstation, and the degree of aortic luminal irregularity from the level of the left subclavian artery ostium to that of the celiac artery ostium was quantified by computing a shagginess score. We compared the computed scores with subjective visual assessments of aortic shagginess. Subsequently, we evaluated the relationship between the computed scores and postoperative prognosis. The shagginess scores were significantly correlated with the visual assessments of the aortic lumen, which were performed by 5 experienced vascular surgeons (rho ranged from 0.564–0.654, all P < 0.001). Multiple logistic regression analysis demonstrated that the shagginess score was independently associated with the development of renal impairment within a month after EVAR (odds ratio, 2.78; 95% confidence interval [CI], 1.83–4.22, P < 0.001). The shagginess score was significantly higher in patients who suffered postoperative intestinal and peripheral ischemic complications, as compared with those who did not (P < 0.001). The mean postoperative follow-up period was 1207 ± 641 days. Cox proportional hazards regression showed that the shagginess score was a significant independent predictor of all-cause and cardiovascular mortality (hazard ratio [HR], 1.37; 95% CI, 1.09–1.72, P = 0.007, and HR, 1.51; 95% CI, 1.04–2.18, P = 0.030, respectively). The results suggest that the shagginess score provides a quantitative reflection of aortic luminal irregularity. It may serve as a useful predictive factor for postoperative renal function deterioration, embolic complications, and long-term mortality after elective EVAR. PMID:26945368

[Medical application of nano-materials].

PubMed

Jiang, Hui-qing; Chen, Yi-fei

2002-11-01

To review the research progress and medical application of nano-materials. The literature review and comprehensive analysis, methods were used in this study. The Nanotechnology is a typical crossing knowledge. It could be extensively applied in the fields of novel biomaterials, effective transmission of bioactive factor; the detection of functions for all vital organ systems, vascular circulation condition, the control of repair of burn trauma wounds will be monitored by the varied methods of nano technology combined with molecular biological engineering. The application of Nanotechnology will play important roles in clinical medicine, wound repair and basic research for the traditional Chinese medicine.

Liver repair and hemorrhage control using laser soldering of liquid albumin in a porcine model

NASA Astrophysics Data System (ADS)

Wadia, Yasmin; Xie, Hua; Kajitani, Michio; Gregory, Kenton W.; Prahl, Scott A.

2000-05-01

The purpose of this study was to evaluate laser soldering using liquid albumin for welding liver lacerations and sealing raw surfaces created by segmental resection of a lobe. Major liver trauma has a high mortality due to immediate exsanguination and a delayed morbidity and mortality from septicemia, peritonitis, biliary fistulae and delayed secondary hemorrhage. Eight laceration injuries (6 cm long X 2 cm deep) and eight non-anatomical resection injuries (raw surface 6 cm X 2 cm) were repaired. An 805 nm laser was used to weld 53% liquid albumin-ICG solder to the liver surface, reinforcing it with a free autologous omental scaffold. The animals were heparinized to simulate coagulation failure and hepatic inflow occlusion was used for vascular control. For both laceration and resection injuries, eight soldering repairs each were evaluated at three hours. A single suture repair of each type was evaluated at three hours. All 16 laser mediated liver repairs were accompanied by minimal blood loss as compared to the suture controls. No dehiscence, hemorrhage or bile leakage was seen in any of the laser repairs after three hours. In conclusion laser fusion repair of the liver is a quick and reliable technique to gain hemostasis on the cut surface as well as weld lacerations.

NOTCH signaling in skeletal progenitors is critical for fracture repair

PubMed Central

Wang, Cuicui; Inzana, Jason A.; Mirando, Anthony J.; Liu, Zhaoyang; Shen, Jie; O’Keefe, Regis J.; Awad, Hani A.; Hilton, Matthew J.

2016-01-01

Fracture nonunions develop in 10%–20% of patients with fractures, resulting in prolonged disability. Current data suggest that bone union during fracture repair is achieved via proliferation and differentiation of skeletal progenitors within periosteal and soft tissues surrounding bone, while bone marrow stromal/stem cells (BMSCs) and other skeletal progenitors may also contribute. The NOTCH signaling pathway is a critical maintenance factor for BMSCs during skeletal development, although the precise role for NOTCH and the requisite nature of BMSCs following fracture is unknown. Here, we evaluated whether NOTCH and/or BMSCs are required for fracture repair by performing nonstabilized and stabilized fractures on NOTCH-deficient mice with targeted deletion of RBPjk in skeletal progenitors, maturing osteoblasts, and committed chondrocytes. We determined that removal of NOTCH signaling in BMSCs and subsequent depletion of this population result in fracture nonunion, as the fracture repair process was normal in animals harboring either osteoblast- or chondrocyte-specific deletion of RBPjk. Together, this work provides a genetic model of a fracture nonunion and demonstrates the requirement for NOTCH and BMSCs in fracture repair, irrespective of fracture stability and vascularity. PMID:26950423

Prognostic value of DNA repair based stratification of hepatocellular carcinoma

PubMed Central

Lin, Zhuo; Xu, Shi-Hao; Wang, Hai-Qing; Cai, Yi-Jing; Ying, Li; Song, Mei; Wang, Yu-Qun; Du, Shan-Jie; Shi, Ke-Qing; Zhou, Meng-Tao

2016-01-01

Aberrant activation of DNA repair is frequently associated with tumor progression and response to therapy in hepatocellular carcinoma (HCC). Bioinformatics analyses of HCC data in the Cancer Genome Atlas (TCGA) were performed to define DNA repair based molecular classification that could predict the prognosis of patients with HCC. Furthermore, we tested its predictive performance in 120 independent cases. Four molecular subgroups were identified on the basis of coordinate DNA repair cluster (CDRC) comprising 15 genes in TCGA dataset. Increasing expression of CDRC genes were significantly associated with TP53 mutation. High CDRC was significantly correlated with advanced tumor grades, advanced pathological stage and increased vascular invasion rate. Multivariate Cox regression analysis indicated that the molecular subgrouping was an independent prognostic parameter for both overall survival (p = 0.004, hazard ratio (HR): 2.989) and tumor-free survival (p = 0.049, HR: 3.366) in TCGA dataset. Similar results were also obtained by analyzing the independent cohort. These data suggest that distinct dysregulation of DNA repair constituents based molecular classes in HCC would be useful for predicting prognosis and designing clinical trials for targeted therapy. PMID:27174663

Vascular Shunts in Civilian Trauma

PubMed Central

Abou Ali, Adham N.; Salem, Karim M.; Alarcon, Louis H.; Bauza, Graciela; Pikoulis, Emmanuel; Chaer, Rabih A.; Avgerinos, Efthymios D.

2017-01-01

Experience with temporary intravascular shunts (TIVS) for vessel injury comes from the military sector and while the indications might be clear in geographically isolated and under resourced war zones, this may be an uncommon scenario in civilian trauma. Data supporting TIVS use in civilian trauma have been extrapolated from the military literature where it demonstrated improved life and limb salvage. Few non-comparative studies from the civilian literature have also revealed similar favorable outcomes. Still, TIVS placement in civilian vascular injuries is uncommon and by some debatable given the absence of clear indications for placement, the potential for TIVS-related complications, the widespread resources for immediate and definitive vascular repair, and the need for curtailing costs and optimizing resources. This article reviews the current evidence and the role of TIVS in contemporary civilian trauma management. PMID:28775985

Genetic modification of cerebral arterial wall: implications for prevention and treatment of cerebral vasospasm.

PubMed

Vijay, Anantha; Santhanam, R; Katusic, Zvonimir S

2006-10-01

Genetic modification of cerebral vessels represents a promising and novel approach for prevention and/or treatment of various cerebral vascular disorders, including cerebral vasospasm. In this review, we focus on the current understanding of the use of gene transfer to the cerebral arteries for prevention and/or treatment of cerebral vasospasm following subarachnoid hemorrhage (SAH). We also discuss the recent developments in vascular therapeutics, involving the autologous use of progenitor cells for repair of damaged vessels, as well as a cell-based gene delivery approach for the prevention and treatment of cerebral vasospasm.

Evolving strategies for the treatment of aortoenteric fistulas.

PubMed

Baril, Donald T; Carroccio, Alfio; Ellozy, Sharif H; Palchik, Eugene; Sachdev, Ulka; Jacobs, Tikva S; Marin, Michael L

2006-08-01

Aortoenteric fistulas (AEFs) are a rare but often fatal cause of gastrointestinal bleeding. Operative repair of AEF has been historically associated with extremely high morbidity and mortality. We reviewed our experience of open surgical and endovascular treatment of AEF to compare outcomes over a contemporaneous time period. Over a 9-year period between January 1997 and January 2006, 16 patients (11 men and 5 women) were diagnosed with and treated for AEFs. Seven patients underwent open surgical repair, and nine, with anatomically suitable lesions, underwent endovascular repair. The outcome after treatment of these patients was investigated for survival, perioperative complications, length of hospital stay, and long-term disposition. Three primary and 13 secondary AEFs were treated. The mean time from the initial aortic operation until AEF diagnosis was 5.9 years (range, 0.7-12.2 years) for patients with secondary AEFs. The overall 30-day mortality rate was 18.8%. One intraoperative death and one in-hospital death secondary to multisystem organ failure occurred in patients undergoing open repair. One in-hospital death related to persistent sepsis occurred in the endovascular group. The overall perioperative complication rate was 50.0%. Complications in the open group included sepsis, renal failure, bowel obstruction, and pancreatitis. Complications in the endovascular group were related to persistent sepsis. The mean in-hospital length of stay was significantly longer for patients undergoing open repair compared with endovascular repair (44.0 vs 19.4 days; P = .04). Four (80%) of five patients who were discharged from the hospital in the open group were placed in skilled nursing facilities, and seven (87.5%) of eight patients discharged in the endovascular group returned home. The median overall survival after hospital discharge was 23.1 months. There were no late aneurysm-related deaths or late deaths related to septic complications. Patients with AEFs have limited overall survival. Endovascular therapy offers an alternative to open surgical repair, seems to be associated with decreased perioperative morbidity and mortality and a shorter in-hospital stay, and allows for acceptable survival given the presence of coexisting medical comorbidities. Furthermore, endovascular repair provides a therapeutic option to control bleeding and allow for continued intervention in a stabilized setting.

Contemporary Surgical Trends in the Management of Symptomatic Meniscal Tears among United States Military Servicemembers from 2010 to 2015.

PubMed

Pekari, Timothy B; Wang, Kevin C; Cotter, Eric J; Kusnezov, Nicholas; Waterman, Brian R

2018-03-07

The purpose of this investigation is to report on trends over time in the treatment of meniscal pathology among military orthopaedic surgeons, as well as to evaluate the impact of patient demographics and concomitant procedure on the type of meniscal procedure performed. We performed a retrospective analysis of all active-duty United States military servicemembers who underwent a meniscal procedure from 2010 to 2015 within the Military Health System. Patient demographics and surgical variables were extracted from the electronic medical record. Treatments were categorized by location and by type of intervention (i.e., repair or debridement). Chi-square and linear regression analyses were performed to identify temporal trends in meniscal procedures and factors that were correlated with the type of meniscal procedure performed. Out of 29,571 meniscal procedures analyzed, partial meniscectomy was performed in 81.3% ( n  = 24,343) of cases, meniscal repair in 20.3% ( n  = 6,073), and meniscus allograft transplantation (MAT) in 0.7% ( n  = 206). The rates of debridement, repair, and concomitant surgeries did not demonstrate any significant temporal trends, whereas MAT demonstrated a significant decrease in overall utilization. Nearly two-thirds of all meniscal procedures were performed in the medial compartment. MAT occurred equally between the medial and lateral compartments. Lateral meniscal lesions demonstrated significantly higher rates of debridement. With each year of advancing age, there was a 3.7% increasing likelihood of meniscectomy and 6.5% decreasing likelihood of repair. Females were more likely to undergo meniscal repair than males. Patients in the military population were more likely to undergo meniscal repair compared with previously reported rates in the civilian population. In this physically active cohort of nearly 30,000 military patients, 1 in 5 meniscal tears were treated with meniscal repair. Meniscal repairs were performed at a higher rate for all age groups compared with previously reported rates in the civilian population. Further research is required to elucidate the causative factors behind these differences and the effect on postoperative outcomes. IV, cross-sectional study. Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Abdominal Wall Reconstruction with Concomitant Ostomy-Associated Hernia Repair: Outcomes and Propensity Score Analysis.

PubMed

Mericli, Alexander F; Garvey, Patrick B; Giordano, Salvatore; Liu, Jun; Baumann, Donald P; Butler, Charles E

2017-03-01

The optimal strategy for abdominal wall reconstruction in the presence of a stomal-site hernia is unclear. We hypothesized that the rate of ventral hernia recurrence in patients undergoing a combined ventral hernia repair and stomal-site herniorraphy would not differ clinically from the ventral hernia recurrence rate in patients undergoing an isolated ventral hernia repair. We also hypothesized that bridged ventral hernia repairs result in worse outcomes compared with reinforced repairs, regardless of stomal hernia. We retrospectively reviewed prospectively collected data from consecutive abdominal wall reconstructions performed with acellular dermal matrix (ADM) at a single center between 2000 and 2015. We compared patients who underwent a ventral hernia repair alone (AWR) and those who underwent both a ventral hernia repair and ostomy-associated herniorraphy (AWR+O). We conducted a propensity score matched analysis to compare the outcomes between the 2 groups. Multivariable Cox proportional hazards and logistic regression models were used to study associations between potential predictive or protective reconstructive strategies and surgical outcomes. We included 499 patients (median follow-up 27.2 months; interquartile range [IQR] 12.4 to 46.6 months), 118 AWR+O and 381 AWR. After propensity score matching, 91 pairs were obtained. Ventral hernia recurrence was not statistically associated with ostomy-associated herniorraphy (adjusted hazard ratio [HR] 0.7; 95% CI 0.3 to 1.5; p = 0.34). However, the AWR+O group experienced a significantly higher percentage of surgical site occurrences (34.1%) than the AWR group (18.7%; adjusted odds ratio 2.3; 95% CI 1.4 to 3.7; p < 0.001). In the AWR group, there were significantly fewer ventral hernia recurrences when the repair was reinforced compared with bridged (5.3% vs 38.5%; p < 0.001). There was no statistically significant difference in ventral hernia recurrence between the AWR and AWR+O groups. Bridging was associated with an increased rate of hernia recurrence and should be avoided if possible. Copyright © 2016 American College of Surgeons. Published by Elsevier Inc. All rights reserved.

Vascular Permeability and Remodelling Coincide with Inflammatory and Reparative Processes after Joint Bleeding in Factor VIII-Deficient Mice.

PubMed

Cooke, Esther J; Zhou, Jenny Y; Wyseure, Tine; Joshi, Shweta; Bhat, Vikas; Durden, Donald L; Mosnier, Laurent O; Drygalski, Annette von

2018-06-01

Vascular remodelling is a prominent feature of haemophilic arthropathy (HA) that may underlie re-bleeding, yet the nature of vascular changes and underlying mechanisms remain largely unknown. Here, we aimed to characterize synovial vascular remodelling and vessel integrity after haemarthrosis, as well as temporal changes in inflammatory and tissue-reparative pathways. Thirty acutely painful joints in patients with haemophilia (PWH) were imaged by musculoskeletal ultrasound with Power Doppler (MSKUS/PD) to detect vascular abnormalities and bloody effusions. Nineteen out of 30 painful joint episodes in PWH were associated with haemarthrosis, and abnormal vascular perfusion was unique to bleeding joints. A model of induced haemarthrosis in factor VIII (FVIII)-deficient mice was used for histological assessment of vascular remodelling (α-smooth muscle actin [αSMA] expression), and monitoring of in vivo vascular perfusion and permeability by MSKUS/PD and albumin extravasation, respectively. Inflammatory (M1) and reparative (M2) macrophage markers were quantified in murine synovium over a 10-week time course by real-time polymerase chain reaction. The abnormal vascular perfusion observed in PWH was recapitulated in FVIII-deficient mice after induced haemarthrosis. Neovascularization and increased vessel permeability were apparent 2 weeks post-bleed in FVIII-deficient mice, after a transient elevation of inflammatory macrophage M1 markers. These vascular changes subsided by week 4, while vascular remodelling, evidenced by architectural changes and pronounced αSMA expression, persisted alongside a reparative macrophage M2 response. In conclusion, haemarthrosis leads to transient inflammation coupled with neovascularization and associated vascular permeability, while subsequent tissue repair mechanisms coincide with vascular remodelling. Together, these vascular changes may promote re-bleeding and HA progression. Schattauer GmbH Stuttgart.

Proteomic identification of dysferlin-interacting protein complexes in human vascular endothelium

DOE Office of Scientific and Technical Information (OSTI.GOV)

Leung, Cleo; Utokaparch, Soraya; Sharma, Arpeeta

2011-11-18

Highlights: Black-Right-Pointing-Pointer Bi-directional (inward and outward) movement of GFP-dysferlin in COS-7 cells. Black-Right-Pointing-Pointer Dysferlin interacts with key signaling proteins for transcytosis in EC. Black-Right-Pointing-Pointer Dysferlin mediates trafficking of vesicles carrying protein cargos in EC. -- Abstract: Dysferlin is a membrane-anchored protein known to facilitate membrane repair in skeletal muscles following mechanical injury. Mutations of dysferlin gene impair sarcolemma integrity, a hallmark of certain forms of muscular dystrophy in patients. Dysferlin contains seven calcium-dependent C2 binding domains, which are required to promote fusion of intracellular membrane vesicles. Emerging evidence reveal the unexpected expression of dysferlin in non-muscle, non-mechanically active tissues, suchmore » as endothelial cells, which cast doubts over the belief that ferlin proteins act exclusively as membrane repair proteins. We and others have shown that deficient trafficking of membrane bound proteins in dysferlin-deficient cells, suggesting that dysferlin might mediate trafficking of client proteins. Herein, we describe the intracellular trafficking and movement of GFP-dysferlin positive vesicles in unfixed reconstituted cells using live microscopy. By performing GST pull-down assays followed by mass spectrometry, we identified dysferlin binding protein complexes in human vascular endothelial cells. Together, our data further support the claims that dysferlin not only mediates membrane repair but also trafficking of client proteins, ultimately, help bridging dysferlinopathies to aberrant membrane signaling.« less

Case Report: Use of reinforced buccal mucosa graft over gracilis muscle flap in management of post high intensity focused ultrasound (HIFU) rectourethral fistula.

PubMed

Jai, Shrikant; Ganpule, Arvind; Singh, Abhishek; Vijaykumar, Mohankumar; Bopaiah, Vinod; Sabnis, Ravindra; Desai, Mahesh

2016-01-01

High intensity focused ultrasound (HIFU) has come forward as alternative treatment for carcinoma of the prostate. Though minimally invasive,HIFUhas potential side effects. Urethrorectal fistula is one such rare side effect. Management of these fistulas has been described by Vanni et al. This case report describes points of technique that will help successful management of resilient rectourethral fistula. Urinary and faecal diversion in the form of suprapubic catheter and colostomy is vital. Adequate time between stoma formation, fistula closure and then finally stoma closure is needed. Lithotomy position and perineal approach gives best exposure to the fistula. The rectum should be dissected 2cm above the fistula; this aids in tension free closure of the rectal defect. Similarly buccal mucosal graft was used on the urethra to achieve tension free closure. A good vascular pedicle gracilis muscle flap is used to interpose between the two repairs. This not only provides a physical barrier but also provides a vascular bed for BMG uptake. Perfect haemostasis is essential, as any collection may become a site of infection thus compromising results.  We strongly recommend rectourethral fistula be directly repaired with gracilis muscle flap with reinforced buccal mucosa graft without attempting any less invasive repairs because the "first chance is the best chance".

Case Report: Use of reinforced buccal mucosa graft over gracilis muscle flap in management of post high intensity focused ultrasound (HIFU) rectourethral fistula

PubMed Central

Jai, Shrikant; Ganpule, Arvind; Singh, Abhishek; Vijaykumar, Mohankumar; Bopaiah, Vinod; Sabnis, Ravindra; Desai, Mahesh

2017-01-01

High intensity focused ultrasound (HIFU) has come forward as alternative treatment for carcinoma of the prostate. Though minimally invasive,HIFUhas potential side effects. Urethrorectal fistula is one such rare side effect. Management of these fistulas has been described by Vanni et al. This case report describes points of technique that will help successful management of resilient rectourethral fistula. Urinary and faecal diversion in the form of suprapubic catheter and colostomy is vital. Adequate time between stoma formation, fistula closure and then finally stoma closure is needed. Lithotomy position and perineal approach gives best exposure to the fistula. The rectum should be dissected 2cm above the fistula; this aids in tension free closure of the rectal defect. Similarly buccal mucosal graft was used on the urethra to achieve tension free closure. A good vascular pedicle gracilis muscle flap is used to interpose between the two repairs. This not only provides a physical barrier but also provides a vascular bed for BMG uptake. Perfect haemostasis is essential, as any collection may become a site of infection thus compromising results.  We strongly recommend rectourethral fistula be directly repaired with gracilis muscle flap with reinforced buccal mucosa graft without attempting any less invasive repairs because the “first chance is the best chance”. PMID:28299181

VEGF blockade inhibits angiogenesis and reepithelialization of endometrium.

PubMed

Fan, Xiujun; Krieg, Sacha; Kuo, Calvin J; Wiegand, Stanley J; Rabinovitch, Marlene; Druzin, Maurice L; Brenner, Robert M; Giudice, Linda C; Nayak, Nihar R

2008-10-01

Despite extensive literature on vascular endothelial growth factor (VEGF) expression and regulation by steroid hormones, the lack of clear understanding of the mechanisms of angiogenesis in the endometrium is a major limitation for use of antiangiogenic therapy targeting endometrial vessels. In the current work, we used the rhesus macaque as a primate model and the decidualized mouse uterus as a murine model to examine angiogenesis during endometrial breakdown and regeneration. We found that blockade of VEGF action with VEGF Trap, a potent VEGF blocker, completely inhibited neovascularization during endometrial regeneration in both models but had no marked effect on preexisting or newly formed vessels, suggesting that VEGF is essential for neoangiogenesis but not survival of mature vessels in this vascular bed. Blockade of VEGF also blocked reepithelialization in both the postmenstrual endometrium and the mouse uterus after decidual breakdown, evidence that VEGF has pleiotropic effects in the endometrium. In vitro studies with a scratch wound assay showed that the migration of luminal epithelial cells during repair involved signaling through VEGF receptor 2-neuropilin 1 (VEGFR2-NP1) receptors on endometrial stromal cells. The leading front of tissue growth during endometrial repair was strongly hypoxic, and this hypoxia was the local stimulus for VEGF expression and angiogenesis in this tissue. In summary, we provide novel experimental data indicating that VEGF is essential for endometrial neoangiogenesis during postmenstrual/postpartum repair.

Radiation damage to the microvasculature in the rabbit ear chamber. An electron microscope study. [X radiation

DOE Office of Scientific and Technical Information (OSTI.GOV)

Yang, V.V.; Stearner, S.P.; Dimitrievich, G.S.

1977-04-01

Cell aggregates in increased numbers appear along blood vessel walls within a few days after local x irradiation of the tissue within rabbit ear chambers. At 7 days after irradiation with 400 or 700 rad of 250 kVp of x rays, electron microscopic studies of the microvasculature were carried out to determine the morphological characteristics of the cell types involved in the aggregates and the relation of these cells to vascular repair. The cell aggregates usually occur in the interstitial region subjacent to the endothelium. The cells that make up the aggregates show morphological characteristics of relatively undifferentiated mesenchymal cells;more » they have an irregularly rounded shape and contain large amounts of rough endoplasmic reticulum, Golgi vesicles, and mitochondria. In a few instances, cells of similar morphology also occur as part of the lining of the blood vessels. The perivascular cell aggregates may originate from the pericyte population or from undifferentiated mesenchymal cells that occur in the interstitial region surrounding blood vessels; it is improbable that they are dedifferentiated smooth muscle cells. It is suggested that the cells that make up these aggregates contribute to the repair of the microvasculation after radiation injury. The radiosensitivity of vascular endothelium reported by previous investigators seems to preclude endothelial proliferation as the principal repair mechanism at higher radiation doses.« less

Minimally invasive mitral valve surgery through right mini-thoracotomy: recommendations for good exposure, stable cardiopulmonary bypass, and secure myocardial protection.

PubMed

Ito, Toshiaki

2015-07-01

An apparent advantage of minimally invasive mitral surgery through right mini-thoracotomy is cosmetic appearance. Possible advantages of this procedure are a shorter ventilation time, shorter hospital stay, and less blood transfusion. With regard to hard endpoints, such as operative mortality, freedom from reoperation, or cardiac death, this method is reportedly equivalent, but not superior, to the standard median sternotomy technique. However, perfusion-related complications (e.g., stroke, vascular damage, and limb ischemia) tend to occur more frequently in minimally invasive technique than with the standard technique. In addition, valve repair through a small thoracotomy is technically demanding. Therefore, screening out patients who are not appropriate for performing minimally invasive surgery is the first step. Vascular disease and inadequate anatomy can be evaluated with contrast-enhanced computed tomography. Peripheral cannulation should be carefully performed, using transesophageal echocardiography guidance. Preoperative detailed planning of the valve repair process is desirable because every step is time-consuming in minimally invasive surgery. Three-dimensional echocardiography is a powerful tool for this purpose. For satisfactory exposure and detailed observation of the valve, a special left atrial retractor and high-definition endoscope are useful. Valve repair can be performed in minimally invasive surgery as long as cardiopulmonary bypass is stable and bloodless exposure of the valve is obtained.

Panorama of Reconstruction of Skull Base Defects: From Traditional Open to Endonasal Endoscopic Approaches, from Free Grafts to Microvascular Flaps

PubMed Central

Reyes, Camilo; Mason, Eric; Solares, C. Arturo

2014-01-01

Introduction A substantial body of literature has been devoted to the distinct characteristics and surgical options to repair the skull base. However, the skull base is an anatomically challenging location that requires a three-dimensional reconstruction approach. Furthermore, advances in endoscopic skull base surgery encompass a wide range of surgical pathology, from benign tumors to sinonasal cancer. This has resulted in the creation of wide defects that yield a new challenge in skull base reconstruction. Progress in technology and imaging has made this approach an internationally accepted method to repair these defects. Objectives Discuss historical developments and flaps available for skull base reconstruction. Data Synthesis Free grafts in skull base reconstruction are a viable option in small defects and low-flow leaks. Vascularized flaps pose a distinct advantage in large defects and high-flow leaks. When open techniques are used, free flap reconstruction techniques are often necessary to repair large entry wound defects. Conclusions Reconstruction of skull base defects requires a thorough knowledge of surgical anatomy, disease, and patient risk factors associated with high-flow cerebrospinal fluid leaks. Various reconstruction techniques are available, from free tissue grafting to vascularized flaps. Possible complications that can befall after these procedures need to be considered. Although endonasal techniques are being used with increasing frequency, open techniques are still necessary in selected cases. PMID:25992142

Diabetes impairs adipose tissue-derived stem cell function and efficiency in promoting wound healing.

PubMed

Cianfarani, Francesca; Toietta, Gabriele; Di Rocco, Giuliana; Cesareo, Eleonora; Zambruno, Giovanna; Odorisio, Teresa

2013-01-01

Adipose tissue-derived stem cells (ASCs) are gaining increasing consideration in tissue repair therapeutic application. Recent evidence indicates that ASCs enhance skin repair in animal models of impaired wound healing. To assess the therapeutic activity of autologous vs. allogeneic ASCs in the treatment of diabetic ulcers, we functionally characterized diabetic ASCs and investigated their potential to promote wound healing with respect to nondiabetic ones. Adipose tissue-derived cells from streptozotocin-induced type 1 diabetic mice were analyzed either freshly isolated as stromal vascular fraction (SVF), or following a single passage of culture (ASCs). Diabetic ASCs showed decreased proliferative potential and migration. Expression of surface markers was altered in diabetic SVF and cultured ASCs, with a reduction in stem cell marker-positive cells. ASCs from diabetic mice released lower amounts of hepatocyte growth factor, vascular endothelial growth factor (VEGF)-A, and insulin-like growth factor-1, growth factors playing important roles in skin repair. Accordingly, the supernatant of diabetic ASCs manifested reduced capability to promote keratinocyte and fibroblast proliferation and migration. Therapeutic potential of diabetic SVF administered to wounds of diabetic mice was blunted as compared with cells isolated from nondiabetic mice. Our data indicate that diabetes alters ASC intrinsic properties and impairs their function, thus affecting therapeutic potential in the autologous treatment for diabetic ulcers. © 2013 by the Wound Healing Society.

Scabies in a bilateral hand allograft recipient: An additional mimicker of acute skin rejection in vascularized composite allotransplantation.

PubMed

Kanitakis, Jean; Morelon, Emmanuel

2017-06-01

Vascularized composite tissue allografts include skin, which frequently undergoes, in the early post-graft period, acute rejections. The diagnosis of acute rejection may be difficult as it can be mimicked by several dermatoses. We present a bilateral hand allograft recipient who developed, 16.5 years post-graft, cutaneous lesions raising suspicion about rejection. Physical examination and skin biopsy were diagnostic of scabies. This ectoparasitosis should be added in the list of dermatoses that can mimic allograft rejection in vascular composite allografts. © 2017 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.

Relationship among mismatch repair deficiency, CDX2 loss, p53 and E-cadherin in colon carcinoma and suitability of using a double panel of mismatch repair proteins by immunohistochemistry.

PubMed

Sayar, Ilyas; Akbas, Emin Murat; Isik, Arda; Gokce, Aysun; Peker, Kemal; Demirtas, Levent; Gürbüzel, Mehmet

2015-09-01

Biomarkers such as mismatch repair proteins, CDX2, p53, and E-cadherin are blamed for colon cancers, but the relationships of these biomarkers with each other and with pathological risk factors in colon carcinoma are still not clear. The aim of this study was to evaluate the association of these biomarkers with each other by using immunohistochemical staining and to compare their expression with pathological risk factors for colonic adenocarcinoma. We also aimed to study the usability of a double panel of mismatch repair proteins. One hundred and eleven cases with colonic adenocarcinoma were examined. There was a statistically significant relationship between tumor histological differentiation and perineural invasion, vascular invasion, mismatch repair deficiency, p53, CDX2, and E-cadherin (p < 0.05). PMS2 and MSH6 loss covered 100% of cases with mismatch repair deficiency. Mismatch repair deficiency was correlated with CDX2 loss and E-cadherin expression (p < 0.05). It was also observed that cases with PMS2 loss covered all the cases with CDX2 loss. In conclusion, this double panel may be used instead of a quadruple panel for detecting mismatch repair deficiency. Association of CDX2 and PMS2 in the present study is necessary to conduct further genetic and pathological studies focusing on these two markers together.

Decubitus ulcers in patients undergoing vascular operations do not influence mortality but affect resource utilization.

PubMed

Mehaffey, J Hunter; Politano, Amani D; Bhamidipati, Castigliano M; Tracci, Margaret C; Cherry, Kenneth J; Kern, John A; Kron, Irving L; Upchurch, Gilbert R

2017-06-01

While it is anticipated that decubitus ulcers are detrimental to outcomes after vascular operations, the contemporary influence of perioperative decubitus ulcers in vascular surgery remains unknown. Using the National Impatient Survey, all adult patients who underwent vascular operation were selected. Patients were stratified by the presence or absence (non-decubitus ulcers) of decubitus ulcer. Case-mix adjusted hierarchical mixed-models examined in-hospital mortality, the occurrence of any complication, and discharge disposition. A total of 538,808 cases were analyzed. Decubitus ulcers were most prevalent among Caucasian male Medicare beneficiaries (P < .001). Decubitus ulcer patients also underwent more nonelective vascular operations (P < .001). Wound, infectious, and procedural complications were more common in patients with decubitus ulcers (P < .001). Failure to rescue, defined as mortality after any complication, was more than doubled in decubitus ulcers (non-decubitus ulcers: 1.5%, decubitus ulcers: 3.2%, P < .001). Similarly, unadjusted mortality was also doubled in patients undergoing vascular operation with decubitus ulcers (non-decubitus ulcers: 3%, decubitus ulcers: 6%, P < .001). After risk adjustment among all patients, neither the presence of a decubitus ulcer nor specific ulcer staging increased the adjusted odds of death. Having a decubitus ulcer increased the adjusted odds of discharge to an intermediate care facility (odds ratio 2.9, P < .001). These patients also had 1.6 times the total charges compared to their non-decubitus ulcer cohort (non-decubitus ulcers: $49,460 ± $281 vs decubitus ulcers: $81,149 ± $5,855, P < .001). Contrary to common perception, perioperative decubitus ulcer does not adversely affect mortality after vascular operation in patients proceeding to operative intervention. Patients with decubitus ulcers are, however, at higher risk for complications and incur sizeable additional charges. Copyright © 2017 Elsevier Inc. All rights reserved.

First Insights into Human Fingertip Regeneration by Echo-Doppler Imaging and Wound Microenvironment Assessment.

PubMed

Jafari, Paris; Muller, Camillo; Grognuz, Anthony; Applegate, Lee Ann; Raffoul, Wassim; di Summa, Pietro G; Durand, Sébastien

2017-05-13

Fingertip response to trauma represents a fascinating example of tissue regeneration. Regeneration derives from proliferative mesenchymal cells (blastema) that subsequently differentiate into soft and skeletal tissues. Clinically, conservative treatment of the amputated fingertip under occlusive dressing can shift the response to tissue loss from a wound repair process towards regeneration. When analyzing by Immunoassay the wound exudate from occlusive dressings, the concentrations of brain-derived neurotrophic factor (BDNF) and leukemia inhibitory factor (LIF) were higher in fingertip exudates than in burn wounds (used as controls for wound repair versus regeneration). Vascular endothelial growth factor A (VEGF-A) and platelet-derived growth factor (PDGF) were highly expressed in both samples in comparable levels. In our study, pro-inflammatory cytokines were relatively higher expressed in regenerative fingertips than in the burn wound exudates while chemokines were present in lower levels. Functional, vascular and mechanical properties of the regenerated fingertips were analyzed three months after trauma and the data were compared to the corresponding fingertip on the collateral uninjured side. While sensory recovery and morphology (pulp thickness and texture) were similar to uninjured sides, mechanical parameters (elasticity, vascularization) were increased in the regenerated fingertips. Further studies should be done to clarify the importance of inflammatory cells, immunity and growth factors in determining the outcome of the regenerative process and its influence on the clinical outcome.

First Insights into Human Fingertip Regeneration by Echo-Doppler Imaging and Wound Microenvironment Assessment

PubMed Central

Jafari, Paris; Muller, Camillo; Grognuz, Anthony; Applegate, Lee Ann; Raffoul, Wassim; di Summa, Pietro G.; Durand, Sébastien

2017-01-01

Fingertip response to trauma represents a fascinating example of tissue regeneration. Regeneration derives from proliferative mesenchymal cells (blastema) that subsequently differentiate into soft and skeletal tissues. Clinically, conservative treatment of the amputated fingertip under occlusive dressing can shift the response to tissue loss from a wound repair process towards regeneration. When analyzing by Immunoassay the wound exudate from occlusive dressings, the concentrations of brain-derived neurotrophic factor (BDNF) and leukemia inhibitory factor (LIF) were higher in fingertip exudates than in burn wounds (used as controls for wound repair versus regeneration). Vascular endothelial growth factor A (VEGF-A) and platelet-derived growth factor (PDGF) were highly expressed in both samples in comparable levels. In our study, pro-inflammatory cytokines were relatively higher expressed in regenerative fingertips than in the burn wound exudates while chemokines were present in lower levels. Functional, vascular and mechanical properties of the regenerated fingertips were analyzed three months after trauma and the data were compared to the corresponding fingertip on the collateral uninjured side. While sensory recovery and morphology (pulp thickness and texture) were similar to uninjured sides, mechanical parameters (elasticity, vascularization) were increased in the regenerated fingertips. Further studies should be done to clarify the importance of inflammatory cells, immunity and growth factors in determining the outcome of the regenerative process and its influence on the clinical outcome. PMID:28505080

Renal function changes after fenestrated endovascular aneurysm repair.

PubMed

Tran, Kenneth; Fajardo, Andres; Ullery, Brant W; Goltz, Christopher; Lee, Jason T

2016-08-01

Limited data exist regarding the effect of fenestrated endovascular aneurysm repair (fEVAR) on renal function. We performed a comprehensive analysis of acute and chronic renal function changes in patients after fEVAR. This study included patients undergoing fEVAR at two institutions between September 2012 and March 2015. Glomerular filtration rate was estimated using the Modification of Diet in Renal Disease formula with serum creatinine levels obtained during the study period. Acute and chronic renal dysfunction was assessed using the RIFLE (Risk, Injury, Failure, Loss, End-stage renal disease) criteria and the chronic kidney disease (CKD) staging system, respectively. fEVAR was performed in 110 patients for juxtarenal or paravisceral aortic aneurysms, with a mean follow-up of 11.7 months. A total of 206 renal stents were placed, with a mean aneurysm size of 62.9 mm (range, 45-105 mm) and a mean neck length of 4.1 mm. Primary renal stent patency was 97.1% at the latest follow-up. Moderate kidney disease (CKD stage ≥ 3) was present in 51% of patients at baseline, with a mean preoperative glomerular filtration rate of 60.0 ± 19.6 mL/min/1.73 m 2 . Acute kidney injury occurred in 25 patients (22.7%), although 15 of these (60%) were classified as having mild dysfunction. During follow-up, 59 patients (73.7%) were found to have no change or improved renal disease by CKD staging, and 19 (23.7%) had a CKD increase of one stage. Two patients were noted to have end-stage renal failure requiring hemodialysis. Clinically significant renal dysfunction was noted in 21 patients (26.2%) at the latest follow-up. Freedom from renal decline at 1 year was 76.1% (95% confidence interval, 63.2%-85.0%). Surrogate markers for higher operative complexity, including operating time (P = .001), fluoroscopy time (P < .001), contrast volume (P = .017), and blood loss (P = .002), served as dependent risk factors for acute kidney injury, although though no independent predictors were identified. Age (P = .008) was an independent risk factor for long-term decline, whereas paradoxically, baseline kidney disease (P = .032) and longer operative times (P = .014) were protective of future renal dysfunction. Acute and chronic renal dysfunction both occur in approximately one-quarter of patients after fEVAR; however, most of these cases are classified as mild according to consensus definitions of renal injury. The presence of mild or moderate baseline kidney disease should not preclude endovascular repair in the juxtarenal population. Routine biochemical analysis and branch vessel surveillance remain important aspects of clinical follow-up for patients undergoing fEVAR. Copyright © 2016 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.

Vascular Repair by Circumferential Cell Therapy Using Magnetic Nanoparticles and Tailored Magnets.

PubMed

Vosen, Sarah; Rieck, Sarah; Heidsieck, Alexandra; Mykhaylyk, Olga; Zimmermann, Katrin; Bloch, Wilhelm; Eberbeck, Dietmar; Plank, Christian; Gleich, Bernhard; Pfeifer, Alexander; Fleischmann, Bernd K; Wenzel, Daniela

2016-01-26

Cardiovascular disease is often caused by endothelial cell (EC) dysfunction and atherosclerotic plaque formation at predilection sites. Also surgical procedures of plaque removal cause irreversible damage to the EC layer, inducing impairment of vascular function and restenosis. In the current study we have examined a potentially curative approach by radially symmetric re-endothelialization of vessels after their mechanical denudation. For this purpose a combination of nanotechnology with gene and cell therapy was applied to site-specifically re-endothelialize and restore vascular function. We have used complexes of lentiviral vectors and magnetic nanoparticles (MNPs) to overexpress the vasoprotective gene endothelial nitric oxide synthase (eNOS) in ECs. The MNP-loaded and eNOS-overexpressing cells were magnetic, and by magnetic fields they could be positioned at the vascular wall in a radially symmetric fashion even under flow conditions. We demonstrate that the treated vessels displayed enhanced eNOS expression and activity. Moreover, isometric force measurements revealed that EC replacement with eNOS-overexpressing cells restored endothelial function after vascular injury in eNOS(-/-) mice ex and in vivo. Thus, the combination of MNP-based gene and cell therapy with custom-made magnetic fields enables circumferential re-endothelialization of vessels and improvement of vascular function.

Fetal Bovine Dermal Repair Scaffold Used for the Treatment of Difficult-to- Heal Complex Wounds.

PubMed

Strauss, Neil H; Brietstein, Richard J

2012-11-01

 Introduction. Treating difficult-to-heal wounds with complexities, including those with exposed tendon/bone or infection, is a challenge that regularly confronts practitioners in a variety of clinical environments. The purpose of this study was to review the effectiveness of an acellular fetal bovine dermal repair scaffold (PriMatrix Dermal Repair Scaffold, TEI Biosciences, Inc, Boston, MA) used to treat complex difficult-to-heal wounds presenting in the authors' practice. A retrospective chart review was conducted of a single practice with multiple practicing physicians between 2008 and 2010. Over this time period, 70 patients with 83 wounds were treated with the acellular fetal bovine dermis following surgical debridement of the wound. Forty-nine patients (58 wounds) met established inclusion/exclusioncriteria and were critically evaluated. Wounds treated with the acellular fetal bovine dermis included chronic diabetic wounds, venous wounds, and pressure ulcers, as well as wounds caused by trauma and surgery. Additionally, the patients treated had comorbidities commonly associated with recalcitrant wounds. Of the wounds evaluated in this study, 75.9% successfully healed; 63.8% reepithelialized, and 12.1% were closed with a skin graft subsequent to treatment. Notably, the majority (58.6%) of the wounds reepithelialized by 12 weeks following a single application of the dermal repair scaffold. In the subset of challenging wounds with exposed tendon/bone, 80.8% of the wounds were treated successfully (61.5% reepithelialized, and 19.3% were skin grafted), indicating the successful regeneration and reepithelialization of new vascularized tissue by fetal dermal collagen in relatively avascular wound defects. The acellular fetal bovine dermal repair scaffold can be used as part of an effective treatment regimen to heal complex wounds with exposed tendon/bone caused by varying etiologies. The product actively participates in the generation of a new, vascularized tissue capable of reepithelializing, or successfully supporting, a split-thickness skin graft in defects where initial grafting or living skin substitutes are not viable options. .

The Regulation of Vascular Endothelial Growth Factor by Hypoxia and Prostaglandin F2α during Human Endometrial Repair

PubMed Central

Maybin, Jacqueline A.; Hirani, Nikhil; Brown, Pamela; Jabbour, Henry N.

2011-01-01

Context: The human endometrium has an exceptional capacity for repeated repair after menses, but its regulation remains undefined. Premenstrually, progesterone levels fall and prostaglandin (PG) F2α synthesis increases, causing spiral arteriole constriction. We hypothesized that progesterone withdrawal, PGF2α, and hypoxia increase vascular endothelial growth factor (VEGF), an endometrial repair factor. Design and Results: Endometrial biopsies were collected (n = 47) with ethical approval and consent. VEGF mRNA, quantified by quantitative RT-PCR, was increased during menstruation (P < 0.01).VEGF protein was maximally secreted from proliferative endometrial explants. Treatment of an endometrial epithelial cell line and primary human endometrial stromal cells with 100 nm PGF2α or hypoxia (0.5% O2) resulted in significant increases in VEGF mRNA and protein. VEGF was maximal when cells were cotreated with PGF2α and hypoxia simultaneously (P < 0.05–0.001). Secretory-phase endometrial explants also showed an increase in VEGF with cotreatment (P < 0.05). However, proliferative-phase explants showed no increase in VEGF on treatment with PGF2α and/or hypoxia. Proliferative tissue was induced to increase VEGF mRNA expression when exposed to progesterone and its withdrawal in vitro but only in the presence of hypoxia and PG. Hypoxia-inducible factor-1α (HIF-1α) silencing with RNA interference suppressed hypoxia-induced VEGF expression in endometrial cells but did not alter PGF2α-induced VEGF expression. Conclusions: Endometrial VEGF is increased at the time of endometrial repair. Progesterone withdrawal, PGF2α, and hypoxia are necessary for this perimenstrual VEGF expression. Hypoxia acts via HIF-1α to increase VEGF, whereas PGF2α acts in a HIF-1α-independent manner. Hence, two pathways regulate the expression of VEGF during endometrial repair. PMID:21677035

Profiles and experiences of women undergoing genital fistula repair: Findings from five countries

PubMed Central

Landry, Evelyn; Vera, Frajzyngier; Ruminjo, Joseph; Asiimwe, Frank; Barry, Thierno Hamidou; Bello, Abubakar; Danladi, Dantani; Ganda, Sanda Oumarou; Idris, Sa'ad; Inoussa, Maman; Kanoma, Bashir; Lynch, Maura; Mussell, Felicity; Podder, Dulal Chandra; Wali, Abba; Mielke, Erin; Barone, Mark A.

2013-01-01

This article presents data from 1354 women from five countries who participated in a prospective cohort study conducted between 2007 and 2010. Women undergoing surgery for fistula repair were interviewed at the time of admission, discharge, and at a 3-month follow-up visit. While women's experiences differed across countries, a similar picture emerges across countries: women married young, most were married at the time of admission, had little education, and for many, the fistula occurred after the first pregnancy. Median age at the time of fistula occurrence was 20.0 years (interquartile range 17.3–26.8). Half of the women attended some antenatal care (ANC); among those who attended ANC, less than 50% recalled being told about signs of pregnancy complications. At follow-up, most women (even those who were not dry) reported improvements in many aspects of social life, however, reported improvements varied by repair outcome. Prevention and treatment programmes need to recognise the supportive role that husbands, partners, and families play as women prepare for safe delivery. Effective treatment and support programmes are needed for women who remain incontinent after surgery. PMID:23947903

Structural and functional alterations in rhodamine-123- and doxycycline-photosensitized cells

NASA Astrophysics Data System (ADS)

Shea, Christopher R.; Whitaker, Diana; Murphy, George F.; Chen, Norah; Wimberly, Joanne; Scholz, M.; Sherwood, M. E.; Flotte, Thomas J.; Hasan, Tayyaba

1990-06-01

In order to elucidate the mechanisms of photosensitized injury to mitochondria, two photosensitizers have been compared. Both doxycycline (DOTC) and rhodamine-l23 (R123) localize preferentially within the mitochondria of MGH-IJ1 bladder carcinoma cells j1 vitro, and both sensitize phototoxic injury that is selective for mitochondria. Mitochondria of cells pretreated with DOTC and irradiated with UVA (1 J/cm2, 320-400 rim) undergo massive swelling that begins by 10 mm after irradiation, is maximal by 1 h, and is partially repaired by 4 h; damage caused by exposure to a higher UVA dose (6 J/cm2), however, is not repaired. In contrast, cells pretreated with R123 and irradiated with an argon-ion laser (10 J/cm2, 514.5 rim) undergo a different type of mitochondrial injury, characterized by the delayed (4 h) onset of moderate mitochondrial swelling and striking mitochondrial distortion and fragmentation, which is not repaired by 48 h after irradiation. These differences indicate that the reactions underlying cellular phototoxicity can be distinguished even on an ultrastructural level. Probably both the primary photochemistry and the submitochondrial targets of these reactions differ with the two photosensitizers.

Metabolite damage and repair in metabolic engineering design.

PubMed

Sun, Jiayi; Jeffryes, James G; Henry, Christopher S; Bruner, Steven D; Hanson, Andrew D

2017-11-01

The necessarily sharp focus of metabolic engineering and metabolic synthetic biology on pathways and their fluxes has tended to divert attention from the damaging enzymatic and chemical side-reactions that pathway metabolites can undergo. Although historically overlooked and underappreciated, such metabolite damage reactions are now known to occur throughout metabolism and to generate (formerly enigmatic) peaks detected in metabolomics datasets. It is also now known that metabolite damage is often countered by dedicated repair enzymes that undo or prevent it. Metabolite damage and repair are highly relevant to engineered pathway design: metabolite damage reactions can reduce flux rates and product yields, and repair enzymes can provide robust, host-independent solutions. Herein, after introducing the core principles of metabolite damage and repair, we use case histories to document how damage and repair processes affect efficient operation of engineered pathways - particularly those that are heterologous, non-natural, or cell-free. We then review how metabolite damage reactions can be predicted, how repair reactions can be prospected, and how metabolite damage and repair can be built into genome-scale metabolic models. Lastly, we propose a versatile 'plug and play' set of well-characterized metabolite repair enzymes to solve metabolite damage problems known or likely to occur in metabolic engineering and synthetic biology projects. Copyright © 2017 International Metabolic Engineering Society. All rights reserved.

Three-dimensional echocardiographic assessment of the repaired mitral valve.

PubMed

Maslow, Andrew; Mahmood, Feroze; Poppas, Athena; Singh, Arun

2014-02-01

This study examined the geometric changes of the mitral valve (MV) after repair using conventional and three-dimensional echocardiography. Prospective evaluation of consecutive patients undergoing mitral valve repair. Tertiary care university hospital. Fifty consecutive patients scheduled for elective repair of the mitral valve for regurgitant disease. Intraoperative transesophageal echocardiography. Assessments of valve area (MVA) were performed using two-dimensional planimetry (2D-Plan), pressure half-time (PHT), and three-dimensional planimetry (3D-Plan). In addition, the direction of ventricular inflow was assessed from the three-dimensional imaging. Good correlations (r = 0.83) and agreement (-0.08 +/- 0.43 cm(2)) were seen between the MVA measured with 3D-Plan and PHT, and were better than either compared to 2D-Plan. MVAs were smaller after repair of functional disease repaired with an annuloplasty ring. After repair, ventricular inflow was directed toward the lateral ventricular wall. Subgroup analysis showed that the change in inflow angle was not different after repair of functional disease (168 to 171 degrees) as compared to those presenting with degenerative disease (168 to 148 degrees; p<0.0001). Three-dimensional imaging provides caregivers with a unique ability to assess changes in valve function after mitral valve repair. Copyright © 2014 Elsevier Inc. All rights reserved.

Metabolite damage and repair in metabolic engineering design

DOE Office of Scientific and Technical Information (OSTI.GOV)

Sun, Jiayi; Jeffryes, James G.; Henry, Christopher S.

The necessarily sharp focus of metabolic engineering and metabolic synthetic biology on pathways and their fluxes has tended to divert attention from the damaging enzymatic and chemical side-reactions that pathway metabolites can undergo. Although historically overlooked and underappreciated, such metabolite damage reactions are now known to occur throughout metabolism and to generate (formerly enigmatic) peaks detected in metabolomics datasets. It is also now known that metabolite damage is often countered by dedicated repair enzymes that undo or prevent it. Metabolite damage and repair are highly relevant to engineered pathway design: metabolite damage reactions can reduce flux rates and product yields,more » and repair enzymes can provide robust, host-independent solutions. Herein, after introducing the core principles of metabolite damage and repair, we use case histories to document how damage and repair processes affect efficient operation of engineered pathways - particularly those that are heterologous, non-natural, or cell-free. We then review how metabolite damage reactions can be predicted, how repair reactions can be prospected, and how metabolite damage and repair can be built into genome-scale metabolic models. Lastly, we propose a versatile 'plug and play' set of well-characterized metabolite repair enzymes to solve metabolite damage problems known or likely to occur in metabolic engineering and synthetic biology projects.« less

A novel perspective for burn-induced myopathy: Membrane repair defect

PubMed Central

Wang, Chao; Wang, Hongyu; Wu, Dan; Hu, Jianhong; Wu, Wei; Zhang, Yong; Peng, Xi

2016-01-01

Myopathy is a common complication of severe burn patients. One potential cause of this myopathy could be failure of the plasma membrane to undergo repair following injuries generated from toxin or exercise. The aim of this study is to assess systemic effect on muscle membrane repair deficiency in burn injury. Skeletal muscle fibers isolated from burn-injured mice were damaged with a UV laser and dye influx imaged confocally to evaluate membrane repair capacity. Membrane repair failure was also tested in burn-injured mice subjected to myotoxin or treadmill exercise. We further used C2C12 myotubules and animal models to investigate the role of MG53 in development of burn-induced membrane repair defect. We demonstrated that skeletal muscle myofibers in burn-injured mice showed significantly more dye uptake after laser damage than controls, indicating a membrane repair deficiency. Myotoxin or treadmill exercise also resulted in a higher-grade repair defect in burn-injured mice. Furthermore, we observed that burn injury induced a significant decrease in MG53 levels and its dimerization in skeletal muscles. Our findings highlight a new mechanism that implicates membrane repair failure as an underlying cause of burn-induced myopathy. And, the disorders in MG53 expression and MG53 dimerization are involved in this cellular pathology. PMID:27545095

Smoking Habits of Patients Undergoing Treatment for Intermittent Claudication in the Vascular Quality Initiative.

PubMed

Gabel, Joshua; Jabo, Brice; Patel, Sheela; Kiang, Sharon; Bianchi, Christian; Chiriano, Jason; Teruya, Theodore; Abou-Zamzam, Ahmed M

2017-10-01

Society for Vascular Surgery practice guidelines for the medical treatment of intermittent claudication give a GRADE 1A recommendation for smoking cessation. Active smoking is therefore expected to be low in patients suffering from intermittent claudication selected for vascular surgical intervention. The aim of this study is to evaluate the prevalence of smoking in patients undergoing intervention for intermittent claudication at the national level and to determine the relationship between smoking status and intervention. The Vascular Quality Initiative (VQI) registries for infra-inguinal bypass, supra-inguinal bypass, and peripheral vascular intervention (PVI) were queried to identify patients who underwent invasive treatment for intermittent claudication. Patient factors, procedure type (bypass versus PVI), and level of disease (supra-inguinal versus infra-inguinal) were evaluated for associations with smoking status (active smoking or nonsmoking) by univariate and covariate analysis. Between 2010 and 2015, 101,055 procedures were entered in the 3 registries, with 40,269 (40%) performed for intermittent claudication. Complete data for analysis were present in 37,632 cases. At the time of intervention, 44% of patients were active smokers, with wide variation by regional quality group (16-53%). In covariate analysis, active smoking at treatment was associated with age <70 years (prevalence ratio [PR] 2.42), male gender (PR 1.03), chronic obstructive pulmonary disease (PR 1.35), absence of prior cardiovascular procedures (PR 1.15), poor medication usage (PR 1.10), preoperative ankle-brachial index (ABI) <0.9 (PR 1.19), and supra-inguinal disease (PR 1.14). Invasiveness of treatment (PVI versus bypass procedures) was not significantly associated with smoking status. During follow-up, 36% of patients had quit smoking. Predictors of smoking cessation included age ≥70 years (RR 1.45), ABI ≥0.9 (RR 1.12), and bypass procedures (RR 1.22). At the time of treatment, 44% of patients undergoing intervention for intermittent claudication in the VQI were active smokers and there was a wide regional variation. Prevalence of active smoking was greater in the presence of younger age, fewer comorbidities, lower ABI, and supra-inguinal disease. Type of procedure performed, and in turn level of invasiveness required, did not appear to be influenced by smoking status. Elderly patients and those undergoing open procedures were more likely to quit smoking during follow up. These findings suggest opportunities for greater smoking cessation efforts before invasive therapies for intermittent claudication. Copyright © 2017 Elsevier Inc. All rights reserved.

The interrelationship between preoperative anemia and N-terminal pro-B-type natriuretic peptide: the effect on predicting postoperative cardiac outcome in vascular surgery patients.

PubMed

Goei, Dustin; Flu, Willem-Jan; Hoeks, Sanne E; Galal, Wael; Dunkelgrun, Martin; Boersma, Eric; Kuijper, Ruud; van Kuijk, Jan-Peter; Winkel, Tamara A; Schouten, Olaf; Bax, Jeroen J; Poldermans, Don

2009-11-01

N-terminal pro-B-type natriuretic peptide (NT-proBNP) predicts adverse cardiac outcome in patients undergoing vascular surgery. However, several conditions might influence this prognostic value, including anemia. In this study, we evaluated whether anemia confounds the prognostic value of NT-proBNP for predicting cardiac events in patients undergoing vascular surgery. A detailed cardiac history, resting echocardiography, and hemoglobin and NT-proBNP levels were obtained in 666 patients before vascular surgery. Anemia was defined as serum hemoglobin <13 g/dL for men and <12 g/dL for women. Troponin T measurements and 12-lead electrocardiograms were performed on postoperative days 1, 3, 7, and 30 and whenever clinically indicated. The primary end point of the study was the composite of 30-day postoperative cardiovascular death, nonfatal myocardial infarction, and troponin T release. Receiver operating characteristic curve analysis was used to assess the optimal cutoff value of NT-proBNP for the prediction of the composite end point. Multivariable regression analysis was used to assess the additional value of NT-proBNP for the prediction of postoperative cardiac events in nonanemic and anemic patients. Anemia was present in 206 patients (31%) before surgery. Hemoglobin level was inversely related with the NT-proBNP levels (beta coefficient = -2.242; P = 0.025). The optimal predictive cutoff value of NT-proBNP for predicting the composite cardiovascular outcome was 350 pg/mL. After adjustment for clinical cardiac risk factors, both anemia (odds ratio [OR] 1.53; 95% confidence interval [CI]: 1.07-2.99) and increased levels of NT-proBNP (OR 4.09; 95% CI: 2.19-7.64) remained independent predictors for postoperative cardiac events. However, increased levels of NT-proBNP were not predictive for the risk of adverse cardiac events in the subgroup of anemic patients (OR 2.16; 95% CI: 0.90-5.21). Both anemia and NT-proBNP are independently associated with an increased risk for postoperative cardiac events in patients undergoing vascular surgery. NT-proBNP has less predictive value in anemic patients.

Emerging Transcatheter Options for Tricuspid Regurgitation

PubMed Central

Kalra, Ankur; Uberoi, Angad S.; Latib, Azeem; Khera, Sahil; Little, Stephen H.; Bhatt, Deepak L.; Reardon, Michael J.; Kleiman, Neal S.; Barker, Colin M.

2017-01-01

Tricuspid regurgitation (TR) presents as either primary valve pathology or secondary to pulmonary or left-sided heart disease. Severe TR portends a worse prognosis independent of age, right ventricular size and function, severe left ventricular dysfunction, and increased pulmonary arterial pressures. Surgical treatment for TR has mostly been limited to patients undergoing mitral valve repair since those at high surgical risk are not candidates for traditional TR surgery. For these patients, minimally invasive techniques could be of great benefit, yet these techniques have been slow to develop because of the various anatomic and physiological aspects of the tricuspid valve apparatus. Several promising new techniques are currently undergoing clinical investigation, including caval valve implantation, percutaneous tricuspid annuloplasty techniques (Trialign, TriCinch, Cardioband), edge-to-edge repair with the MitraClip system, the FORMA device, and the GATE tricuspid Atrioventricular Valved Stent. Further evaluation of their safety and long-term efficacy is warranted prior to commercial approval and widespread adoption. PMID:29743996

The angulation of the septal structures impacts ventricular imbalance in atrioventricular septal defects with a common atrioventricular junction.

PubMed

Ahmad, Zaheer; Lim, Zek; Roman, Kevin; Haw, Marcus; Anderson, Robert H; Vettukattil, Joseph

2016-02-01

Multiplanar re-formatting of full-volume three-dimensional echocardiography data sets offers new insights into the morphology of atrioventricular septal defects. We hypothesised that distortion of the alignment between the atrial and ventricular septums results in imbalanced venous return to the ventricles, with consequent proportional ventricular hypoplasia. A single observer evaluated 31 patients, with a mean age of 52.09 months, standard deviation of 55, and with a range from 2 to 264 months, with atrioventricular septal defects, of whom 17 were boys. Ventricular imbalance, observed in nine patients, was determined by two-dimensional assessment, and confirmed at surgical inspection in selected cases when a univentricular strategy was undertaken. Offline analysis using multiplanar re-formatting was performed. A line was drawn though the length of the ventricular septum and a second line along the plane of the atrial septum, taking the angle between these two lines as the atrioventricular septal angle. We compared the angle between 22 patients with adequately sized ventricles, and those with ventricular imbalance undergoing univentricular repair. In the 22 patients undergoing biventricular repair, the septal angle was 0 in 14 patients; the other eight patients having angles ranging from 1 to 36, with a mean angle of 7.4°, and standard deviation of 11.1°.The mean angle in the nine patients with ventricle imbalance was 28.6°, with a standard deviation of 3.04°, and with a range from 26 to 35°. Of those undergoing univentricular repair, two patients died, with angles of 26 and 30°, respectively. The atrioventricular septal angle derived via multiplanar formatting gives important information regarding the degree of ventricular hypoplasia and imbalance. When this angle is above 25°, patients are likely to have ventricular imbalance requiring univentricular repair.

Repairing the damage to Atlantis' External Tank

NASA Image and Video Library

2007-03-07

On an upper level of high bay 1 of the Vehicle Assembly Building, technicians prepare the area around the nose cone (left) of Atlantis' external tank that will undergo repair for hail damage. A severe thunderstorm with golf ball-sized hail caused visible divots in the giant tank's foam insulation and minor surface damage to about 26 heat shield tiles on the shuttle's left wing. Further evaluation of the tank is necessary to get an accurate accounting of foam damage and determine the type of repair required and the time needed for that work. A new target launch date has not been determined, but teams will focus on preparing Atlantis for liftoff in late April on mission STS-117.

Repairing the damage to Atlantis' External Tank

NASA Image and Video Library

2007-03-07

On an upper level of high bay 1 of the Vehicle Assembly Building, technicians place protective material around the nose cone of Atlantis' external tank. The nose cone will undergo repair for hail damage. A severe thunderstorm with golf ball-sized hail caused visible divots in the giant tank's foam insulation and minor surface damage to about 26 heat shield tiles on the shuttle's left wing. Further evaluation of the tank is necessary to get an accurate accounting of foam damage and determine the type of repair required and the time needed for that work. A new target launch date has not been determined, but teams will focus on preparing Atlantis for liftoff in late April on mission STS-117.

Repairing the damage to Atlantis' External Tank

NASA Image and Video Library

2007-03-07

On an upper level of high bay 1 of the Vehicle Assembly Building, technicians prepare the area around the nose cone (foreground) of Atlantis' external tank that will undergo repair for hail damage. A severe thunderstorm with golf ball-sized hail caused visible divots in the giant tank's foam insulation and minor surface damage to about 26 heat shield tiles on the shuttle's left wing. Further evaluation of the tank is necessary to get an accurate accounting of foam damage and determine the type of repair required and the time needed for that work. A new target launch date has not been determined, but teams will focus on preparing Atlantis for liftoff in late April on mission STS-117.

Vascular and Cognitive Assessments in Patients With Breast Cancer Undergoing Chemotherapy After Surgery

ClinicalTrials.gov

2017-05-25

Cognitive/Functional Effects; Recurrent Breast Cancer; Stage IA Breast Cancer; Stage IB Breast Cancer; Stage II Breast Cancer; Stage IIIA Breast Cancer; Stage IIIB Breast Cancer; Stage IIIC Breast Cancer

The Usefulness of Patch Repair Using the Repermeabilized Umbilical Vein of the Round Ligament for Hepatobiliary Malignancies.

PubMed

Takahashi, Michiro; Saiura, Akio; Takahashi, Yu

2017-11-01

Patients with tumors invading major veins may require combined resection and reconstruction. However, venous reconstruction often demands complex hepatobiliary and vascular surgical procedures. In this study, we report a simple patch repair technique for venous reconstruction using the repermeabilized umbilical vein of the round ligament. We reviewed the outcomes of eleven patients who underwent venous wedge resection and patch repair using the repermeabilized umbilical vein of the round ligament at our institution. Procurement of the round ligament and method of making a patch is simple. The duration of anastomosis was approximately 15 min. Eight patients (73%) underwent hepatic resection followed by hepatic vein reconstruction; two (18%) pancreaticoduodenectomy followed by inferior vena cava (IVC) reconstruction; one (9%) hepatic resection followed by IVC reconstruction. Although one reconstructed vein became narrowed, the other ten veins were patent after surgery. Patch repair using the repermeabilized umbilical vein of the round ligament is a simple and useful technique.

Inflammation, Fracture and Bone Repair

PubMed Central

Loi, Florence; Córdova, Luis A.; Pajarinen, Jukka; Lin, Tzu-hua; Yao, Zhenyu; Goodman, Stuart B.

2016-01-01

The reconstitution of lost bone is a subject that is germane to many orthopaedic conditions including fractures and non-unions, infection, inflammatory arthritis, osteoporosis, osteonecrosis, metabolic bone disease, tumors, and periprosthetic particle-associated osteolysis. In this regard, the processes of acute and chronic inflammation play an integral role. Acute inflammation is initiated by endogenous or exogenous adverse stimuli, and can become chronic in nature if not resolved by normal homeostatic mechanisms. Dysregulated inflammation leads to increased bone resorption and suppressed bone formation. Crosstalk amongst inflammatory cells (polymorphonuclear leukocytes and cells of the monocyte-macrophage-osteoclast lineage) and cells related to bone healing (cells of the mesenchymal stem cell-osteoblast lineage and vascular lineage) is essential to the formation, repair and remodeling of bone. In this review, the authors provide a comprehensive summary of the literature related to inflammation and bone repair. Special emphasis is placed on the underlying cellular and molecular mechanisms, and potential interventions that can favorably modulate the outcome of clinical conditions that involve bone repair. PMID:26946132

The midline central artery forehead flap: a valid alternative to supratrochlear-based forehead flaps.

PubMed

Faris, Callum; van der Eerden, Paul; Vuyk, Hade

2015-01-01

This study clarifies the pedicle geometry and vascular supply of a midline forehead flap for nasal reconstruction. It reports on the vascular reliability of this flap and its ability to reduce hair transposition to the nose, a major complicating factor of previous forehead flap designs. To compare the vascular reliability of 3 different pedicle designs of the forehead flap in nasal reconstruction (classic paramedian, glabellar paramedian, and central artery flap design) and evaluate hair transposition rates and aesthetic results. Retrospective analysis of patient data and outcomes retrieved from computer files generated at the time of surgery, supplemented by data from the patient medical records and photographic documentation, from a tertiary referral nasal reconstructive practice, within a secondary-care hospital setting. The study population included all consecutive patients over a 19-year period who underwent primary forehead flap repair of nasal defects, with more than 3 months of postoperative follow-up and photographic documentation. Three sequential forehead flap patterns were used (classic paramedian flap, glabella flap, and central artery flap) for nasal reconstruction over the study duration. Data collected included patient characteristics, method of repair, complications, functional outcome, and patient satisfaction score. For cosmetic outcome, photographic documentation was scored by a medical juror. No forehead flap had vascular compromise in the first stage. Partial flap necrosis was reported in subsequent stages in 4 patients (1%), with no statistical difference in the rate of vascular compromise between the 3 flap designs. Hair transposition to the nose was lower in the central artery forehead flap (7%) compared with the classic paramedian (23%) and glabellar paramedian (13%) flaps (P < .05). Photographic evaluation in 227 patients showed that brow position (98%) and color match (83%) were good in the majority of the patients. In this series, the central artery forehead flap was as reliable (in terms of vascularity) as the glabellar and classic paramedian forehead flap. Its use resulted in a statistically significant reduction in transfer of hair to the nose in our series. 3.

Endovascular Repair of Traumatic Rupture of the Thoracic Aorta: Single-Center Experience

DOE Office of Scientific and Technical Information (OSTI.GOV)

Saratzis, Nikolaos A., E-mail: saratzis@germanosnet.gr; Saratzis, Athanasios N.; Melas, Nikolaos

Purpose. Traumatic rupture of the thoracic aorta secondary to blunt chest trauma is a life-threatening emergency and a common cause of death, usually following violent collisions. The objective of this retrospective report was to evaluate the efficacy of endovascular treatment of thoracic aortic disruptions with a single commercially available stent-graft. Methods. Nine men (mean age 29.5 years) were admitted to our institution between January 2003 and January 2006 due to blunt aortic trauma following violent motor vehicle collisions. Plain chest radiography, spiral computed tomography, aortography, and transesophageal echocardiography were used for diagnostic purposes in all cases. All patients were diagnosedmore » with contained extramural thoracic aortic hematomas, secondary to aortic disruption. One patient was also diagnosed with a traumatic thoracic aortic dissection, secondary to blunt trauma. All subjects were poor surgical candidates, due to major injuries such as multiple bone fractures, abdominal hematomas, and pulmonary contusions. All repairs were performed using the EndoFit (LeMaitre Vascular) stent-graft. Results. Complete exclusion of the traumatic aortic disruption and pseudoaneurysm was achieved and verified at intraoperative arteriography and on CT scans, within 10 days of the repair in all patients. In 1 case the deployment of a second cuff was necessary due to a secondary endoleak. In 2 cases the left subclavian artery was occluded to achieve adequate graft fixation. No procedure-related deaths have occurred and no cardiac or peripheral vascular complications were observed within the 12 months (range 8-16 months) follow-up. Conclusions. This is the first time the EndoFit graft has been utilized in the treatment of thoracic aortic disruptions secondary to chest trauma. The repair of such pathologies is technically feasible and early follow-up results are promising.« less

Management of traumatic brachial artery injuries: A report on 49 patients

PubMed Central

Ekim, Hasan; Tuncer, Mustafa

2009-01-01

BACKGROUND AND OBJECTIVE: The brachial artery is the most frequently injured artery in the upper extremity due to its vulnerability. The purpose of our study was to review our experience with brachial artery injuries over a 9-year period, describing the type of injury, surgical procedures, complications, and associated injuries. PATIENTS AND METHODS: Forty-nine patients with brachial artery injury underwent surgical repair procedures at our hospital, from the beginning of May 1999 to the end of June 2008. The brachial artery injuries were diagnosed by physical examination and Doppler ultrasonography. Depending on the mode of presentation, patients were either taken immediately to the operating room for bleeding control and vascular repair or were assessed by preoperative duplex ultrasonography. RESULTS: This study group consisted of 43 males and 6 females, ranging in age from 6 to 65 years with a mean (SD) age of 27.9 (6.7) years. The mechanism of trauma was penetrating in 45 patients and blunt in the remaining 4 patients. Stab injury was the most frequent form of penetrating trauma (24 of 45). Treatment included primary arterial repair in 5 cases, end-to-end anastomosis in 28 cases, interposition vein graft in 15 cases, and interposition-ringed polytetrafluoroethylene graft in 1 case. Associated injuries were common and included venous injury (14), bone fracture (5), and peripheral nerve injury (11). Fifteen patients developed postoperative complications. One patient underwent an above-elbow amputation. CONCLUSIONS: Prompt and appropriate management of the brachial artery injuries, attention to associated injuries, and a readiness to revise the vascular repair early in the event of failure will maximize patient survival and upper extremity salvage. PMID:19318753

Mortality After Elective and Ruptured Abdominal Aortic Aneurysm Surgical Repair: 12-Year Single-Center Experience of Estonia.

PubMed

Lieberg, J; Pruks, L-L; Kals, M; Paapstel, K; Aavik, A; Kals, J

2018-06-01

Abdominal aortic aneurysm is a degenerative vascular pathology with high mortality due to its rupture, which is why timely treatment is crucial. The current single-center retrospective study was undertaken to analyze short- and long-term all-cause mortality after operative treatment of abdominal aortic aneurysm and to examine the factors that influence outcome. The data of all abdominal aortic aneurysm patients treated with open repair or endovascular aneurysm repair in 2004-2015 were retrospectively retrieved from the clinical database of Tartu University Hospital. The primary endpoint was 30-day, 90-day, and 5-year all-cause mortality. The secondary endpoint was determination of the risk factors for mortality. Elective abdominal aortic aneurysm repair was performed on 228 patients (mean age 71.8 years), of whom 178 (78%) were treated with open repair and 50 (22%) with endovascular aneurysm repair. A total of 48 patients with ruptured abdominal aortic aneurysm were treated with open repair (mean age 73.8 years) at the Department of Vascular Surgery, Tartu University Hospital, Estonia. Mean follow-up period was 4.2 ± 3.3 years. In patients with elective abdominal aortic aneurysm, 30-day, 90-day, and 5-year all-cause mortality rates were 0.9%, 2.6%, and 32%, respectively. In multivariate analysis, the main predictors for 5-year mortality were preoperative creatinine value and age (p < 0.05). In patients with ruptured abdominal aortic aneurysm, 30-day, 90-day, and 5-year all-cause mortality rates were 22.9%, 33.3%, and 55.1%, respectively. In multivariate analysis, the risk factors for 30-day mortality in ruptured abdominal aortic aneurysm were perioperative hemoglobin and lactate levels (p < 0.05). According to this study, the all-cause mortality rates of elective abdominal aortic aneurysm and ruptured abdominal aortic aneurysm at our hospital were comparable to those at other centers worldwide. Even though some variables were identified as potential predictors of survival, the mortality rates after ruptured abdominal aortic aneurysm remain high. Early diagnosis, timely treatment, and detection of the risk factors for abdominal aortic aneurysm progression would improve survival in patients with abdominal aortic aneurysm.

Modified Eversion Carotid Endarterectomy (mECEA): Analysis of Clinical and Financial Outcomes.

PubMed

Musicant, Scott E; Guzzetta, Vincent J; Terramani, Thomas T; Greenwood, Kristina L; Chiodo, Wendy C; Heaney, Karen M; Berthiaume, Shelley J

2017-07-01

Several carotid endarterectomy techniques have been described, including conventional carotid endarterectomy (CCEA) performed with patch repair and eversion carotid endarterectomy (ECEA) performed with transection of the internal carotid artery. We describe our simplified technique of modified eversion carotid endarterectomy (mECEA) with longitudinal arteriotomy limited to the carotid bulb, without transection of the internal carotid artery and present our analysis of its safety, efficacy, and cost effectiveness. A retrospective review of all carotid endarterectomies performed by 3 vascular surgeons over a 3-year period was completed. About 197 mECEA were performed during the study period. Follow-up data were obtained on 77.7% of patients. A comparison was made with the contemporary literature with respect to outcomes for both CCEA and ECEA. Between January 2012 and December 2014, a total of 197 mECEA were performed. The perioperative stroke and death rates for those undergoing mECEA was 0.5% and 0.5%, respectively. Late stroke and death rates were 3.0% and 5.1%, respectively. Perioperative rate of myocardial infarction was 1.0%. Early restenosis rates of >70% occurred in 1.4%, whereas late restenosis of >70% occurred in 2.7%. Mean operating time for those undergoing mECEA was 57.9 min. Average costs savings for mECEA compared to CCEA were $5,835. This simplified technique has comparable outcomes to those described in the contemporary literature for both CCEA and ECEA with respect to postoperative neurologic events as well as restenosis rates. In our institution, the short mean operative times with mECEA has led to reduced resource utilization. Copyright © 2017 Elsevier Inc. All rights reserved.

The gene expression profile of non-cultured, highly purified human adipose tissue pericytes: Transcriptomic evidence that pericytes are stem cells in human adipose tissue

DOE Office of Scientific and Technical Information (OSTI.GOV)

Silva Meirelles, Lindolfo da, E-mail: lindolfomeirelles@gmail.com; Laboratory for Stem Cells and Tissue Engineering, PPGBioSaúde, Lutheran University of Brazil, Av. Farroupilha 8001, 92425-900 Canoas, RS; Deus Wagatsuma, Virgínia Mara de

Pericytes (PCs) are a subset of perivascular cells that can give rise to mesenchymal stromal cells (MSCs) when culture-expanded, and are postulated to give rise to MSC-like cells during tissue repair in vivo. PCs have been suggested to behave as stem cells (SCs) in situ in animal models, although evidence for this role in humans is lacking. Here, we analyzed the transcriptomes of highly purified, non-cultured adipose tissue (AT)-derived PCs (ATPCs) to detect gene expression changes that occur as they acquire MSC characteristics in vitro, and evaluated the hypothesis that human ATPCs exhibit a gene expression profile compatible with anmore » AT SC phenotype. The results showed ATPCs are non-proliferative and express genes characteristic not only of PCs, but also of AT stem/progenitor cells. Additional analyses defined a gene expression signature for ATPCs, and revealed putative novel ATPC markers. Almost all AT stem/progenitor cell genes differentially expressed by ATPCs were not expressed by ATMSCs or culture-expanded ATPCs. Genes expressed by ATMSCs but not by ATPCs were also identified. These findings strengthen the hypothesis that PCs are SCs in vascularized tissues, highlight gene expression changes they undergo as they assume an MSC phenotype, and provide new insights into PC biology. - Highlights: • Non-cultured adipose tissue-derived human pericytes (ncATPCs) exhibit a distinctive gene expression signature. • ncATPCs express key adipose tissue stem cell genes previously described in vivo in mice. • ncATPCs express message for anti-proliferative and antiangiogenic molecules. • Most ncATPC-specific transcripts are absent in culture-expanded pericytes or ATMSCs • Gene expression changes ncATPCs undergo as they acquire a cultured ATMSC phenotype are pointed out.« less

Intervention Associated Acute Kidney Injury and Long-Term Cardiovascular Outcomes.

PubMed

Saratzis, Athanasios; Harrison, Seamus; Barratt, Jonathan; Sayers, Robert D; Sarafidis, Pantelis A; Bown, Matthew J

2015-01-01

Acute kidney injury (AKI) has been associated with all-cause short- and long-term mortality. However, its association with cardiovascular (CV) events remains unclear. We sought to investigate this in patients undergoing open (OAR) or endovascular (EVAR) abdominal aortic aneurysm repair, as they are likely to develop both AKI and CV morbidity. A meta-analysis was subsequently performed to confirm this in other CV-interventions. AKI-incidence was assessed in a multicentre-cohort of 1,068 patients undergoing EVAR (947 individuals) or OAR electively using the 'Acute Kidney Injury Network' criteria. A composite-endpoint was used, consisting of non-fatal myocardial infarction (MI), stroke, vascular event, hospitalisation due to heart failure and CV death. A systematic literature review identified studies reporting AKI-incidence and CV events. Risk ratios (RRs) at 1 and 5 years were combined using meta-analysis. During a median follow-up of 62 months (range 11-121), AKI was associated with CV events on adjusted (for CV risk-factors) analyses (Incidence 36% of EVAR, 32% of OAR patients; hazard ratio 1.73, 95% CI 1.06-3.39, p=0.03) for the overall population. In the meta-analysis, 7 studies reported incidence of MI on 23,936 patients 1-year after coronary intervention (PCI) with a pooled RR of 1.76 (95% CI 1.45-2.83, p<0.001); at 2 years, 3 studies reported MI incidence on 17,773 patients after PCI with a pooled RR of 1.34 (95% CI 1.10-1.63, p=0.003). MI-incidence was reported 5 years after cardiac surgery by 3 studies (33,701 patients) with a pooled RR of 1.60 (95% CI 1.43-1.81). AKI is associated with long-term CV events after surgery or endovascular intervention. © 2015 S. Karger AG, Basel.

Glomerular parietal epithelial cells of adult murine kidney undergo EMT to generate cells with traits of renal progenitors

PubMed Central

G, Swetha; Chandra, Vikash; Phadnis, Smruti; Bhonde, Ramesh

2011-01-01

Abstract Glomerular parietal epithelial cells (GPECs) are known to revert to embryonic phenotype in response to renal injury. However, the mechanism of de-differentiation in GPECs and the underlying cellular processes are not fully understood. In the present study, we show that cultured GPECs of adult murine kidney undergo epithelial-mesenchymal transition (EMT) to generate cells, which express CD24, CD44 and CD29 surface antigens. Characterization by qRT-PCR and immunostaining of these clonogenic cells demonstrate that they exhibit metastable phenotype with co-expression of both epithelial (cytokeratin-18) and mesenchymal (vimentin) markers. Transcript analysis by qRT-PCR revealed high expression of metanephric mesenchymal (Pax-2, WT-1, Six-1, Eya-1, GDNF) and uteric bud (Hoxb-7, C-Ret) genes in these cells, indicating their bipotent progenitor status. Incubation of GPECs with EMT blocker Prostaglandin E2, resulted in low expression of renal progenitor markers reflecting the correlation between EMT and acquired stemness in these cells. Additional in vitro renal commitment assays confirmed their functional staminality. When injected into E13.5 kidney rudiments, the cells incorporated into the developing kidney primordia and co-culture with E13.5 spinal cord resulted in branching and tubulogenesis in these cells. When implanted under renal capsule of unilaterally nephrectomized mice, these cells differentiated into immature glomeruli and vascular ducts. Our study demonstrates that EMT plays a major role in imparting plasticity to terminally differentiated GPECs by producing metastable cells with traits of kidney progenitors. The present study would improve our understanding on epithelial cell plasticity, furthering our knowledge of its role in renal repair and regeneration. PMID:19840197

Percutaneous endovascular aneurysm repair in morbidly obese patients.

PubMed

Chin, Jason A; Skrip, Laura; Sumpio, Bauer E; Cardella, Jonathan A; Indes, Jeffrey E; Sarac, Timur P; Dardik, Alan; Ochoa Chaar, Cassius I

2017-03-01

Endovascular aneurysm repair (EVAR) with percutaneous femoral access (PEVAR) has several potential advantages. Morbidly obese (MO) patients present unique anatomical challenges and have not been specifically studied. This study examines the trends in the use of PEVAR and its surgical outcomes compared with open femoral cutdown (CEVAR) in MO patients. The American College of Surgeons National Surgical Quality Improvement Program files for the years 2005 to 2013 were reviewed. The study included all MO patients (body mass index [BMI] ≥40 kg/m 2 ) undergoing EVAR. Patients were categorized as having CEVAR if they had any one of 11 selected Current Procedural Terminology (American Medical Association, Chicago, Ill) codes describing an open femoral procedure. The PEVAR group included any remaining patients who had only codes for EVAR and endovascular procedures. Linear correlation was used to evaluate temporal trends in the use of PEVAR among MO patients. Baseline comorbidities and surgical outcomes were compared between the PEVAR and CEVAR groups using χ 2 tests or t-tests. There were 833 MO patients (470 CEVAR and 363 PEVAR) constituting 3.0% of all patients undergoing EVAR. The use of PEVAR in MO patients significantly increased from 27.3% of total EVARs in the years 2005 to 2006 to 48.6% in 2013 (P = .039). The two groups had similar baseline characteristics, including age, BMI, comorbidities, and emergency procedures, except for history of severe chronic obstructive pulmonary disease (29.6% CEVAR vs 22.6% PEVAR; P = .024). PEVAR patients had shorter duration of anesthesia (244 vs 260 minutes; P = .048) and shorter total operation time (158 vs 174 minutes; P = .002). PEVAR patients had significantly decreased wound complications (5.5% vs 9.4%; P = .039). There was a trend towards PEVAR patients being more likely to be discharged home than to a facility (93.6% vs 87.8%; P = .060). There was no difference in any other complication or mortality. A subgroup analysis of 109 superobese patients with BMI ≥50 kg/mg 2 (59 CEVAR and 50 PEVAR) demonstrated no significant differences in outcomes between groups. PEVAR is increasingly used in MO patients and decreases operating time and rates of wound infection compared with CEVAR. The advantages of PEVAR seem to be lost in the superobese patients. Copyright © 2016 Society for Vascular Surgery. All rights reserved.

Genetic Analysis Reveals a Longevity-Associated Protein Modulating Endothelial Function and Angiogenesis.

PubMed

Villa, Francesco; Carrizzo, Albino; Spinelli, Chiara C; Ferrario, Anna; Malovini, Alberto; Maciąg, Anna; Damato, Antonio; Auricchio, Alberto; Spinetti, Gaia; Sangalli, Elena; Dang, Zexu; Madonna, Michele; Ambrosio, Mariateresa; Sitia, Leopoldo; Bigini, Paolo; Calì, Gaetano; Schreiber, Stefan; Perls, Thomas; Fucile, Sergio; Mulas, Francesca; Nebel, Almut; Bellazzi, Riccardo; Madeddu, Paolo; Vecchione, Carmine; Puca, Annibale A

2015-07-31

Long living individuals show delay of aging, which is characterized by the progressive loss of cardiovascular homeostasis, along with reduced endothelial nitric oxide synthase activity, endothelial dysfunction, and impairment of tissue repair after ischemic injury. Exploit genetic analysis of long living individuals to reveal master molecular regulators of physiological aging and new targets for treatment of cardiovascular disease. We show that the polymorphic variant rs2070325 (Ile229Val) in bactericidal/permeability-increasing fold-containing-family-B-member-4 (BPIFB4) associates with exceptional longevity, under a recessive genetic model, in 3 independent populations. Moreover, the expression of BPIFB4 is instrumental to maintenance of cellular and vascular homeostasis through regulation of protein synthesis. BPIFB4 phosphorylation/activation by protein-kinase-R-like endoplasmic reticulum kinase induces its complexing with 14-3-3 and heat shock protein 90, which is facilitated by the longevity-associated variant. In isolated vessels, BPIFB4 is upregulated by mechanical stress, and its knock-down inhibits endothelium-dependent vasorelaxation. In hypertensive rats and old mice, gene transfer of longevity-associated variant-BPIFB4 restores endothelial nitric oxide synthase signaling, rescues endothelial dysfunction, and reduces blood pressure levels. Furthermore, BPIFB4 is implicated in vascular repair. BPIFB4 is abundantly expressed in circulating CD34(+) cells of long living individuals, and its knock-down in endothelial progenitor cells precludes their capacity to migrate toward the chemoattractant SDF-1. In a murine model of peripheral ischemia, systemic gene therapy with longevity-associated variant-BPIFB4 promotes the recruitment of hematopoietic stem cells, reparative vascularization, and reperfusion of the ischemic muscle. Longevity-associated variant-BPIFB4 may represent a novel therapeutic tool to fight endothelial dysfunction and promote vascular reparative processes. © 2015 American Heart Association, Inc.

Peripheral nerve injuries secondary to missiles.

PubMed

Katzman, B M; Bozentka, D J

1999-05-01

Peripheral nerve injuries secondary to missiles can present some of the most challenging problems faced by hand surgeons. This article reviews the pertinent neural anatomy, injury classifications, and repair techniques. Options in the management of nerve gaps are presented including the use of vascularized nerve grafts. The results are discussed and a treatment algorithm is presented.

Cartilage tissue engineering: From biomaterials and stem cells to osteoarthritis treatments.

PubMed

Vinatier, C; Guicheux, J

2016-06-01

Articular cartilage is a non-vascularized and poorly cellularized connective tissue that is frequently damaged as a result of trauma and degenerative joint diseases such as osteoarthrtis. Because of the absence of vascularization, articular cartilage has low capacity for spontaneous repair. Today, and despite a large number of preclinical data, no therapy capable of restoring the healthy structure and function of damaged articular cartilage is clinically available. Tissue-engineering strategies involving the combination of cells, scaffolding biomaterials and bioactive agents have been of interest notably for the repair of damaged articular cartilage. During the last 30 years, cartilage tissue engineering has evolved from the treatment of focal lesions of articular cartilage to the development of strategies targeting the osteoarthritis process. In this review, we focus on the different aspects of tissue engineering applied to cartilage engineering. We first discuss cells, biomaterials and biological or environmental factors instrumental to the development of cartilage tissue engineering, then review the potential development of cartilage engineering strategies targeting new emerging pathogenic mechanisms of osteoarthritis. Copyright © 2016 Elsevier Masson SAS. All rights reserved.

Impact of alterations in target vessel curvature on branch durability after endovascular repair of thoracoabdominal aortic aneurysms.

PubMed

Sylvan, Joshua; Brier, Corey; Wolski, Katherine; Yanof, Jeffrey; Goel, Vikash; Kuramochi, Yuki; Eagleton, Matthew J

2016-03-01

The aim of this study was to evaluate curvature and its effect on the durability of visceral and renal branches in patients undergoing endovascular repair of thoracoabdominal aortic aneurysms (TAAAs) with fenestrated/branched endovascular aneurysm repair (F/B-EVAR). Quantitative branch vessel curvature assessment on branches arising from reinforced fenestrations was performed for 168 patients undergoing F/B-EVAR for type II and type III TAAAs. Preoperative and postoperative centerline coordinates were obtained using iNtuition (TeraRecon, Foster City, Calif) and exported into MATLAB (The MathWorks, Inc, Natick, Mass) based on thin-slice computed tomography imaging. Spline interpolation was applied to the centerline coordinates and resampled at 100 equally spaced points, and curvature calculations (κ, mm(-1)) were applied. Global and maximal curvatures for each of the target vessels were measured and categorized by severity. Categories for curvature were 0 to 0.05 mm(-1) (low), 0.05 to 0.1 mm(-1) (medium), 0.1 to 0.15 mm(-1) (high), and >0.15 mm(-1) (extreme) for global curvature and 0 to 0.2 mm(-1), 0.2 to 0.4 mm(-1), 0.4 to 0.6 mm(-1), and >0.6 mm(-1), respectively, for maximum curvature. Curvature variances were assessed for an association with vessel patency and need for reintervention. There were 558 vessels that underwent analysis based on repairs involving 650 vessels, whereby 92 vessels were excluded as they were treated with an external helical branch (58 celiac arteries and 34 superior mesenteric arteries). There was a significant difference found before and after F/B-EVAR for the global celiac artery curvature (median difference, -0.01; P < .001), global left renal artery curvature (median, -0.01; P = .014), maximum left renal artery curvature (median, 0.05; P < .001), and maximum right renal artery curvature (median, 0.03; P = .009). Maximum artery curvature was found to have shifted distally in all vessels postoperatively; 37 adverse events (AEs) were observed in 30 patients (6 branched occlusions and 31 reinterventions [24 type III endoleaks, 5 vessel stenoses, and 2 vessel occlusions]). The majority of AEs (>70%) occurred within the range of low to medium curvature. Univariate analysis found gender to be a dependent variable associated with high (maximum) preoperative curvature (odds ratio, 0.395; P = .02). The use of self-expanding stents (vs balloon-expandable stents alone) in vessels with high preoperative curvature (>0.6 mm(-1)) was significant in the right renal artery (P = .044). This study did not show a significant relationship between the severity of artery curvature or changes in curvature and AEs found for visceral or renal branches after F/B-EVAR for extensive TAAA. Surprisingly, the majority of AEs occurred in low- and medium-curved vessels. This study is limited in that it does not take into account other factors that may affect AEs, like motion, which would be valuable in future studies. Copyright © 2016 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.

Robotic-assisted laparoscopic prostatectomy in umbilical hernia patients: University of California, Irvine, technique for port placement and repair.

PubMed

Kim, William; Abdelshehid, Corollos; Lee, Hak J; Ahlering, Thomas

2012-06-01

To discuss a technique currently used at our institution for the management of umbilical hernias during robot-assisted laparoscopic prostatectomy. As more patients undergo robot-assisted radical prostatectomy, there will be an increase in patients who qualify for robotic surgery with comorbidities. This technique has been utilized in clinically localized prostate cancer patients with umbilical hernias using the da Vinci Surgical System and standard laparoscopic instrumentation. Port placements and closures were performed by a resident assistant and a nurse at the operating table. The prostatectomy was performed by a single experienced surgeon at the console. Currently, no data are available regarding patients with umbilical hernias undergoing robotic prostatectomy. We reviewed our technique of port placement for patients with a pre-existing umbilical hernia undergoing robot-assisted laparoscopic prostatectomy. This technique allows for a reduction of the umbilical hernia, the use of the fascial defect as a robotic port, and the removal of the prostate by way of transverse incision and transverse repair. In our experience, this technique is feasible and reproducible for any small or large umbilical hernia. Copyright © 2012 Elsevier Inc. All rights reserved.

Angiogenesis mediated by soluble forms of E-selectin and vascular cell adhesion molecule-1

NASA Astrophysics Data System (ADS)

Koch, Alisa E.; Halloran, Margaret M.; Haskell, Catherine J.; Shah, Manisha R.; Polverini, Peter J.

1995-08-01

ENDOTHELIAL adhesion molecules facilitate the entry of leukocytes into inflamed tissues. This in turn promotes neovascularization, a process central to the progression of rheumatoid arthritis, tumour growth and wound repair1. Here we test the hypothesis that soluble endothelial adhesion molecules promote angiogenesis2á¤-4. Human recombinant soluble E-selectin and soluble vascular cell adhesion molecule-1 induced chemotaxis of human endothelial cells in vitro and were angiogenic in rat cornea. Soluble E-selectin acted on endothelial cells in part through a sialyl Lewis-X-dependent mechanism, while soluble vascular cell adhesion molecule-1 acted on endothelial cells in part through a very late antigen (VLA)-4 dependent mechanism. The chemotactic activity of rheumatoid synovial fluid for endothelial cells, and also its angiogenic activity, were blocked by antibodies to either soluble E-selectin or soluble vascular cell adhesion molecule-1. These results suggest a novel function for soluble endothelial adhesion molecules as mediators of angiogenesis.

Endothelial Cell Autonomous Role of Akt1: Regulation of Vascular Tone and Ischemia-Induced Arteriogenesis.

PubMed

Lee, Monica Y; Gamez-Mendez, Ana; Zhang, Jiasheng; Zhuang, Zhenwu; Vinyard, David J; Kraehling, Jan; Velazquez, Heino; Brudvig, Gary W; Kyriakides, Themis R; Simons, Michael; Sessa, William C

2018-04-01

The importance of PI3K/Akt signaling in the vasculature has been demonstrated in several models, as global loss of Akt1 results in impaired postnatal ischemia- and VEGF-induced angiogenesis. The ubiquitous expression of Akt1, however, raises the possibility of cell-type-dependent Akt1-driven actions, thereby necessitating tissue-specific characterization. Herein, we used an inducible, endothelial-specific Akt1-deleted adult mouse model (Akt1iECKO) to characterize the endothelial cell autonomous functions of Akt1 in the vascular system. Endothelial-targeted ablation of Akt1 reduces eNOS (endothelial nitric oxide synthase) phosphorylation and promotes both increased vascular contractility in isolated vessels and elevated diastolic blood pressures throughout the diurnal cycle in vivo. Furthermore, Akt1iECKO mice subject to the hindlimb ischemia model display impaired blood flow and decreased arteriogenesis. Endothelial Akt1 signaling is necessary for ischemic resolution post-injury and likely reflects the consequence of NO insufficiency critical for vascular repair. © 2018 American Heart Association, Inc.

Benefits of pre-emptive analgesia by local infiltration at day-case general anaesthetic open inguinal hernioplasty.

PubMed

Radwan, R W; Gardner, A; Jayamanne, H; Stephenson, B M

2018-03-15

Introduction The open prosthetic repair of inguinal hernias under local anaesthesia (LA) is well established, with the concept of intraoperative 'pre-emptive analgesia' evolving so that patients are as comfortable as possible. We used a peri-incisional LA solution in patients undergoing day-case inguinal hernioplasty under general anaesthesia (GA) and recorded use of analgesia in the immediate postoperative period. Methods In this observational cohort study, 100 consecutive unselected men underwent open inguinal hernia repair as a day case. Of these, 75 underwent repair under GA and 25 with peri-incisional LA solution (equal mixture of 0.5% bupivacaine and 1% lignocaine with 1:200,000 adrenaline). Analgesia prescribed at induction, for maintenance and after cessation of anaesthesia was scored in accordance with the World Health Organization (WHO) analgesic ladder. Results The median age in the GA group was 59 years (range: 25-89 years) and in the GA+LA group, it was 62 years (range: 27-88 years). Of the 100 patients, 82 underwent a mesh plug repair by seven surgeons whereas 18 underwent a flat (Lichtenstein) mesh repair by two surgeons. WHO analgesic induction and postoperative scores were significantly lower in the GA+LA group (p=0.034 and p<0.001 respectively). There was also a significant difference in use of postoperative antiemetics (23% vs 0% in the GA only and GA+LA cohorts respectively, p=0.020). Six patients (8%) in the GA group failed day-case discharge criteria. Conclusions Patients undergoing contemporary day-case GA inguinal hernioplasty with pre-emptive LA solution infiltration require lower levels of postoperative opioid analgesia and antiemetics. These cases are less likely to fail discharge criteria for planned day surgery.

The Impact of Aortic Occlusion Balloon on Mortality After Endovascular Repair of Ruptured Abdominal Aortic Aneurysms: A Meta-analysis and Meta-regression Analysis.

PubMed

Karkos, Christos D; Papadimitriou, Christina T; Chatzivasileiadis, Theodoros N; Kapsali, Nikoletta S; Kalogirou, Thomas E; Giagtzidis, Ioakeim T; Papazoglou, Konstantinos O

2015-12-01

We aimed to investigate whether the use of aortic occlusion balloon (AOB) has an impact on mortality of patients undergoing endovascular repair of ruptured abdominal aortic aneurysms (RAAAs). A meta-analysis of the English-language literature was undertaken through February 2013. Articles reporting data on outcome after endovascular repair of RAAAs were identified and information regarding the use of AOB was sought. Included in this meta-analysis were 39 eligible studies reporting 1277 patients. The pooled perioperative mortality was 21.6% (95% CI 18.1-25.1%). There was significant within-study heterogeneity (I(2) 50.2%, P < 0.001). A total of 200 patients required AOB with an estimated pooled proportion of 14.1% (8.9-19.3%). Individual random-effects meta-regression investigating the effect of AOB and other risk factors on mortality revealed a significant linear association of hemodynamic instability, bifurcated endograft approach, and primary conversion to open repair with mortality and a nonlinear (second degree polynomial) association of AOB with mortality. On multivariable meta-regression models, both hemodynamic instability and AOB were found to be statistically significant, independent predictors of mortality. In particular, there was a statistically significant negative correlation between AOB and mortality and a positive effect of hemodynamic instability on mortality. In practical terms, mortality was significantly higher in studies with a higher proportion of hemodynamically unstable patients and lower in studies with a higher rate of AOB use. This study provides meta-analytical evidence that the use of an AOB in unstable RAAA patients undergoing endovascular repair may improve the results.

Robotic inferior vena cava surgery.

PubMed

Davila, Victor J; Velazco, Cristine S; Stone, William M; Fowl, Richard J; Abdul-Muhsin, Haidar M; Castle, Erik P; Money, Samuel R

2017-03-01

Inferior vena cava (IVC) surgery is uncommon and has traditionally been performed through open surgical approaches. Renal cell carcinoma with IVC extension generally requires vena cavotomy and reconstruction. Open removal of malpositioned IVC filters (IVCF) is occasionally required after endovascular retrieval attempts have failed. As our experience with robotic surgery has advanced, we have applied this technology to surgery of the IVC. We reviewed our institution's experience with robotic surgical procedures involving the IVC to determine its safety and efficacy. All patients undergoing robotic surgery that included cavotomy and repair from 2011 to 2014 were retrospectively reviewed. Data were obtained detailing preoperative demographics, operative details, and postoperative morbidity and mortality. Ten patients (6 men) underwent robotic vena caval procedures at our institution. Seven patients underwent robotic nephrectomy with removal of IVC tumor thrombus and retroperitoneal lymph node dissection. Three patients underwent robotic explantation of an IVCF after multiple endovascular attempts at removal had failed. The patients with renal cell carcinoma were a mean age of was 65.4 years (range, 55-74 years). Six patients had right-sided malignancy. All patients had T3b lesions at time of diagnosis. Mean tumor length extension into the IVC was 5 cm (range, 1-8 cm). All patients underwent robotic radical nephrectomy, with caval tumor thrombus removal and retroperitoneal lymph node dissection. The average operative time for patients undergoing surgery for renal cell carcinoma was 273 minutes (range, 137-382 minutes). Average intraoperative blood loss was 428 mL (range, 150-1200 mL). The patients with IVCF removal were a mean age of 33 years (range, 24-41 years). Average time from IVCF placement until robotic removal was 35.5 months (range, 4.3-57.3 months). Before robotic IVCF removal, a minimum of two endovascular retrievals were attempted. Average operative time for patients undergoing IVCF removal was 163 minutes (range, 131-202 minutes). Intraoperative blood loss averaged 250 mL (range, 150-350 mL). All procedures were completed robotically. The mean length of stay for all patients was 3.5 days (range, 1-8 days). All patients resumed ambulation on postoperative day 1. Nine patients resumed a regular diet on postoperative day 2. One patient with a renal tumor sustained a colon injury during initial adhesiolysis, before robotic radical nephrectomy, which was recognized at the initial operation and repaired robotically. Robotic radical nephrectomy and caval tumor removal were then completed. No blood transfusions were required intraoperatively, but three patients required blood transfusions postoperatively. Although robotic IVC surgery is uncommon, our initial limited experience demonstrates it is safe and efficacious. Copyright © 2016 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.

A prospective randomized study comparing laparoscopic transabdominal preperitoneal (TAPP) versus Lichtenstein repair for bilateral inguinal hernias.

PubMed

Ielpo, Benedetto; Duran, Hipolito; Diaz, Eduardo; Fabra, Isabel; Caruso, Riccardo; Malavé, Luis; Ferri, Valentina; Lazzaro, Sara; Kalivaci, Denis; Quijano, Yolanda; Vicente, Emilio

2017-07-19

In literature, only a few studies have prospectively compared the results of laparoscopic with open inguinal hernia repair yet none have compared bilateral inguinal hernia repair. The aim of this study is to compare the open Lichtenstein repair (OLR) with laparoscopic trans-abdominal preperitoneal (TAPP) repair in patients undergoing surgery for bilateral inguinal hernia. Patients were prospectively randomized between March 2013 and March 2015. Outcome parameters included hospital stay, operation time, postoperative complications, immediate postoperative pain and chronic pain, recurrence and quality of life. Sixty-one patients underwent TAPP repair and 73 underwent OLR. TAPP procedure had less early post-operative pain up to 7 days from surgery (p = 0.003), a shorter length of hospital stay (p = 0.001), less postoperative complications (p = 0.012) and less chronic pain (0.04) when compared with the OLR approach. TAPP procedure for bilateral inguinal hernia effectively reduces early postoperative pain, hospital stay and postoperative complications. Copyright © 2017 Elsevier Inc. All rights reserved.

Advanced Age: Is It an Indication or Contraindication for Laparoscopic Ventral Hernia Repair?

PubMed Central

Elgamal, Mohamed H.; Mancl, Tara B.; Norman, Earl; Boros, Michael J.

2008-01-01

Introduction: Ventral hernias are common surgical problems in the geriatric population. Although ventral hernias are electively repaired in younger patients, the safety and efficacy of elective laparoscopic hernia repair in the geriatric age group is not well documented in the literature. Methods: A review of 155 patients undergoing laparoscopic ventral hernia repair was undertaken. The patients were classified according to their age into 2 groups, Group A (n=126) for those who are ≤65 years old and Group B (n=29) for those who are >65 years old. The patient demographics, comorbidities, hernia characteristics, and operative and postoperative data were compared. Results: Younger patients were found to have a significantly increased BMI, while the older group had an increased number of comorbidities. No difference was found in the complication or recurrence rates between the 2 groups. Conclusion: Elective laparoscopic ventral hernia repair in senior citizens is safe and feasible in our experience. We believe that the decision to perform an elective hernia repair in this patient population should be based on the general condition of the patient rather than the patient's chronological age. PMID:18402738

DNA repair mechanisms in cancer development and therapy

PubMed Central

Torgovnick, Alessandro; Schumacher, Björn

2015-01-01

DNA damage has been long recognized as causal factor for cancer development. When erroneous DNA repair leads to mutations or chromosomal aberrations affecting oncogenes and tumor suppressor genes, cells undergo malignant transformation resulting in cancerous growth. Genetic defects can predispose to cancer: mutations in distinct DNA repair systems elevate the susceptibility to various cancer types. However, DNA damage not only comprises a root cause for cancer development but also continues to provide an important avenue for chemo- and radiotherapy. Since the beginning of cancer therapy, genotoxic agents that trigger DNA damage checkpoints have been applied to halt the growth and trigger the apoptotic demise of cancer cells. We provide an overview about the involvement of DNA repair systems in cancer prevention and the classes of genotoxins that are commonly used for the treatment of cancer. A better understanding of the roles and interactions of the highly complex DNA repair machineries will lead to important improvements in cancer therapy. PMID:25954303

Indentation Damage and Crack Repair in Human Enamel*

PubMed Central

Rivera, C.; Arola, D.; Ossa, A.

2013-01-01

Tooth enamel is the hardest and most highly mineralized tissue in the human body. While there have been a number of studies aimed at understanding the hardness and crack growth resistance behavior of this tissue, no study has evaluated if cracks in this tissue undergo repair. In this investigation the crack repair characteristics of young human enamel were evaluated as a function of patient gender and as a function of the distance from the Dentin Enamel Junction (DEJ). Cracks were introduced via microindentation along the prism direction and evaluated as a function of time after the indentation. Microscopic observations indicated that the repair of cracks began immediately after crack initiation and reaches saturation after approximately 48 hours. During this process he crack length decreased up to 10% of the initial length, and the largest degree of reduction occurred in the deep enamel, nearest the DEJ. In addition, it was found that the degree of repair was significantly greater in the enamel of female patients. PMID:23541701

Indentation damage and crack repair in human enamel.

PubMed

Rivera, C; Arola, D; Ossa, A

2013-05-01

Tooth enamel is the hardest and most highly mineralized tissue in the human body. While there have been a number of studies aimed at understanding the hardness and crack growth resistance behavior of this tissue, no study has evaluated if cracks in this tissue undergo repair. In this investigation the crack repair characteristics of young human enamel were evaluated as a function of patient gender and as a function of the distance from the Dentin Enamel Junction (DEJ). Cracks were introduced via microindentation along the prism direction and evaluated as a function of time after the indentation. Microscopic observations indicated that the repair of cracks began immediately after crack initiation and reaches saturation after approximately 48 h. During this process he crack length decreased up to 10% of the initial length, and the largest degree of reduction occurred in the deep enamel, nearest the DEJ. In addition, it was found that the degree of repair was significantly greater in the enamel of female patients. Copyright © 2013 Elsevier Ltd. All rights reserved.

Insulin sensitizers prevent fine particulate matter-induced vascular insulin resistance and changes in endothelial progenitor cell homeostasis

PubMed Central

McCracken, James P.; Bhatnagar, Aruni; Conklin, Daniel J.

2016-01-01

Exposure to fine particular matter (PM2.5) increases the risk of developing cardiovascular disease and Type 2 diabetes. Because blood vessels are sensitive targets of air pollutant exposure, we examined the effects of concentrated ambient PM2.5 (CAP) on vascular insulin sensitivity and circulating levels of endothelial progenitor cells (EPCs), which reflect cardiovascular health. We found that CAP exposure for 9 days decreased insulin-stimulated Akt phosphorylation in the aorta of mice maintained on control diet. This change was accompanied by the induction of IL-1β and increases in the abundance of cleaved IL-18 and p10 subunit of Casp-1, consistent with the activation of the inflammasome pathway. CAP exposure also suppressed circulating levels of EPCs (Flk-1+/Sca-1+ cells), while enhancing the bone marrow abundance of these cells. Although similar changes in vascular insulin signaling and EPC levels were observed in mice fed high-fat diet, CAP exposure did not exacerbate diet-induced changes in vascular insulin resistance or EPC homeostasis. Treatment with an insulin sensitizer, metformin or rosiglitazone, prevented CAP-induced vascular insulin resistance and NF-κB and inflammasome activation and restored peripheral blood and bone marrow EPC levels. These findings suggest that PM2.5 exposure induces diet-independent vascular insulin resistance and inflammation and prevents EPC mobilization, and that this EPC mobilization defect could be mediated by vascular insulin resistance. Impaired vascular insulin sensitivity may be an important mechanism underlying PM2.5-induced vascular injury, and pharmacological sensitization to insulin action could potentially prevent deficits in vascular repair and mitigate vascular inflammation due to exposure to elevated levels of ambient air pollution. Listen to this article's corresponding podcast at http://ajpheart.podbean.com/e/particulate-matter-induced-vascular-insulin-resistance/. PMID:27016579

VEGFR tyrosine kinase inhibitor II (VRI) induced vascular insufficiency in zebrafish as a model for studying vascular toxicity and vascular preservation

DOE Office of Scientific and Technical Information (OSTI.GOV)

Li, Shang; Dang, Yuan Ye; Oi Lam Che, Ginny

In ischemic disorders such as chronic wounds and myocardial ischemia, there is inadequate tissue perfusion due to vascular insufficiency. Besides, it has been observed that prolonged use of anti-angiogenic agents in cancer therapy produces cardiovascular toxicity caused by impaired vessel integrity and regeneration. In the present study, we used VEGFR tyrosine kinase inhibitor II (VRI) to chemically induce vascular insufficiency in zebrafish in vivo and human umbilical vein endothelial cells (HUVEC) in vitro to further study the mechanisms of vascular morphogenesis in these pathological conditions. We also explored the possibility of treating vascular insufficiency by enhancing vascular regeneration and repairmore » with pharmacological intervention. We observed that pretreatment of VRI induced blood vessel loss in developing zebrafish by inhibiting angiogenesis and increasing endothelial cell apoptosis, accompanied by down-regulation of kdr, kdrl and flt-1 genes expression. The VRI-induced blood vessel loss in zebrafish could be restored by post-treatment of calycosin, a cardiovascular protective isoflavone. Similarly, VRI induced cytotoxicity and apoptosis in HUVEC which could be rescued by calycosin post-treatment. Further investigation of the underlying mechanisms showed that the PI3K/AKT/Bad cell survival pathway was a main contributor of the vascular regenerative effect of calycosin. These findings indicated that the cardiovascular toxicity in anti-angiogenic therapy was mainly caused by insufficient endothelial cell survival, suggesting its essential role in vascular integrity, repair and regeneration. In addition, we showed that VRI-induced blood vessel loss in zebrafish represented a simple and effective in vivo model for studying vascular insufficiency and evaluating cancer drug vascular toxicities. - Highlights: • In vivo VRI model • Rescue effects of calycosin • Calycosin EC survival pathways.« less

Ventral hernia repair with poly-4-hydroxybutyrate mesh.

PubMed

Plymale, Margaret A; Davenport, Daniel L; Dugan, Adam; Zachem, Amanda; Roth, John Scott

2018-04-01

Biomaterial research has made available a biologically derived fully resorbable poly-4-hydroxybutyrate (P4HB) mesh for use in ventral and incisional hernia repair (VIHR). This study evaluates outcomes of patients undergoing VIHR with P4HB mesh. An IRB-approved prospective pilot study was conducted to assess clinical and quality of life (QOL) outcomes for patients undergoing VIHR with P4HB mesh. Perioperative characteristics were defined. Clinical outcomes, employment status, QOL using 12-item short form survey (SF-12), and pain assessments were followed for 24 months postoperatively. 31 patients underwent VIHR with bioresorbable mesh via a Rives-Stoppa approach with retrorectus mesh placement. The median patient age was 52 years, median body mass index was 33 kg/m 2 , and just over half of the patients were female. Surgical site occurrences occurred in 19% of patients, most of which were seroma. Hernia recurrence rate was 0% (median follow-up = 414 days). Patients had significantly improved QOL at 24 months compared to baseline for SF-12 physical component summary and role emotional (p < 0.05). Ventral hernia repair with P4HB bioresorbable mesh results in favorable outcomes. Early hernia recurrence was not identified among the patient cohort. Quality of life improvements were noted at 24 months versus baseline for this cohort of patients with bioresorbable mesh. Use of P4HB mesh for ventral hernia repair was found to be feasible in this patient population. (ClinicalTrials.gov Identifier: NCT01863030).

Evaluation of Anesthesia Profile in Pediatric Patients after Inguinal Hernia Repair with Caudal Block or Local Wound Infiltration

PubMed Central

Gavrilovska-Brzanov, Aleksandra; Kuzmanovska, Biljana; Kartalov, Andrijan; Donev, Ljupco; Lleshi, Albert; Jovanovski-Srceva, Marija; Spirovska, Tatjana; Brzanov, Nikola; Simeonov, Risto

2016-01-01

AIM: The aim of this study is to evaluate anesthesia and recovery profile in pediatric patients after inguinal hernia repair with caudal block or local wound infiltration. MATERIAL AND METHODS: In this prospective interventional clinical study, the anesthesia and recovery profile was assessed in sixty pediatric patients undergoing inguinal hernia repair. Enrolled children were randomly assigned to either Group Caudal or Group Local infiltration. For caudal blocks, Caudal Group received 1 ml/kg of 0.25% bupivacaine; Local Infiltration Group received 0.2 ml/kg 0.25% bupivacaine. Investigator who was blinded to group allocation provided postoperative care and assessments. Postoperative pain was assessed. Motor functions and sedation were assessed as well. RESULTS: The two groups did not differ in terms of patient characteristic data and surgical profiles and there weren’t any hemodynamic changes between groups. Regarding the difference between groups for analgesic requirement there were two major points - on one hand it was statistically significant p < 0.05 whereas on the other hand time to first analgesic administration was not statistically significant p = 0.40. There were significant differences in the incidence of adverse effects in caudal and local group including: vomiting, delirium and urinary retention. CONCLUSIONS: Between children undergoing inguinal hernia repair, local wound infiltration insures safety and satisfactory analgesia for surgery. Compared to caudal block it is not overwhelming. Caudal block provides longer analgesia, however complications are rather common. PMID:27275337

Transvaginal prolapse repair with or without the addition of a midurethral sling in women with genital prolapse and stress urinary incontinence: a randomised trial.

PubMed

van der Ploeg, J M; Oude Rengerink, K; van der Steen, A; van Leeuwen, J H S; Stekelenburg, J; Bongers, M Y; Weemhoff, M; Mol, B W; van der Vaart, C H; Roovers, J-P W R

2015-06-01

To compare transvaginal prolapse repair combined with midurethral sling (MUS) versus prolapse repair only. Multi-centre randomised trial. Fourteen teaching hospitals in the Netherlands. Women with symptomatic stage two or greater pelvic organ prolapse (POP), and subjective or objective stress urinary incontinence (SUI) without prolapse reduction. Women were randomly assigned to undergo vaginal prolapse repair with or without MUS. Analysis was according to intention to treat. The primary outcome at 12 months' follow-up was the absence of urinary incontinence (UI) assessed with the Urogenital Distress Inventory and treatment for SUI or overactive bladder. Secondary outcomes included complications. One hundred and thirty-four women were analysed at 12 months' follow-up (63 in MUS and 71 in control group). More women in the MUS group reported the absence of UI and SUI; respectively 62% versus 30% UI (relative risk [RR] 2.09; 95% confidence interval [CI] 1.39-3.15) and 78% versus 39% SUI (RR 1.97; 95% CI 1.44-2.71). Fewer women underwent treatment for postoperative SUI in the MUS group (10% versus 37%; RR 0.26; 95% CI 0.11-0.59). In the control group, 12 women (17%) underwent MUS after prolapse surgery versus none in the MUS group. Severe complications were more common in the MUS group, but the difference was not statistically significant (16% versus 6%; RR 2.82; 95% CI 0.93-8.54). Women with prolapse and co-existing SUI are less likely to have SUI after transvaginal prolapse repair with MUS compared with prolapse repair only. However, only 17% of the women undergoing POP surgery needed additional MUS. A well-informed decision balancing risks and benefits of both strategies should be tailored to individual women. © 2015 Royal College of Obstetricians and Gynaecologists.