Initial experience with the ambulatory management of acute iliofemoral deep vein thrombosis with May-Thurner syndrome with percutaneous mechanical thrombectomy, angioplasty and stenting.

OBJECTIVE: Patients undergoing intervention for acute iliofemoral deep vein thrombosis (IFDVT) with May-Thurner syndrome (MTS) typically require inpatient (IP) hospitalization for initial treatment with anticoagulation and management with pharmacomechanical thrombectomy. Direct oral anticoagulants and percutaneous mechanical thrombectomy (PMT) devices offer the opportunity for outpatient (OP) management. We describe our approach with these patients. METHODS: Patients receiving intervention for acute IFDVT from January 2020 through October 2022 were retrospectively reviewed. Patients undergoing unilateral thrombectomy, venous angioplasty, and stenting for IFDVT with MTS comprised the study population and were divided into two groups: (1) patients admitted to the hospital and treated as IPs and (2) patients who underwent therapy as OPs. The two groups were compared regarding demographics, risk factors, procedural success, complications, and follow-up. RESULTS: A total of 92 patients were treated for IFDVT with thrombectomy, angioplasty, and stenting of whom 58 comprised the IP group and 34 the OP group. All 92 patients underwent PMT using the Inari ClotTriever (Inari Medical), intravascular ultrasound, angioplasty, and stenting with 100% technical success. Three patients in the IP group required adjuvant thrombolysis. There was no difference in primary patency of the treated IFDVT segment at 12 months between the two groups (IP, 73.5%; OP, 86.7%; P = .21, log-rank test). CONCLUSIONS: Patients with acute IFDVT and MTS deemed appropriate for thrombectomy and iliac revascularization can be managed with initiation of ambulatory direct oral anticoagulant therapy and subsequent return for ambulatory PMT, angioplasty, and stenting. This approach avoids the expense of IP care and allows for effective use of resources at a time when staffing and supply chain shortages have led to inefficiencies in the provision of IP care for nonemergent conditions.

Mycotic aneurysm of the distal thoracic aorta after botulinum toxin injection for esophageal dysmotility.

Endoscopic injection of botulinum toxin is a common method to treat esophageal dysmotility and achalasia. Patients undergoing this procedure who subsequently present with abdominal or back pain and constitutional symptoms should be evaluated for possible complications of the procedure, including occult esophageal perforation, mediastinitis, and mycotic aneurysm of the thoracic aorta. The case described herein illustrates the importance of serial imaging in a patient with persistent symptoms after botulinum toxin injection to identify and to treat occult aortic inoculation leading to mycotic aneurysm before sepsis and aortic rupture ensue with their attendant morbidity and mortality risks.

Diffuse Cutaneous Manifestations after Drug-Coated Balloon Angioplasty.

We present here a case of an uncommon cutaneous manifestation after paclitaxel-coated balloon angioplasty. In this case, the patient underwent drug-coated balloon angioplasty for stenosis of a prior vein bypass graft. The patient subsequently developed extensive cutaneous lesions not confined to a single arterial distribution. This case represents a rare complication related to paclitaxel-eluting balloons and provides a cautionary tale as well as clinical acumen for providers in using such devices in their practice.

Risk factors associated with microembolization after carotid intervention.

BACKGROUND: Microembolization after carotid artery stenting (CAS) and carotid endarterectomy (CEA) has been documented and may confer risk for neurocognitive impairment. Patients undergoing stenting are known to be at higher risk for microembolization. In this prospective cohort study, we compare the microembolization rates for patients undergoing CAS and CEA and perioperative characteristics that may be associated with microembolization. METHODS: Patients undergoing CAS and CEA were prospectively recruited under local institutional review board approval from an academic medical center. All patients also received 3T brain magnetic resonance imaging with a diffusion-weighted imaging sequence preoperatively and within 24 hours postoperatively to identify procedure-related new embolic lesions. Preoperative, postoperative, procedural factors, and plaque characteristics were collected. Factors were tested for statistical significance with logistic regression. RESULTS: A total of 202 patients were enrolled in the study. There were 107 patients who underwent CAS and 95 underwent CEA. Patients undergoing CAS were more likely to have microemboli than patients undergoing CEA (78% vs 27%; P < .0001). For patients undergoing CAS, patency of the external carotid artery (odds ratio [OR], 11.4; 95% confidence interval [CI], 1.11-117.6; P = .04), lesion calcification (OR, 5.68; 95% CI, 1.12-28.79; P = .04), and lesion length (OR, 0.29; 95% CI, 0.08-1.01; P = .05) were all found to be independent risk factors for perioperative embolization. These factors did not confer increased risk to patients undergoing CEA. CONCLUSIONS: Patients undergoing CAS are at higher risk for perioperative embolization. The risk for perioperative embolization is related to the length of the lesion and calcification. Identifying the preoperative risk factors may help to guide patient selection and, thereby, reduce embolization-related neurocognitive impairment.

Length of Stay and ICU Stay Are Increased With Repair of Traumatic Superior Mesenteric Vein Injury.

BACKGROUND: Traumatic superior mesenteric vein (SMV) injury is rare, and the ideal treatment is controversial. We compared the outcomes of ligation versus repair of SMV injury using the National Trauma Databank. MATERIALS AND METHODS: All adult patients who suffered from traumatic SMV injury were identified from the National Trauma Databank (2002-2014) by International Classification of Diseases (ICD) codes. Patients were stratified by treatment modality into no repair, ligation, and surgical repair using ICD procedure codes. Patient characteristics were compared between ligation and surgical repair groups using the Kruskal-Wallis test for continuous variables and Fisher's exact test for categorical variables. Outcomes, including mortality, rates of small bowel resection, length of stay (LOS), and ventilation days were compared using logistic regression. RESULTS: Among 952 patients with SMV injury, 192 patients (20.2%) had ligation, 428 (50%) underwent surgical repair, and 332 patients (34.9%) had neither repair nor ligation of the SMV. Overall hospital mortality was 32%. Age, gender, injury severity score (ISS), and Glasgow Coma Scale (GCS) were similar between groups that underwent ligation and surgical repair. Although the mortality rate (29.4% versus 36.5%, P = 0.20) and bowel resection rate (4% versus 3%, P = 0.12) were similar, patients who underwent repair had significantly longer hospital LOS (19.4 ± 24.8 versus15.2 ± 24.4 d, P < 0.001) and ICU LOS (13 ± 17.1 versus 9.3 ± 11.8 d, P = 0.02) compared to ligation. Similar results were observed in multivariable analysis when adjusted for race, associated vascular injuries, and other associated injuries. CONCLUSIONS: In patients with traumatic SMV injury, surgical repair does not appear to confer a significant survival advantage over ligation and can be associated with greater LOS and ICU LOS. Ligation may be an acceptable option for management of a traumatic SMV injury, especially when surgical repair cannot be performed, without compromising patient mortality or bowel resection rates.

The mortality for surgical repair is similar to ligation in patients with traumatic portal vein injury.

BACKGROUND: Portal vein injury is uncommon, and the optimal treatment is controversial. We compared the outcomes of ligation vs repair of portal injury using the National Trauma Data Bank. METHODS: Adult patients who suffered portal injury were identified from the National Trauma Data Bank (2002-2014) by International Classification of Diseases, Ninth Revision diagnosis codes. Patients were stratified by treatment modality into no surgery, ligation, and surgical repair using International Classification of Diseases procedure codes. Outcomes including hospital mortality, bowel resection, and length of stay between ligation and surgical repair were compared by Kruskal-Wallis or Fisher exact test as appropriate. Multivariable analyses were performed with logistic regression. RESULTS: Among 752 patients with portal vein injury, 345 patients (45.9%) underwent no surgery, 103 patients (13.7%) had ligation, and 304 (40.4%) underwent surgical repair. Overall mortality was 49%. Age, sex, Injury Severity Score, Glasgow Coma Scale score, presenting blood pressure, and heart rate were similar between groups that underwent ligation and surgical repair. The hospital mortality (59.2% vs 47.7%; P = .08), bowel resection (1.9% vs 1.0%; P = .55), and length of stay (12.5 vs 15.0 days; P = .08) were also comparable between ligation and repair in univariate analysis. In multivariable analysis, hospital mortality for surgical repair was similar to ligation (risk ratio, 0.69; 95% confidence interval, 0.41-1.16; P = .16). CONCLUSIONS: Portal vein injury is associated with significant mortality and morbidity. Surgical repair showed a trend for lower postoperative mortality than ligation, but this was not statistically significant on multivariate analysis. Repair of a traumatic portal vein injury should be attempted, but ligation is an acceptable alternative without an increase in bowel resection rates or a statistically significant increase in mortality.

The use of finger-stick blood to assess lactate in critically ill surgical patients.

BACKGROUND: Using finger-stick capillary blood to assess lactate from the microcirculation may have utility in treating critically ill patients. Our goals were to determine how finger-stick capillary lactate correlates with arterial lactate levels in patients from the surgical intensive care unit, and to compare how capillary and arterial lactate trend over time in patients undergoing resuscitation for shock. METHODS: Capillary whole blood specimens were obtained from finger-sticks using a lancet, and assessed for lactate via a handheld point-of-care device as part of an "investigational use only" study. Comparison was made to arterial blood specimens that were assessed for lactate by standard laboratory reference methods. RESULTS: 40 patients (mean age 68, mean APACHEII 18, vasopressor use 62%) were included. The correlation between capillary and arterial lactate levels was 0.94 (p < 0.001). Capillary lactate measured slightly higher on average than paired arterial values, with a mean difference 0.99 mmol/L. In patients being resuscitated for septic and hemorrhagic shock, capillary and arterial lactate trended closely over time: rising, peaking, and falling in tandem. Clearance of capillary and arterial lactate mirrored clinical improvement, normalizing in all patients except two that expired. CONCLUSION: Finger-stick capillary lactate both correlates and trends closely with arterial lactate in critically ill surgical patients, undergoing resuscitation for shock.

Long-term survivor of primary malignant melanoma of the esophagus treated with surgical resection.

INTRODUCTION: Primary malignant melanoma of the esophagus is a rare diagnosis with only a few hundred cases reported in the literature. Due to the aggressive nature of this disease, long-term survivors are exceedingly rare with only a handful of case reports. PRESENTATION OF CASE: We report the case of a 38 year old man who presented with chest and back pain. Workup revealed a mediastinal mass and the patient was diagnosed with primary malignant melanoma of the esophagus and treated with radical resection. Despite the poor prognosis associated with primary malignant melanoma of the esophagus, he remains disease free for over 7 years. DISCUSSION: Initially primary malignant melanoma of the esophagus was a controversial diagnosis until the demonstration of normal melanocytes in healthy patients. It is an aggressive disease that is nearly uniformly fatal. Review of the literature shows that treatment with radical surgical resection extends prognosis by months while treatment with adjuvant chemotherapy is controversial. CONCLUSION: Primary malignant melanoma of the esophagus is a rare and aggressive disease that should be treated with surgical resection when feasible. We report the rare case of a long term survivor over 7 years since diagnosis.

Reverse micelles as a tool for probing solvent modulation of protein dynamics: Reverse micelle encapsulated hemoglobin.

Hydration waters impact protein dynamics. Dissecting the interplay between hydration waters and dynamics requires a protein that manifests a broad range of dynamics. Proteins in reverse micelles (RMs) have promise as tools to achieve this objective because the water content can be manipulated. Hemoglobin is an appropriate tool with which to probe hydration effects. We describe both a protocol for hemoglobin encapsulation in reverse micelles and a facile method using PEG and cosolvents to manipulate water content. Hydration properties are probed using the water-sensitive fluorescence from Hb bound pyranine and covalently attached Badan. Protein dynamics are probed through ligand recombination traces derived from photodissociated carbonmonoxy hemoglobin on a log scale that exposes the potential role of both α and ß solvent fluctuations in modulating protein dynamics. The results open the possibility of probing hydration level phenomena in this system using a combination of NMR and optical probes.

Catalytic intermediates of inducible nitric-oxide synthase stabilized by the W188H mutation.

Nitric-oxide synthase (NOS) catalyzes nitric oxide (NO) synthesis via a two-step process: L-arginine (L-Arg) → N-hydroxy-L-arginine → citrulline + NO. In the active site the heme is coordinated by a thiolate ligand, which accepts a H-bond from a nearby tryptophan residue, Trp-188. Mutation of Trp-188 to histidine in murine inducible NOS was shown to retard NO synthesis and allow for transient accumulation of a new intermediate with a Soret maximum at 420 nm during the L-Arg hydroxylation reaction (Tejero, J., Biswas, A., Wang, Z. Q., Page, R. C., Haque, M. M., Hemann, C., Zweier, J. L., Misra, S., and Stuehr, D. J. (2008) J. Biol. Chem. 283, 33498-33507). However, crystallographic data showed that the mutation did not perturb the overall structure of the enzyme. To understand how the proximal mutation affects the oxygen chemistry, we carried out biophysical studies of the W188H mutant. Our stopped-flow data showed that the 420-nm intermediate was not only populated during the L-Arg reaction but also during the N-hydroxy-L-arginine reaction. Spectroscopic data and structural analysis demonstrated that the 420-nm intermediate is a hydroxide-bound ferric heme species that is stabilized by an out-of-plane distortion of the heme macrocycle and a cation radical centered on the tetrahydrobiopterin cofactor. The current data add important new insights into the previously proposed catalytic mechanism of NOS (Li, D., Kabir, M., Stuehr, D. J., Rousseau, D. L., and Yeh, S. R. (2007) J. Am. Chem. Soc. 129, 6943-6951).

Characterization of the proximal ligand in the P420 form of inducible nitric oxide synthase.

The nitric oxide (NO) produced by inducible nitric oxide synthase (iNOS) up-regulates the expression of heme oxygenase (HO), which in turn produces carbon monoxide (CO) that down-regulates iNOS activity by reducing its expression level or by inhibiting its activity by converting it to an inactive P420 form (iNOS(P420)). Accordingly, CO has been considered as a potentially important attenuator of inflammation. Despite its importance, the nature of the proximal heme ligand of the iNOS(P420) species remains elusive. Here we show that the 221 cm(-1) mode of the photoproduct of iNOS(P420) does not exhibit any H(2)O-D(2)O solvent isotope shift such as that found in the iron-histidine stretching mode of myoglobin, indicating that the proximal ligand of iNOS(P420) is not a histidine. The nu(Fe-CO) and nu(C-O) data reveal that the proximal heme ligand of iNOS(P420) is consistent with a protonated thiol instead of a thiolate anion. Furthermore, the optical absorption properties of iNOS(P420) are similar to those of a neutral thiol-heme model complex but not myoglobin. Together the data support the scenario that iNOS(P420) is inactivated by protonation of the native proximal thiolate ligand to a neutral thiol, instead of by ligand switching to a histidine, as prior studies have suggested.